RESUMEN
Objectively structured clinical examinations (OSCEs) are widely used in medical education, but we know of none described that are specifically for nephrology fellowship training. OSCEs use simulation to educate and evaluate. We describe a technically simple, multidisciplinary, low-cost OSCE developed by our program that contains both examination and training features and focuses on management and clinical knowledge of rare hemodialysis emergencies. The emergencies tested are venous air embolism, blood leak, dialysis membrane reaction, and hemolysis. Fifteen fellows have participated in the OSCE as examinees and/or preceptors since June 2010. All have passed the exercise. Thirteen responded to an anonymous survey in July 2013 that inquired about their confidence in managing each of the 4 tested emergencies pre- and post-OSCE. Fellows were significantly more confident in their ability to respond to the emergencies after the OSCE. Those who subsequently saw such an emergency reported that the OSCE experience was somewhat or very helpful in managing the event. The OSCE tested and trained fellows in the recognition and management of rare hemodialysis emergencies. OSCEs and simulation generally deserve greater use in nephrology subspecialty training; however, collaboration between training programs would be necessary to validate such exercises.
Asunto(s)
Educación Basada en Competencias/organización & administración , Educación de Postgrado en Medicina/normas , Nefrología/educación , Adulto , Evaluación Educacional/métodos , Urgencias Médicas , Humanos , Competencia Profesional/estadística & datos numéricos , Diálisis RenalRESUMEN
BACKGROUND: We report the influence of race on transplant outcomes in the Department of Defense (DOD) system. METHODS: Retrospective cohort analysis of all kidney transplants performed at WRAMC from 1996 to 2005. Kaplan-Meier analysis was used to assess for differences in graft survival, and Cox regression was used to calculate adjusted hazard ratios for graft loss. For our analyses, we used the cutoff of 6 years (year 2000) when we introduced thymoglobulin induction; maintenance immunosuppression consisted of mycophenolate mofetil and tacrolimus, and rapid steroid taper (completed withdrawal at 6 weeks) was used for all patients. RESULTS: There were 220 transplants (91 Blacks, 107 Caucasians and 22 Asians). Because the curve for graft survival for Blacks over time violated the proportional hazards assumption (at 6 years post-transplant), analysis was segregated into two segments. Through 6 years of follow-up, graft survival was 77% for Blacks and 81% for non-Blacks (p = 0.74 by log rank). Through 9 potential years of follow-up, graft survival for Blacks was 56% and 78% for Whites (p = 0.005). In Cox regression analysis, Black race, compared with non-Black race, was not significantly associated with graft loss at 6 years, but was significantly associated with graft loss occurring after 6 years. CONCLUSIONS: In the DOD health system, no significant differences were seen in graft survival among recipients of different races at 6 years. Black recipients who received a kidney transplant before the year 2000 showed decreased graft survival compared to non-Blacks. This was consistent with change in immunosuppressive regimen in our institution with the introduction of thymoglobulin induction and maintenance therapy with tacrolimus, mycophenolate mofetil and withdrawal of prednisone at 6 weeks.
Asunto(s)
Rechazo de Injerto/etnología , Supervivencia de Injerto , Trasplante de Riñón/etnología , Medicina Militar/estadística & datos numéricos , Grupos Raciales/estadística & datos numéricos , United States Government Agencies/estadística & datos numéricos , Adulto , Asiático/estadística & datos numéricos , Población Negra/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Rechazo de Injerto/tratamiento farmacológico , Humanos , Inmunosupresores/uso terapéutico , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados Unidos/epidemiología , Población Blanca/estadística & datos numéricosAsunto(s)
Catárticos/administración & dosificación , Catárticos/efectos adversos , Riñón/efectos de los fármacos , Fosfatos/administración & dosificación , Fosfatos/efectos adversos , Administración Oral , Anciano , Anciano de 80 o más Años , Humanos , Persona de Mediana Edad , Polietilenglicoles/administración & dosificación , Polietilenglicoles/efectos adversosRESUMEN
Mycophenolate mofetil (MMF) use may be associated with progressive multifocal leukoencephalopathy (PML). We conducted a retrospective cohort study of 32,757 renal transplant recipients using the United States Renal Data System kidney transplant files for the incidence, prognosis, and clinical features associated with PML occurring after kidney transplant. Subjects were transplanted from January 1, 2000 to July 31, 2004 and followed through December 31, 2004. The incidence density of PML in MMF users was 14.4 cases/100,000 person-years at risk versus 0 for non-MMF users (P=0.11) by log rank test. Factors significantly associated with PML were BK virus infection (22.2% vs. 1.1%), pretransplant transfusion (75% vs. 34%), panel reactive antibody more than 20% (56% vs. 14%), and use of antirejection medications in the first year (33% vs. 9.2%), all P less than 0.05. PML is rare in the renal transplant population. There was no significant association between PML and MMF, but MMF use in this cohort is too high to accurately assess an association.
