Abstract Background and Aims Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease. Little is known about differences in cardiovascular outcomes between home hemodialysis (HHD) and peritoneal dialysis (PD). Methods We evaluated 68 645 patients who initiated home dialysis between 1/1/2005 and 12/31/2018 using the United States Renal Data System with linked Medicare claims. Rates for incident cardiovascular events of acute coronary syndrome, heart failure, and stroke hospitalizations were determined. Using adjusted time-to-event models, the associations of type of home dialysis modality with the outcomes of incident cardiovascular events, cardiovascular death, and all-cause death were examined. Results The mean age of patients in the study cohort was 64 ± 15 years, and 42.3% were women. Mean time of follow up was 1.8 ± 1.6 years. The unadjusted cardiovascular event rate was 95.1 per thousand person-years [PTPY] (95% CI, 93.6-96.8), with a higher rate in patients on HHD than on PD (127.8 PTPY; 95% CI, 118.9-137.2 vs. 93.3 PTPY; 95% CI, 91.5-95.1). However, HHD was associated with a slightly lower adjusted risk of cardiovascular events than PD (HR, 0.92; 95% CI, 0.85 to 0.997). Compared to PD patients, HHD patients had 42% lower adjusted risk of stroke (HR, 0.58; 95% CI, 0.48-0.71), 17% lower adjusted risk of acute coronary syndrome (HR, 0.83; 95% CI, 0.72-0.95), and no difference in risk of heart failure (HR, 1.05; 95% CI, 0.94-1.16). HHD was associated with 22% lower adjusted risk of cardiovascular death (HR, 0.78; 95% CI, 0.71-0.86) and 8% lower adjusted risk of all-cause death (HR, 0.92; 95% CI, 0.87-0.97) as compared to PD. Conclusion Relative to PD, HHD is associated with decreased risk of stroke, acute coronary syndrome, cardiovascular death, and all-cause death. Further studies are needed to better understand the factors associated with differences in cardiovascular outcomes by type of home dialysis modality in patients with kidney failure.
Introduction: Kidney transplant improves reproductive function in women with end-stage kidney disease (ESKD). Little is known about contraceptive use in women with history of kidney transplants. Methods: Using data from the United States Renal Data System covering 1/1/2005 through 12/31/2014, we evaluated for each calendar year women for the first three entire years after the date of kidney transplantation who were aged 15-44 years, and with Medicare as the primary payer. We determined rates of contraceptive use in the first three post-transplant years using Poisson regression and used multivariable logistic regression to identify factors associated with contraceptive use. Results: The study cohort included 13,362 women with kidney transplants. The rate of contraceptive use was 7.1% of person-years. Compared to women aged 15–24 years, contraceptive use was lower in women aged 30–34 years (OR, 0.80; CI, 0.68-0.94), 35-39 years (OR, 0.48; CI, 0.40-0.56), and 40-44 years (OR, 0.29; CI, 0.24-0.34). Compared to white women, contraceptive use was higher in black women (OR, 1.19; CI, 1.04-1.37) and lower in Asian women (OR, 0.71; CI, 0.54-0.94). Women had lower rates of contraceptive use in the second-year post-transplant (OR, 0.67; CI 0.61-0.74) and third-year post-transplant (0.23; CI 0.20-0.27) than in the first year post-transplant. In transplant recipients, women with a history of ESKD due to cystic disease had a lower likelihood of contraceptive use than in women with ESKD due to diabetes (OR, 0.67; CI, 0.50-0.89). Conclusion: Among women with kidney transplants, contraceptive use remains low at 7.1%. Significant factors associated with contraceptive use included age, race/ethnicity, post-transplant year, and ESKD cause. The study highlights the importance of counseling for contraceptive use in women with kidney transplants.
Perfusion imaging strongly predicts coronary artery disease (CAD), whereas cardiac volumes and left ventricular ejection fraction (LVEF) strongly predict mortality. Compared to conventional Anger single-photon emission computed tomography (SPECT) cameras, cadmium-zinc-telluride (CZT) cameras provide higher resolution, resulting in different left ventricular volumes. The cadmium-zinc-telluride D-SPECT camera is commonly used to image in the upright position, which introduces changes in left ventricular loading conditions and potentially alters left ventricular volumes. However, little or no data exist on the predictive value of left ventricular volumes and ejection fraction when acquired in the upright position. We investigated models for the prediction of CAD and mortality, comparing upright and supine imaging.
