Background Kidney biopsy provides important information for nephrologists, but the risk of complications has not been systematically described. Study Design Meta-analysis of randomized controlled ...trials and prospective or retrospective observational studies. Setting & Population Adults undergoing native kidney biopsy in an inpatient or outpatient setting. Selection Criteria for Studies MEDLINE indexed studies from January 1980 through June 2011; sample size of 50 or more. Intervention Native kidney biopsy with automated biopsy device and real-time ultrasonographic guidance. Outcomes Macroscopic hematuria and erythrocyte transfusion rates and factors associated with these outcomes. Results 34 studies of 9,474 biopsies met inclusion criteria. The rate of macroscopic hematuria was 3.5% (95% CI, 2.2%-5.1%), and erythrocyte transfusion was 0.9% (95% CI, 0.4%-1.5%). Significantly higher rates of transfusion were seen with the following: 14-gauge compared with smaller needles (2.1% vs 0.5%; P = 0.009), studies with mean serum creatinine level ≥2.0 mg/dL (2.1% vs 0.4%; P = 0.02), ≥50% women (1.9% vs 0.6%; P = 0.03), and ≥10% of biopsies for acute kidney injury (1.1% vs 0.04%; P < 0.001). Higher transfusion rates also were observed in studies with a mean age of 40 years or older (1.0% vs 0.2%; P = 0.2) and mean systolic blood pressure ≥130 mm Hg (1.4% vs 0.1%; P = 0.09). Similar relationships were noted for the macroscopic hematuria rate with the same predictors, but none was statistically significant. Limitations Publication bias, few randomized controlled trials, and missing data. Conclusions Native kidney biopsy using automated biopsy devices and real-time ultrasonography is associated with a relatively small risk of macroscopic hematuria and erythrocyte transfusion requirement. Using smaller gauge needles may lower complication rates. Patient selection may affect outcome because studies with higher serum creatinine levels, more women, and higher rates of acute kidney injury had higher complication rates. Future studies should further evaluate risk factors for complications.
Background Heart failure (HF) is one of the leading causes of morbidity and mortality among Americans. Despite increased interest in end-of-life care, the implications of do-not-resuscitate (DNR) ...orders in acutely ill patients with HF remain unclear. The goals of this observational study were to describe the use of DNR orders and their impact on treatment approaches in residents of a large New England metropolitan area hospitalized with acute heart failure. Methods Use of HF performance measures, including assessment of left ventricular function, use of angiotensin receptor blocking agents, anticoagulation, smoking cessation counseling, and use of nonpharmacologic strategies, was examined through review of the medical records of 4,537 metropolitan Worcester (MA) residents admitted to 11 central Massachusetts hospitals with acute HF in 1995 and 2000 according to the presence of DNR orders. Results Patients with DNR orders were less likely to have had their left ventricular function assessed (31% vs 43%) as well as receive renin-angiotensin system blockade (49% vs 57%), anticoagulation (65% vs 78%), or nonpharmacologic interventions (87% vs 92%) as compared to patients without DNR orders. Patients with DNR orders were significantly less likely to have received any quality assurance measure for acute HF (adjusted hazard ratio 0.63, 95% confidence interval 0.40-0.99) than patients without DNR orders. Conclusions The use of quality assurance measures in acute HF is markedly lower in patients with DNR orders. The implications of DNR orders need to be further clarified in the treatment of patients with acute HF.
Background Chronic pain is a common condition in the general population. However, large epidemiologic studies examining the role of pain in the deterioration of kidney function, development of ...chronic kidney disease, and risk for death are lacking. Study Design Retrospective cohort study. Setting & Participants A nationally representative cohort of 2,360,056 US veterans with baseline estimated glomerular filtration rates (eGFRs) ≥ 60 mL/min/1.73 m2 , followed up from October 2004 to September 2006. Predictor 4 pain categories were compared: none (score, 0), mild (1-4), moderate (5-6), or severe (≥7). Outcomes eGFR decline (determined by eGFR slope) and combined incident eGFR < 60 mL/min/1.73 m2 or all-cause death. Measurements We examined the pain management pattern and association of reported pain with (1) rapid eGFR decline and (2) a composite outcome of incident eGFR < 60 mL/min/1.73 m2 or all-cause death using logistic regression and Cox models adjusted for baseline eGFR, demographics, comorbid conditions, cardiovascular risk factors, and depression. Results ∼60% of veterans reported pain of any severity during the baseline period. The most commonly prescribed analgesics were opioids. In a dose-response relationship, veterans reporting moderate or severe pain had a higher risk for faster eGFR decline compared with those reporting none (ORs of 1.11 95% CI, 1.09-1.14 and 1.17 95% CI, 1.13-1.21 for moderate and severe pain, respectively). In combined analyses, veterans reporting moderate or severe pain both had 30% higher risk of the combined outcome (incident eGFR, 60 mL/min/1.73 m2 or death) compared with those reporting none (HRs of 1.30 95% CI, 1.28-1.31 and 1.30 95% CI, 1.28-1.32 for moderate and severe pain, respectively). Limitations Lack of granular data regarding type and location of pain. Conclusions We observed a high prevalence of pain and analgesic prescription in the US veteran population with normal eGFRs. Pain was associated with a higher incidence of eGFRs < 60 mL/min/1.73 m2 , faster kidney function decline, and higher mortality.
Lean body mass (LBM) represents the "fat-free" muscle mass in hemodialysis (HD) patients and is an important nutritional measure. Previous studies have found that both higher LBM and body mass index ...(BMI) were related to greater survival in HD patients. Additional studies have shown differences in survival across racial-ethnic groups of HD patients. However, the association of LBM and mortality across racial-ethnic subgroups has not been examined.