Asunto(s)
Inmunosupresores/uso terapéutico , Trasplante de Riñón/inmunología , Leucoencefalopatía Multifocal Progresiva/inducido químicamente , Ácido Micofenólico/análogos & derivados , Adulto , Estudios de Cohortes , Femenino , Humanos , Inmunosupresores/efectos adversos , Incidencia , Fallo Renal Crónico/etiología , Fallo Renal Crónico/cirugía , Leucoencefalopatía Multifocal Progresiva/epidemiología , Masculino , Medicare , Persona de Mediana Edad , Ácido Micofenólico/efectos adversos , Complicaciones Posoperatorias/inducido químicamente , Complicaciones Posoperatorias/epidemiología , Terapia de Reemplazo Renal/estadística & datos numéricos , Estudios Retrospectivos , Tasa de Supervivencia , Estados UnidosRESUMEN
Oral sodium phosphate (OSP) is a commonly used purgative before colonoscopy. There have been numerous reports of acute phosphate nephropathy attributed to the use of OSP. This study evaluated the association between the use of OSP and acute kidney injury (AKI) in an observational, retrospective, cohort study. Of 9799 patients who underwent colonoscopy and had serum creatinine values recorded within 365 days before and after the procedure, AKI, defined as > or =50% increase in baseline serum creatinine, was identified in 114 (1.16%). After adjustment for significant covariates in a multiple logistic regression model, the use of OSP was associated with increased risk for AKI (odds ratio 2.35; 95% confidence interval 1.51 to 3.66; P < 0.001) with an adjusted number need to harm of 81. Age was also independently associated with AKI in this cohort; therefore, until larger, prospective studies define the population at risk for acute phosphate nephropathy, the use of polyethylene glycol-based purgatives should be considered for older patients and possibly for those with comorbid medical conditions.
Asunto(s)
Administración Oral , Enfermedades Renales/tratamiento farmacológico , Fosfatos/administración & dosificación , Enfermedad Aguda , Adulto , Anciano , Catárticos/administración & dosificación , Estudios de Cohortes , Creatinina/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Polietilenglicoles/metabolismo , Análisis de Regresión , Estudios RetrospectivosRESUMEN
BACKGROUND: Hodgkin disease and myeloma were recently included in the classification of posttransplant lymphoproliferative disorder (PTLD). However, because their incidence is low, not much is known about their particular features. METHODS: The incidence, characteristics, risk, and prognostic factors of myeloma, Hodgkin disease, and lymphoid leukemia using the United States Renal Data System from 1991 to 2000 among 66,159 Medicare patients were analyzed. RESULTS: In all, 1,169 recipients developed a lymphoid disease: 823 (1.2%) non-Hodgkin's lymphomas (NHL), 160 (0.24%) myelomas, 60 (0.1%) Hodgkin lymphomas, and 126 (0.2%) lymphoid leukemias. Older age was associated with an increased risk of myeloma and leukemia. The incidence of hepatitis C virus infection was higher in recipients with myeloma (6.9 vs. 3.9%, P=0.05). Induction therapy was associated with a greater risk of myeloma and leukemia, but not Hodgkin disease. Azathioprine was associated with a lower risk of myeloma, and tacrolimus with a lower risk of Hodgkin disease. According to the type of malignancy, ten-year survival rates were significantly different: 42, 26, 55 and 39% respectively for NHL, myeloma, Hodgkin disease, and leukemia. CONCLUSION: These results support specific features and risk factors related to the occurrence of each type of lymphoid-proliferation and suggest for the first time a possible association between hepatitis C virus and myeloma in kidney transplant recipients.
