US Renal Data System 2011 Annual Data Report Collins, Allan J., MD; Foley, Robert N., MB; Chavers, Blanche, MD ...
American journal of kidney diseases,
01/2012, Letnik:
59, Številka:
1
Journal Article
The incidence of peripheral artery disease (PAD) is higher in patients with chronic kidney disease (CKD) than in the general population. PAD is a strong independent risk factor for increased ...cardiovascular disease mortality and morbidity, including limb amputation, in persons with CKD. Diagnosis of PAD in patients with CKD may be challenging in the absence of classic intermittent claudication or the presence of atypical leg symptoms. In addition, pedal artery incompressibility may decrease the accuracy of ankle-brachial index measurement, the most common PAD diagnostic tool. Alternative methods such as toe-brachial index should be used if clinical suspicion persists despite a normal ankle-brachial index value. Aggressive risk-factor modification, including treatment of diabetes, hyperlipidemia, and hypertension and smoking cessation, should be mandatory in all patients. Treatment of all individuals with PAD should include antiplatelet medications and prescribed supervised exercise programs and/or cilostazol for individuals with claudication symptoms. Preventive foot care measures and a multidisciplinary approach involving podiatrists and vascular and wound care specialists should be used to reduce amputations. Revascularization for critical limb ischemia is associated with poor outcomes in patients with CKD with PAD. Future investigation is recommended to evaluate the benefit of earlier treatment strategies in this high cardiovascular disease risk population with CKD.
Background Patients with chronic kidney disease (CKD) experience poor outcomes after acute myocardial infarction (AMI). We sought to compare clinical characteristics of advanced CKD, dialysis, and ...non-CKD patients hospitalized with AMI. Methods This observational study used record-linked data from the US Renal Data System and Third National Registry of Myocardial Infarction to identify 2,390 dialysis patients with AMI hospitalizations between April 1998 and June 2000. Advanced CKD patients (n = 29,319) were identified by baseline creatinine level ≥2.5 mg/dL. Clinical characteristics of CKD, dialysis, and non-CKD patients (n = 274,777) were compared using the χ2 test. Results Clinically significant differences among patients with advanced CKD (dialysis and non-CKD, respectively) on admission were chest pain, 40.4% (41.1% and 61.6%); diagnosis other than acute coronary syndrome, 44% (47.7% and 25.8%); and ST elevation, 15.9% (17.6% and 32.5%). In-hospital adverse outcomes were mortality, 23% (21.7% and 12.6%); unexpected cardiac arrest, 8.9% (12.3% and 6%); congestive heart failure, 41% (25.8% and 21.1%); and major bleeding, 4.9% (4.4% and 3%); P < .001 for all comparisons. In a logistic regression model, the adjusted odds ratio for in-hospital mortality for CKD (vs non-CKD) patients was 1.44 (95% CI 1.39-1.49). Conclusions The clinical characteristics of non–dialysis-dependent, advanced CKD patients with AMI are similar to characteristics of dialysis patients and likely contribute to poor outcomes. Intensive efforts for timely, accurate recognition of AMI in advanced CKD patients are warranted.