We hypothesize that racial differences in LBM affect the mortality in HD patients.
Chronic HD patients from a large dialysis organization in the United States.
Estimated LBM (eLBM), self-identified racial subgroups.
5-year survival.
We examined the association between baseline eLBM and survival using Cox proportional hazard models adjusted for demographics, comorbidities, and laboratory measures. Associations were examined across subgroups of race-ethnicity (non-Hispanic white, African American, and Hispanic) and BMI.
The final cohort included 117,683 HD patients, who were 62 ± 15 (mean ± standard deviation) years old, 43% women and 59% with diabetes mellitus. Higher eLBM was linearly associated with lower mortality. Compared with the reference group (48.4-<50.5 kg), patients with the lowest eLBM (<41.3 kg) had a 1.4-fold higher risk of mortality (hazard ratio: 1.37; 95% confidence interval: 1.30-1.44) in the fully adjusted model. A similar linear association was seen among patients with BMI < 35 kg/m(2) and in non-Hispanic whites and African American subgroups. However, higher eLBM was not associated with improved survival in Hispanic patients or patients with BMI ≥ 35 kg/m(2).
Potential residual confounding.
Higher eLBM is associated with a lower mortality risk in HD patients, especially among non-Hispanic white and African American groups. Hispanic patients do not demonstrate a similar inverse relationship. The association between LBM and mortality among different racial groups of HD patients deserves additional study.
Markers of better nutritional status including both higher levels of serum albumin (as a measure of visceral proteins) and creatinine (as a measure of the muscle mass) are associated with lower ...mortality in conventional (thrice weekly) hemodialysis patients. However, data for these associations in twice-weekly hemodialysis patients, in whom less frequent hemodialysis may confound nutritional predictors, are lacking.
We identified 1,113 twice-weekly and matched 4,448 thrice-weekly hemodialysis patients from a large national dialysis cohort of incident hemodialysis patients over 5 years (2007-2011). Mortality risk, adjusted for potential confounders, was examined across two-by-two combinations of serum creatinine (<6 vs. ≥6 mg/dL) and albumin (<3.5 g/dL vs. ≥3.5 g/dL) for each treatment frequency yielding a total of 8 groups.
Patients were aged 70 ± 14 years and included 48% women and 55% diabetics. Using the thrice-weekly hemodialysis patients with creatinine ≥ 6 mg/dL and albumin ≥ 3.5 g/dL as reference, patients with creatinine <6 mg/dL and albumin <3.5 g/dL had a 1.8-fold higher risk of mortality (hazard ratio: 1.75, 95% confidence interval: 1.33-2.30) in twice-weekly and 2.2-fold increased risk of mortality (hazard ratio: 2.21, 95% confidence interval: 1.81-2.70) in thrice-weekly hemodialysis patients, respectively in fully adjusted models adjusted for demographics, comorbidities, and markers of malnutrition and inflammation. A test for interaction showed that there was no significant difference in albumin creatinine mortality associations between twice-weekly and thrice-weekly hemodialysis patients (P-for-interaction = .7667).
Surrogate markers of higher visceral protein and muscle mass combined may confer greatest survival in both twice-weekly and thrice-weekly hemodialysis patients.
A 90-Year-Old Man With Hyperphosphatemia Lovekar, Shachi, MD; Chen, Joline L.T., MD, MS
American journal of kidney diseases,
02/2011, Volume:
57, Issue:
2
Journal Article
Peer reviewed
Hyperphosphatemia is a common condition in patients with decreased kidney function, and without treatment, it can lead to a variety of clinical consequences. However, the presence of ...hyperphosphatemia in patients with normal kidney function may be true or spurious. We present a case of pseudohyperphosphatemia in a patient with monoclonal gammopathy. An increased paraprotein level can lead to colorimetric interference of the assay of phosphate measurement and result in spurious hyperphosphatemia. The epidemiologic and clinical characteristics of paraprotein-associated pseudohyperphosphatemia also are reviewed here. Ultrafiltration of paraproteins or deproteinization can help correct the measuring error. Patients with spurious hyperphosphatemia should not be treated with phosphate binders. Clinicians treating patients with monoclonal gammopathy should be aware of this relatively common clinical phenomenon and avoid inappropriate treatment of spurious hyperphosphatemia.
Background Patients with kidney disease are at increased risk for adverse health outcomes in comparison to patients without kidney disease. Therefore, patients with kidney disease may have greater ...use of do-not-resuscitate (DNR) orders than patients without kidney disease in the setting of an acute illness. We examined the association between advanced kidney disease and use of DNR orders in patients admitted with an acute myocardial infarction (AMI) to all greater Worcester, MA, hospitals as part of an epidemiological study. Methods Use of DNR orders in 4,033 Worcester residents hospitalized with AMI at 11 greater Worcester medical centers during 1997, 1999, 2001, and 2003 was examined. Advanced kidney disease was defined on the basis of serum creatinine level at the time of hospital admission. Results Forty-nine percent of patients with kidney disease and AMI had a DNR order in their medical records compared with 21% of patients without kidney disease. After controlling for a variety of potentially confounding factors, patients with kidney disease were more likely to have a DNR order than patients without kidney disease (adjusted odds ratio, 1.55; 95% confidence interval, 1.21 to 1.98). Patients with advanced kidney disease who received DNR orders were older, had more comorbid conditions, and were at greater risk for dying than patients with kidney disease without a DNR order. Conclusion Advanced kidney disease is associated with greater rates of DNR orders in patients hospitalized with AMI. Awareness of kidney disease may be an important consideration for patients and health care providers in discussing the use of DNR measures.
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