Asunto(s)
Enfermedad de Hodgkin/etiología , Trasplante de Riñón/efectos adversos , Leucemia Linfoide/etiología , Mieloma Múltiple/etiología , Adulto , Anciano , Femenino , Enfermedad de Hodgkin/mortalidad , Humanos , Leucemia Linfoide/microbiología , Masculino , Persona de Mediana Edad , Mieloma Múltiple/microbiología , Pronóstico , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
BACKGROUND: Whether the previously reported underutilization of standard-of-care medications in the management of patients with acute myocardial infarction (AMI) persists in more recent years or differs by ward of admission has not been reported. METHODS: We performed a retrospective cross-sectional study of patients hospitalized with a discharge diagnosis of incident AMI to a Department of Defense hospital (Walter Reed Army Medical Center, Washington, DC) from 2001 through 2004. Use of beta-blockers and aspirin at the time of discharge after AMI was assessed according to Modification of Diet in Renal Disease (MDRD) estimated glomerular filtration rate (eGFR) in milliliters per minute per 1.73 m2, stratified by admission to the coronary care unit (CCU) versus other wards. Adjusted odds ratios for discharge beta-blocker and aspirin therapy were calculated by using logistic regression. RESULTS: Among 431 patients, overall discharge use of beta-blockers was 86.8%, and aspirin, 86.8%, both significantly greater after CCU admission than admission to other wards (93%, aspirin use; 91.7%, beta-blocker use; P < 0.001 and P < 0.001). In logistic regression, CCU admission was the only independent factor associated with either beta-blocker or aspirin use; MDRD eGFR was not associated significantly with beta-blocker and aspirin use regardless of admission to the CCU or non-CCU. CONCLUSION: Future studies of disparities in use of standard-of-care medications after AMI according to renal function should account for the primary site of admission, particularly CCU versus others. In addition, legitimate contraindications to the use of beta-blockers and aspirin may be subtle, including appropriate end-of-life decisions.
Asunto(s)
Antagonistas Adrenérgicos beta/uso terapéutico , Aspirina/uso terapéutico , Infarto del Miocardio/complicaciones , Infarto del Miocardio/tratamiento farmacológico , Insuficiencia Renal/complicaciones , Anciano , Creatinina/sangre , Estudios Transversales , Utilización de Medicamentos/normas , Femenino , Humanos , Masculino , Infarto del Miocardio/sangre , Insuficiencia Renal/sangre , Estudios RetrospectivosRESUMEN
BACKGROUND: The incidence, risk factors, recurrence rates and prognosis of thrombotic microangiopathy (TMA) among long-term dialysis patients in the United States have not been previously described in a national population. METHODS: 272 024 Medicare primary patients in the United States Renal Data System (USRDS) initiated on end-stage renal disease (ESRD) therapy between 1 April 1995 and 31 December 1999 with Medicare as primary payer were analysed in a retrospective cohort study of USRDS of TMA. Cox regression was used to calculate adjusted hazard ratios (AHR) for risk of TMA and risk of death after TMA. RESULTS: The incidence of TMA in the first year of dialysis was 0.5% overall. Among patients with renal failure due to haemolytic uraemic syndrome (HUS), the incidence of TMA was highest in the first year of dialysis (HUS, 11.3% first year, 4.5% per year thereafter), while among patients without HUS the incidence of TMA was much lower and more constant over time (0.3% per year). In Cox regression analysis, independent risk factors for TMA were renal failure due to HUS (adjusted hazard ratio (AHR) 179, 95% CI 95-338), paediatric age (Asunto(s)
Fallo Renal Crónico/epidemiología
, Fallo Renal Crónico/terapia
, Púrpura Trombocitopénica Trombótica/epidemiología
, Diálisis Renal/efectos adversos
, Distribución por Edad
, Anciano
, Anciano de 80 o más Años
, Comorbilidad
, Femenino
, Estudios de Seguimiento
, Síndrome Hemolítico-Urémico/diagnóstico
, Síndrome Hemolítico-Urémico/epidemiología
, Síndrome Hemolítico-Urémico/terapia
, Humanos
, Fallo Renal Crónico/diagnóstico
, Pruebas de Función Renal
, Masculino
, Persona de Mediana Edad
, Prevalencia
, Probabilidad
, Modelos de Riesgos Proporcionales
, Púrpura Trombocitopénica Trombótica/etiología
, Sistema de Registros
, Diálisis Renal/métodos
, Estudios Retrospectivos
, Medición de Riesgo
