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BACKGROUND/AIMS: All hemodialysis (HD) patients are generally recommended to create a fistula first; but to create a mature arteriovenous fistula (AVF) can be challenging in elderly individuals. It is unclear if elderly incident HD patients derive a survival benefit from an AVF over an arteriovenous graft (AVG) or a tunneled central venous catheter (TDC). METHODS: We examined the association of vascular access type (AVF, AVG, and TDC with and without a maturing AVF/AVG at dialysis transition) at HD initiation with all-cause, cardiovascular (CV), and infection-related mortality in 46,786 US veterans using Cox models with adjustment for confounders. Effect modification by age was examined by examining associations in pre-specified age subgroups (<60, 60-<70, 70-<80, and ≥80 years old), and by including interaction terms. RESULTS: Patients numbering 8,940 (19%) started HD with an AVF, 1,090 (3%) with an AVG, 8,262 (18%) with a TDC and a maturing AVF/AVG and 28,494 (61%) with a TDC without a maturing AVF/AVG. A total of 13,303 all-cause, 4,392 CV, and 1,058 infection-related deaths were observed in the first year after HD transition. Compared to patients with AVF, those with AVG and TDC with and without maturing AVF/AVG had incrementally higher overall risk of all-cause mortality and CV mortality. Only TDC use was associated with higher infection-associated mortality. These associations were not modified by age. CONCLUSION: Although most of our patients consisted of male veterans and the results may not be generalized to the general population, the use of TDCs is associated with poor outcomes even in the most elderly incident HD patients.
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Derivación Arteriovenosa Quirúrgica , Fallo Renal Crónico/mortalidad , Fallo Renal Crónico/terapia , Diálisis Renal/métodos , Dispositivos de Acceso Vascular , Factores de Edad , Anciano , Anciano de 80 o más Años , Catéteres de Permanencia , Catéteres Venosos Centrales , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estados Unidos/epidemiología , VeteranosRESUMEN
BACKGROUND: Mortality in the immediate post-hemodialysis transition period is extremely high. Many end-stage renal disease (ESRD) patients in the US start dialysis in an inpatient setting, but the characteristics of patients starting dialysis as inpatients, and the association of inpatient hemodialysis transition with mortality remain unclear. METHODS: We examined 48,261 US veterans who transitioned to hemodialysis between October 2007 and September 2011. Associations of inpatient hemodialysis starting with all-cause mortality were examined in Cox proportional hazard models, with adjustments for demographics, comorbidities, vascular access type, pre-dialysis nephrology care and medication use, and last pre-ESRD estimated glomerular filtration rate and hemoglobin. RESULTS: A total of 22,338 (46.3%) patients received the first hemodialysis treatment in an inpatient setting. Inpatient hemodialysis transition was associated with older age, presence of a tunneled catheter, higher comorbidity burden, and lack of pre-dialysis nephrology care. A total of 8,674 patients died (mortality rate 405/1,000 patient-years, 95% CI 397-413) during the first 6 months after transition to hemodialysis. The starting of inpatient vs. outpatient hemodialysis was associated with significantly higher crude all-cause mortality, but this association was attenuated after multivariable adjustments. CONCLUSIONS: Transition to hemodialysis in an inpatient setting is more common in older and sicker individuals, and in patients without pre-dialysis nephrology care and those who used a catheter for vascular access. Future studies are needed to determine if a higher proportion of patients could start hemodialysis treatment in outpatient clinics, through interventions targeting modifiable risk factors such as timely vascular access placement or earlier nephrology referrals.