Background Sudden cardiac death constitutes the leading cause of death in patients receiving dialysis. Little is known about the trends in implantable cardioverter-defibrillator (ICD) use and the ...outcomes of such device placement. Study Design Retrospective cohort study. Setting & Participants US long-term dialysis patients who received an ICD in 1994-2006. Predictors, Outcomes, & Measurements ICD utilization rates and incident rates of all-cause mortality, device infections, and other device-related procedures were measured. We compared mortality between recipients and otherwise similar patients who did not receive such a device using high-dimensional propensity score matching. We also examined the associations of demographics, dialysis type, baseline comorbid conditions, cardiovascular events at the time of admission, and recent infection with the study outcomes. Results 9,528 patients received an ICD in 1994-2006, with >88% placed after 2000. Almost all ICD use in the 1990s was for secondary prevention, however, half the patients received ICDs for apparent primary prevention in 2006. Mortality rates after implantation were high (448 deaths/1,000 patient-years) and most deaths were cardiovascular. Postimplantation infection rates were high, especially in the first year after implantation (988 events/1,000 patient-years) and were predicted by diabetes and recent infection. Patients receiving ICDs for secondary prevention had an overall 14% (95% CI, 9%-19%) lower mortality risk compared with propensity-matched controls, but these benefits seemed to be restricted to the early postimplantation time. Limitations Lack of clinical data, especially for laboratory and heart function studies. Residual confounding by indication. Conclusions ICD use in dialysis patients is increasing, but rates of all-cause and cardiovascular mortality remain high in dialysis patients receiving these devices. Device infections are common, particularly in patients with recent infections. Randomized trials of ICDs are needed to determine the efficacy, safety, and risk-benefit ratio of these devices in dialysis patients.
The purpose of this retrospective analysis was to define the incidence of severe adverse events after exposure to ultrasound contrast agents.
Data between January 1, 2001, and September 30, 2007, ...were collected using invited responses to an on-line web-based questionnaire from 1 general and 12 cardiac ultrasound laboratories. During a period of 4.5 +/- 2.4 years, a total of 66,164 doses of Definity (Lantheus Medical Imaging, North Billerica, MA) and 12,219 doses of Optison (GE Healthcare, Buckinghamshire, UK) were administered, reflecting contrast use in 5% of transthoracic and 28% of stress echocardiographic procedures. More than 10,000 doses were given to critically ill patients in intensive care unit settings or to patients with acute chest pain of suspected cardiac origin. The median age of patients who received an ultrasound contrast agent was 60 years, 49% were male, and the mean body mass index was 32 +/- 1.4 g/m(-2).
Severe reactions that were considered "probably" related to an ultrasound contrast agent developed in 8 patients (0.01%), all of whom were outpatients, and 4 (0.006%) of these were consistent with anaphylactoid reactions. There were no deaths reported. All patients recovered with treatment. No serious events were seen in inpatients.
This multicenter, retrospective analysis includes the largest number of doses of ultrasound contrast agents ever published and a large number of patients evaluated in a wide variety of settings, including the critically ill. It shows that these agents have a good safety profile in both cardiac and abdominal ultrasound applications. The incidence of severe adverse reactions to ultrasound contrast agents is no greater, and may be lower, than that reported for contrast agents commonly used in other cardiac imaging tests.
Background Severe secondary hyperparathyroidism, which is associated with life-threatening complications, can develop in dialysis-dependent end-stage renal disease patients. The aim of this study was ...to compare short- and long-term mortality in dialysis patients who underwent near-total parathyroidectomy (NTPTX) and matched nonoperated controls. Study Design We identified 150 dialysis patients who underwent NTPTX (1993−2009) at our institution and compared them with 1,044 nonoperated control patients identified in the US Renal Data System registry, matched for age, sex, race, diabetes as cause of kidney failure, years on dialysis, and dialysis modality. Survival outcomes were estimated using multivariable Cox proportional hazards models with stratification on the matching sets, adjusted for cardiovascular comorbidities, smoking, inability to ambulate/transfer, and payor status. Results During a follow-up of a mean of 3.6 years (range 0.1 month to 16.4 years), NTPTX patients had a significant reduction in the long-term risk of all-cause death (hazard ratio = 0.68; 95% CI, 0.52−0.89; p = 0.006) compared with controls. Thirty-day mortality rates for NTPTX patients and controls were 246 vs 105 per 1,000 person-years (p = 0.21). In adjusted analyses, NTPTX patients had a 37% reduced risk of all-cause death and a 33% reduced risk of cardiovascular death compared with controls. A durable reduction in mean parathyroid hormone was observed after NTPTX; from 1,776 ± 1,416.6 pg/mL to 301 ± 285.7 pg/mL (p < 0.0001). Conclusions In our center, NTPTX in dialysis patients was associated with a significant reduction in long-term risk of death compared with matched control patients, without a significantly increased short-term risk.