, Índice de Severidad de la Enfermedad
, Distribución por Sexo
, Factores de Tiempo
, Resultado del Tratamiento
, Estados Unidos/epidemiología
RESUMEN
In the United States, therapeutic plasma exchange (TPE) is both performed and requested by a wide range of services, often on an empiric basis (before a diagnosis is established). Whether empiric therapy is beneficial has not been established. Patients were identified from an electronic procedure log that included those patients who received plasmapheresis at Walter Reed Army Medical Center from 1996 to 2003. The clinical indications, referring service, and outcomes (including deaths) that occurred were tabulated. Between March 1997 and August 2003, 568 TPE treatments were performed in 54 patients. The majority of the diagnoses were either neurologic (48%) or hematologic (37%). Thirty-three patients (61%) received TPE for a Category I indication. Twelve cases were performed empirically (without an established diagnosis) at the request of the referring service, most (7) performed for presumed thrombotic thrombocytopenic purpura (TTP). Almost 80% of patients required central venous catheters for treatment. Twelve patients (22%) experienced a major complication including death, and six patients (11%) died. Of the patients who died, 5 (83%) were treated empirically versus one death (17%) among patients not treated empirically, P < 0.001 by Chi Square. Only one of the seven patients treated empirically for TTP died, however. In logistic regression analysis, empiric treatment was the only factor independently associated with death, adjusted odds ratio, 34.2, 95% CI, 3.4, 334.8, P = 0.003. The most common indication for TPE was neurological disease, which also accounted for the highest proportion of complications. With the exception of presumed TTP, performing TPE in the absence of a confirmed diagnosis was not beneficial.
Asunto(s)
Enfermedades del Sistema Nervioso/terapia , Intercambio Plasmático , Púrpura Trombocitopénica Trombótica/terapia , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/mortalidad , Púrpura Trombocitopénica Trombótica/mortalidad , Estudios Retrospectivos , Resultado del TratamientoAsunto(s)
Inhibidores de la Calcineurina , Trasplante de Riñón/métodos , Riñón/patología , Inhibidores de la Enzima Convertidora de Angiotensina/farmacología , Presión Sanguínea , Ciclosporina/uso terapéutico , Rechazo de Injerto , Supervivencia de Injerto , Humanos , Inmunosupresores/uso terapéutico , Pruebas de Función Renal , Sirolimus/uso terapéutico , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Avascular necrosis (AVN) after renal transplantation has been largely attributed to the use of corticosteroids. However, other risk factors such as microvascular thrombosis and hyperlipidemia have been well described and may be of increased importance in the era of early steroid cessation and avoidance. We hypothesized that maintenance immunosuppressive medications known to be associated with these risk factors for AVN would also be associated with a higher risk of AVN. METHODS: By using the U.S. Renal Data System database, we studied 27,772 primary patients on Medicare who received a solitary kidney transplant between January 1, 1996, and July 31, 2000. Cox proportional hazards regression models were used to calculate adjusted hazard ratios (AHRs) for patient- and transplant-related factors (including allograft rejection) with Medicare claims for AVN. The intensity and duration of corticosteroid use could not be assessed. RESULTS: Among patients who were prescribed sirolimus at discharge, 3.5% of patients who received the combination of sirolimus-cyclosporine A (CsA) demonstrated AVN, compared with 1.4% of patients who received the combination of sirolimus-tacrolimus (P=0.06 by chi). In Cox regression, CsA use (vs. tacrolimus) (AHR 1.36, 95% confidence interval, 1.09-1.71) was independently associated with an increased risk of AVN. Sirolimus use showed a trend toward significance (AHR 1.59, 95% confidence interval, 0.99-2.56), with no significant interaction with CsA. CONCLUSIONS: Compared with other maintenance immunosuppression, AVN was significantly more common after use of CsA prescribed at the time of discharge for renal transplantation. Whether this increased risk of AVN was directly attributable to hyperlipidemia, microvascular thrombosis, or differences in corticosteroid dosing could not be determined.