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Fallo Renal Crónico/mortalidad , Fallo Renal Crónico/terapia , Diálisis Renal/mortalidad , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , Pacientes Internos , Masculino , Persona de Mediana Edad , Nefrología , Pacientes Ambulatorios , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Estados Unidos/epidemiología , Dispositivos de Acceso Vascular , VeteranosRESUMEN
CONTEXT: The optimal circulating concentration of 25(OH) vitamin D is controversial. OBJECTIVE: The aim was to investigate if FGF-23 and 24,25(OH)2D can guide cholecalciferol replacement. DESIGN: Oral cholecalciferol (10,000 IU weekly) administered to subjects with 25(OH)D levels < 20 ηg/mL and eGFR > 60 mL/min/1.73 m(2) (n = 25), chronic kidney disease (CKD) (n = 27), or end stage renal disease (ESRD) (n = 14). SETTING: The study was conducted at the Veterans Affairs clinics. MAIN OUTCOME MEASURE: Serum FGF-23, PTH, 25(OH)D, 1,25(OH)2D, 24,25(OH)2D, calcium, and phosphorous concentrations, and urinary excretion of calcium and phosphorus at baseline and after 8 weeks of treatment. RESULTS: Cholecalciferol treatment increased concentrations of serum 25(OH)D by (19.3 ± 8 ηg/mL, P = .001; 12.2 ± 9 ηg/mL, P = .0001) and 24,25(OH)2D (1.14 ± 0.89 ηg/mL, P = .0024; 1.0 ± 0.72 ηg/mL P = .0002), and reduced serum PTH (-11 ± 21 pg/mL, P = .0292; -42 ± 68 pg/mL, P = .0494) in normal and CKD subjects, respectively. Cholecalciferol increased serum FGF-23 levels only in normal subjects (44 ± 57 ηg/mL, P = .01). Increments in serum 25(OH)D positively correlated with serum FGF-23 and 24,25(OH)2D and negatively correlated with PTH. In ESRD, cholecalciferol administration increased 25(OH)D by (16.6 ± 6.6 ηg/mL P ≤ .05) without changing 24,25(OH)2D, FGF-23 or PTH levels. CONCLUSION: Modest elevations of serum 25(OH)D levels after cholecalciferol treatment are sufficient to induce compensatory degradative pathways in patients with sufficient renal reserves, suggesting that optimal circulating 25(OH)D levels are approximately 20 ηg/mL. In addition, catabolism of 25(OH)D may also contribute to the low circulating vitamin D levels in CKD, since elevations of FGF-23 in CKD are associated with increased 24,25(OH)2D after cholecalciferol administration.
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24,25-Dihidroxivitamina D 3/sangre , Colecalciferol/administración & dosificación , Monitoreo de Drogas/métodos , Factores de Crecimiento de Fibroblastos/sangre , Deficiencia de Vitamina D/tratamiento farmacológico , Vitamina D/análogos & derivados , 24,25-Dihidroxivitamina D 3/orina , Anciano , Colecalciferol/metabolismo , Factor-23 de Crecimiento de Fibroblastos , Humanos , Riñón/metabolismo , Masculino , Persona de Mediana Edad , Análisis Multivariante , Hormona Paratiroidea/sangre , Estudios Prospectivos , Insuficiencia Renal Crónica/metabolismo , Vitamina D/sangre , Vitamina D/orina , Deficiencia de Vitamina D/sangre , Vitaminas/administración & dosificación , Vitaminas/metabolismoRESUMEN
BACKGROUND: Urinary albumin to creatinine ratio (ACR) in a single urine sample has been proposed to provide an estimate of microalbuminuria by adjusting for variability in urine concentrations. We hypothesized that adjusting the urine albumin concentration of single-void specimens for actual urine osmolality (urinary albumin to osmolality ratio [AOR]) may provide a more accurate estimate of 24-hour urine albumin excretion rates (AERs). METHODS: Patients with diabetes mellitus (DM; n = 136) had urinary concentrations of albumin, glucose, and creatinine and osmolality measured on single-void samples, and albumin levels, on 24-hour samples. Microalbuminuria is defined as an AER between 30 and 300 mg/d. RESULTS: Correlation between AOR on single-void samples and AER on 24-hour samples (r = 0.87; P < 0.001) was similar to that between ACR and AER (r = 0.88; P < 0.001). Using a cutoff value of 18.4 mg/kg/mOsm x 10(2) (18.4 mg/mmol x 10(2)) for AOR resulted in a sensitivity and specificity of 82% and 86% in detecting microalbuminuria, respectively. The area under the curve (AUC) for AOR was 0.89. Using a cutoff value of 15.0 mg/g (1.7 mg/mmol) for ACR resulted in a sensitivity and specificity of 85% and 85% in detecting microalbuminuria, respectively. The AUC for ACR was 0.90. The ability of AOR to predict AER was maintained at varying degrees of glycosuria (glucose < 100 mg/dL [<5.5 mmol/L]; r = 0.77; 100 to 750 mg/dL [5.5 to 42 mmol/L]; r = 0.85; and >750 mg/dL [>42 mmol/L]; r = 0.92). CONCLUSION: Urinary AOR correlates closely with 24-hour microalbuminuria determination, and the correlation is not appreciably affected by glycosuria. Thus, AOR can be used as an alternative test to ACR in the assessment of microalbuminuria in the population with DM.