Abstract Background Administrative data are widely used in observational assessment of patient-centered clinical outcomes. In studies of cardiovascular outcomes, claims data are limited by lack of ...quantitative information, such as left ventricular ejection fraction. We aimed to determine whether left ventricular ejection fraction can be assessed from heart failure claims. Methods This observational, retrospective study used administrative and echocardiographic databases to identify heart failure patients (International Classification of Diseases, Ninth Revision, Clinical Modification ICD-9-CM code 428.XX) who received echocardiograms. The study cohort included patients with at least one inpatient or outpatient claim for systolic (428.2X) or diastolic (428.3X) heart failure from January 1, 2007, through July 10, 2013, who received an echocardiogram within 30 days of the claim. Receiver operating characteristic (ROC) curves were used to determine the optimal left ventricular ejection fraction cut-off threshold between ICD-9-CM heart failure codes 428.2 (systolic) and 428.3 (diastolic). Bootstrapping was used to determine a 95% confidence interval for the best cut-off. Results A total of 2714 echocardiograms with ascertainable left ventricular ejection fraction were performed within 30 days of a heart failure diagnosis. ICD-9-CM codes 428.2 and 428.3 accounted for 28.9% and 18.2%, respectively, of all heart failure codes. The resulting ROC curve had a best threshold cut-off for ejection fractions of 43.5% (confidence interval 39.5%-44.5%). The area under the curve was 0.812, with positive predictive value 0.72 and negative predictive value 0.81. Conclusions Subject to study limitations, we conclude that assessing left ventricular ejection fraction using heart failure claims is possible.
Background Patients on dialysis sustain at least a threefold higher in-hospital mortality rate and markedly higher long-term mortality following coronary artery bypass graft surgery than the general ...population. Smaller studies have suggested that dialysis patients have superior outcomes with off-pump compared with on-pump coronary artery bypass surgery. Methods From the United States Renal Data System database, 13,085 patients on dialysis having first coronary artery bypass surgery between 2001 and 2006 were identified. Of these, 2335 (17.8%) had off-pump coronary artery bypass surgery. The Kaplan-Meier method was used to estimate survival of patients having off-pump coronary artery bypass and patients having on-pump coronary artery bypass. A Cox proportional hazards model was used to assess effects of off-pump coronary artery bypass on mortality with adjustment for baseline patient characteristics. Results Off-pump coronary artery bypass surgery was associated with significantly reduced all-cause mortality compared with on-pump coronary artery bypass surgery (hazard ratio 0.92, 95% confidence interval 0.86–0.99, P = .02). The observed survival benefit was most notable in the first year after surgery (70.3% vs 68.7%) and was lost 2 years after surgery (55.4% vs 55.2%). No difference was noted in the in-hospital mortality rate with off-pump coronary artery bypass surgery versus on-pump coronary artery bypass surgery (9.7% vs 11.0%, P = .06). Cardiac mortality during the follow-up period was similar (23.6% vs 23.8%; adjusted hazard ratio 0.95, 95% confidence interval 0.86–1.04, P = .26). Use of internal thoracic grafts was independently associated with improved survival after coronary artery bypass surgery (hazard ratio, 0.92; 95% confidence interval, 0.87–0.98, P = .0057). Conclusions Patients on dialysis sustain high in-hospital and 2-year mortality rates after coronary artery bypass surgery. Off-pump coronary artery bypass is associated with modestly increased survival compared with on-pump coronary artery bypass, a benefit most marked early after off-pump coronary artery bypass.
The US Renal Data System “Pie Chart of Death” Herzog, Charles A., MD; Gilbertson, David T., PhD; Collins, Allan J., MD
American journal of kidney diseases,
12/2016, Letnik:
68, Številka:
6
Journal Article
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