Asunto(s)
Terapia de Inmunosupresión/métodos , Inmunosupresores/uso terapéutico , Trasplante de Riñón/inmunología , Trasplante de Riñón/patología , Adulto , Ciclosporina/uso terapéutico , Diabetes Mellitus/epidemiología , Femenino , Humanos , Trasplante de Riñón/efectos adversos , Trasplante de Riñón/mortalidad , Lupus Eritematoso Sistémico/epidemiología , Masculino , Medicare , Persona de Mediana Edad , Necrosis , Complicaciones Posoperatorias/clasificación , Complicaciones Posoperatorias/epidemiología , Análisis de Regresión , Sirolimus/uso terapéutico , Análisis de Supervivencia , Estados UnidosRESUMEN
BACKGROUND/AIMS: Previous studies have reported a link between the use of induction sirolimus (INDSRL) and delayed graft function (DGF) after kidney transplantation. However, none have had sufficient power to adjust for all factors known to be associated with DGF. METHODS: We conducted a retrospective cohort study of US deceased donor kidney transplantation recipients in the United States Renal Data System (USRDS) from January 1, 2000 to May 31, 2001. Logistic regression analysis was used to model adjusted odds ratios (AOR) for the development of DGF, adjusted for other factors previously reported to be associated with DGF. RESULTS: Among 8,319 patients meeting inclusion criteria, 361 patients received INDSRL, of whom 98 (27.1%) had DGF, compared to 22.5% among patients who did not receive INDSRL. In multivariate analysis, INDSRL was associated with an increased risk of DGF, with an adjusted odds ratio of 1.42 (95% CI: 1.07-1.90). Other factors associated with DGF were similar to those previously reported. INDSRL was not significantly associated with graft loss at 1 year in Cox regression. CONCLUSIONS: INDSRL was independently associated with DGF in US deceased donor kidney transplantation recipients, adjusted for all other factors previously shown to be associated with DGF.
Asunto(s)
Rechazo de Injerto/tratamiento farmacológico , Supervivencia de Injerto/efectos de los fármacos , Inmunosupresores/administración & dosificación , Trasplante de Riñón , Sirolimus/administración & dosificación , Adulto , Estudios de Cohortes , Bases de Datos Factuales , Femenino , Rechazo de Injerto/mortalidad , Humanos , Inmunosupresores/efectos adversos , Riñón/fisiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Sirolimus/efectos adversos , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Although urinary tract infection (UTI) occurring late after renal transplantation has been considered "benign," this has not been confirmed in a national population of renal transplant recipients. METHODS: We conducted a retrospective cohort study of 28,942 Medicare primary renal transplant recipients in the United States Renal Data System (USRDS) database from January 1, 1996, through July 31, 2000, assessing Medicare claims for UTI occurring later than 6 months after transplantation based on International Classification of Diseases, 9th Revision (ICD-9), codes and using Cox regression to calculate adjusted hazard ratios (AHRs) for time to death and graft loss (censored for death), respectively. RESULTS: The cumulative incidence of UTI during the first 6 months after renal transplantation was 17% (equivalent for both men and women), and at 3 years was 60% for women and 47% for men (P < 0.001 in Cox regression analysis). Late UTI was significantly associated with an increased risk of subsequent death in Cox regression analysis (P < 0.001; AHR, 2.93; 95% confidence interval [CI], 2.22, 3.85); and AHR for graft loss was 1.85 (95% CI, 1.29, 2.64). The association of UTI with death persisted after adjusting for cardiac and other infectious complications, and regardless of whether UTI was assessed as a composite of outpatient/inpatient claims, primary hospitalized UTI, or solely outpatient UTI. CONCLUSION: Whether due to a direct effect or as a marker for serious underlying illness, UTI occurring late after renal transplantation, as coded by clinicians in the United States, does not portend a benign outcome.