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Albúminas/química , Albuminuria/orina , Diabetes Mellitus Tipo 1/orina , Diabetes Mellitus Tipo 2/orina , Nefropatías Diabéticas/orina , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Área Bajo la Curva , Biomarcadores/orina , Creatinina/orina , Femenino , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Concentración OsmolarRESUMEN
BACKGROUND: The albumin-to-creatinine ratio and the 24-hour urine collection to measure microalbuminuria are inconvenient and expensive. The newer rapid and less expensive dipstick methods for screening of microalbuminuria estimate only albumin and are subject to errors caused by variation in volume. We determined the relation between urine-specific gravity (Usg) and urine creatinine (Ucr) so that Ucr can be derived from Usg to correct for albumin concentration in the urine which is influenced by urine volume. METHODS: We randomly included 42 consecutive patients from the primary care clinic, and 34 patients from the diabetic clinic. RESULTS: We found that a very good correlation existed between Usg and Ucr in the 42 patients from the primary care clinic (Ucr = 11.4 x Usg -11,509, r = 0.83, p < 0.001). Patients from the diabetic clinic who had well-controlled blood sugar (n = 21) showed a similar trend (Ucr = 10.82 x Usg -10,882, r = 0.87, p < 0.001). However, this was not the case with uncontrolled diabetics (Ucr = 2.53 x Usg -2,513, r = 0.26, NS). Using simple arithmetic, we derived a simplified formula where Ucr can be predicted from Usg. Using multiple regression to incorporate the urinary glucose level by dipstick, a more generic formula was obtained for estimating urinary creatinine. CONCLUSION: Usg can be used instead of Ucr to normalize for the varied urine concentration while screening for microalbuminuria. Poorly controlled diabetics should be screened after their blood sugars are well controlled or use the more generic formula that incorporates urinary glucose. Thus, by measuring spot urine albumin and specific gravity by dipsticks one gets an easy, immediate and accurate estimation of microalbuminuria in an office setting.
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Albuminuria/diagnóstico , Creatinina/orina , Tamizaje Masivo/métodos , Urinálisis/métodos , Diabetes Mellitus/orina , Errores Diagnósticos , Glucosuria/diagnóstico , Humanos , Modelos Lineales , Tamizaje Masivo/normas , Tiras Reactivas , Gravedad Específica , Urinálisis/normasRESUMEN
INTRODUCTION: Acetaminophen toxicity, which can lead to hepatotoxicity, is a burden on our health care system and contributes significantly to intensive care unit admissions and cost of hospitalization. The aim of our study was to determine the epidemiology of various types of acetaminophen poisoning and analyze their outcome compared with their admission characteristics. METHODS: We identified 93 consecutive patients, hospitalized for acetaminophen toxicity over a 52-month period from 1996 to 1999 in our urban county hospital. Retrospective case-control analysis was carried out using the data obtained from the medical records. RESULTS: Acetaminophen accounted for 7.5% of all cases of poisoning admitted during this period. Of the 93 patients, 80 were classified as suicidal and 13 had accidentally poisoned themselves in an attempt to relieve pain. The ratio of females to males was found to be 2:1. Of the 93 patients studied, 88 were admitted to the intensive care unit for initial 24-48 hours of monitoring. Peak acetaminophen levels were higher in the suicidal overdose group (mean 121.7 +/- 97.0 mg/l vs. 64.5 +/- 61.8 mg/l, P < 0.05) than in the accidental group. In spite of this, peak aminotransferase levels >1000 IU/l were more often seen in the latter (39% vs. 12%, P < 0.05). Hepatic coma and death were seen more often in the accidental overdose group (15% vs 0%, P < 0.05). Interestingly chronic alcohol abuse was also more frequent in the accidental overdose category (39% vs 18%, P = 0.05). DISCUSSION: Although the peak acetaminophen level in the suicidal group was significantly higher, cases of therapeutic misadventure had higher rates of morbidity and mortality. Peak acetaminophen levels correlate poorly with hepatic dysfunction, morbidity and mortality. CONCLUSION: We recommend that the patients with suicidal acetaminophen overdose, without any concomitant poisoning, can safely managed on the medical floors.