<b><i>Background:</i></b> Acute kidney injury (AKI) during pregnancy is a public health problem and is associated with maternal and fetal morbidity and mortality. Clinical outcomes and health care utilization in pregnancy-related AKI, especially in women with diabetes, are not well studied. <b><i>Methods:</i></b> Using data from the 2006 to 2015 Nationwide Inpatient Sample, we identified 42,190,790 pregnancy-related hospitalizations in women aged 15–49 years. We determined factors associated with AKI, including race/ethnicity, and associations between AKI and inpatient mortality, and between AKI and cardiovascular (CV) events, during pregnancy-related hospitalizations. We calculated health care expenditures from pregnancy-related AKI hospitalizations. <b><i>Results:</i></b> Overall, the rate of AKI during pregnancy-related hospitalizations was 0.08%. In the adjusted regression analysis, a higher likelihood of AKI during pregnancy-related hospitalizations was seen in 2015 (OR 2.20; 95% CI 1.89–2.55) than in 2006; in older women aged 36–40 years (OR 1.49; 95% CI 1.36–1.64) and 41–49 years (OR 2.12; 95% CI 1.84–2.45) than in women aged 20–25 years; in blacks (OR 1.52; 95% CI 1.40–1.65) and Native Americans (OR 1.45; 95% CI 1.10–1.91) than in whites, and in diabetic women (OR 4.43; 95% CI 4.04–4.86) than in those without diabetes. Pregnancy-related hospitalizations with AKI were associated with a higher likelihood of inpatient mortality (OR 13.50; 95% CI 10.47–17.42) and CV events (OR 9.74; 95% CI 9.08–10.46) than were hospitalizations with no AKI. The median cost was higher for a delivery hospitalization with AKI than without AKI (USD 18,072 vs. 4,447). <b><i>Conclusion:</i></b> The rates of pregnancy-related AKI hospitalizations have increased during the last decade. Factors associated with a higher likelihood of AKI during pregnancy included older age, black and Native American race/ethnicity, and diabetes. Hospitalizations with pregnancy-related AKI have an increased risk of inpatient mortality and CV events, and a higher health care utilization than do those without AKI.
Bisphenol A (BPA) toxicity and exposure risk to humans has been the subject of considerable scientific debate; however, published occupational exposure data for BPA are limited.In 2013-2014, 77 workers at six US companies making BPA, BPA-based resins, or BPA-filled wax provided seven urine samples over two consecutive work days (151 worker-days, 525 samples). Participant information included industry, job, tasks, personal protective equipment used, hygiene behaviors, and canned food/beverage consumption. Total (free plus conjugated) BPA, quantified in urine by mass spectrometry, was detected in all samples.The geometric mean (GM) creatinine-adjusted total BPA (total BPACR) concentration was 88.0 µg g-1 (range 0.78-18900 µg g-1), ~70 times higher than in US adults in 2013-2014 (1.27 µg g-1). GM total BPACR increased during Day 1 (26.6-127 µg g-1), decreased by pre-shift Day 2 (84.4 µg g-1) then increased during Day 2 to 178 µg g-1. By industry, baseline and post-baseline total BPACR was highest in BPA-filled wax manufacturing/reclaim (GM = 111 µg g-1) and lowest in phenolic resin manufacturing (GM = 6.56 µg g-1). By job, total BPACR was highest at baseline in maintenance workers (GM = 157 µg g-1) and post-baseline in those working with molten BPA-filled wax (GM = 441 µg g-1). Workers in the job of flaking a BPA-based resin had the lowest concentrations at baseline (GM = 4.81 µg g-1) and post-baseline (GM = 23.2 µg g-1). In multiple regression models, at baseline, industry significantly predicted increased total BPACR (P = 0.0248); post-baseline, handling BPA containers (P = 0.0035), taking ≥3 process/bulk samples with BPA (P = 0.0002) and wearing a Tyvek® coverall (P = 0.0042) significantly predicted increased total BPACR (after adjusting for total BPACR at baseline, time point, and body mass index).Several work-related factors, including industry, job, and certain tasks performed, were associated with increased urinary total BPACR concentrations in this group of manufacturing workers. The potential for BPA-related health effects among these workers is unknown.
Introduction: In 2005, the Veterans Health Administration implemented a program that provides automated quarterly reports for every VA intensive care unit (ICU) and supports targeted local ICU improvement. The reports track process measures (adherence to practices to reduce central line associated blood stream infections [CLABSI] and ventilator associated pneumonia [VAP], venous thromboembolism prophylaxis, hypo/hyperglycemia rates) and outcomes (risk adjusted and unadjusted hospital and 30-day mortality, ward transfer mortality, length of stay, and CLABSI and VAP rates). Hypothesis: We asked if implementation of this quality improvement infrastructure was associated with changes in 30-day mortality. Methods: We constructed a cohort composed of all patients (505,007) admitted to VA ICU’s from 2006 through 2010, and accounted for differences in patient severity using a validated risk method that predicted mortality at 30 days. Sensivitivity analyses varied the populations, stratifying by types of ICUs and regions. Standardized mortality ratios (SMR30) and 95% confidence intervals (CI) calculated with bootstrapping, compared outcomes. Quality improvement projects included reduction in CLABSI and VAP, Flow improvement, the surgical care improvement project. Results: The VA admits 101,001 ± 715.4 patients annually to its 132 hospitals and 173 ICUs. Annual unadjusted mortality did not change significantly from 206 to 2010 (10.00% to 9.64%); predicted mortality increased (9.4% to 10.2%). From 2006 to 2010, SMR30 fell from 1.07(95% CI 1.04, 1.08) to 0.94 (95%CI 0.923, 0.961). SMR30 was significantly reduced across 1) large and small ICUs, 2) MICUs, MICU/CCU, SICU, but not CCUs, 3) 11/23 VA regions, 4) among patients admitted with cardiovascular, gastrointestinal, metabolic, renal, respiratory, and infectious diagnoses, and 5) all groups stratified by severity. Trend plots by ICU show a strong negative trend in SMR and variance. Conclusions: Implementation of a quality infrastructure and multiple quality improvement projects was temporally associated with 13% reduction in risk adjusted mortality, but not unadjusted mortality. Severity of illness in the ICU increased.
