David T. Gilbertson

Diabetes Mellitus After Kidney Transplantation in the United States

New onset diabetes is a major complication after kidney transplantation. However, the incidence, risk factors and clinical relevance of post‐transplant diabetes mellitus (PTDM) vary among reports from single‐center observational studies and clinical trials. Using data from the United Renal Data System we identified 11 659 Medicare beneficiaries who received their first kidney transplant in 1996–2000. The cumulative incidence of PTDM was 9.1% (95% confidence interval = 8.6–9.7%), 16.0% (15.3–16.7%), and 24.0% (23.1–24.9%) at 3, 12, and 36 months post‐transplant, respectively. Using Coxs proportional hazards analysis, risk factors for PTDM included age, African American race (relative risk = 1.68, range: 1.52–1.85, p < 0.0001), Hispanic ethnicity (1.35, range: 1.19–1.54, p < 0.0001), male donor (1.12, range: 1.03–1.21, p = 0.0090), increasing HLA mismatches, hepatitis C infection (1.33, range: 1.15–1.55, p < 0.0001), body mass index ≥30 kg/m2 (1.73, range: 1.57–1.90, p < 0.0001), and the use of tacrolimus as the initial maintenance immunosuppressive medication (1.53, range: 1.29–1.81, p < 0.0001). Factors that reduced the risk for PTDM included the use of mycophenolate mofetil, azathioprine, younger recipient age, glomerulonephritis as a cause of kidney failure, and a college education. As a time‐dependent covariate in Cox analyses that also included multiple other risk factors, PTDM was associated with increased graft failure (1.63, 1.46–1.84, p < 0.0001), death‐censored graft failure (1.46, 1.25–1.70, p < 0.0001), and mortality (1.87, 1.60–2.18, p < 0.0001). We conclude that high incidences of PTDM are associated with the type of initial maintenance immunosuppression, race, ethnicity, obesity and hepatitis C infection. It is a strong, independent predictor of graft failure and mortality. Efforts should be made to minimize the risk of this important complication.

Cancer after Kidney Transplantation in the United States

Previous reports of cancer after kidney transplantation have been limited by small numbers of patients in single‐center studies and incomplete ascertainment of cases in large registries.

Projecting the Number of Patients with End-Stage Renal Disease in the United States to the Year 2015

The size of the prevalent ESRD population in the United States increased dramatically during the 1990s, from 196,000 in 1991 to 382,000 in 2000. Incidence also increased considerably during the same period, from 53,000 to 93,000 per year. If previous trends in ESRD incidence and prevalence continue, then current levels of health care resources that are devoted to the care of these patients will eventually be unable to meet the demand. This study discusses a Markov model developed to predict ESRD incidence, prevalence, and mortality to the year 2015 and incorporating expected changes in age/race distributions, diabetes prevalence, ESRD incidence, and probability of death. The model predicted that by 2015 there will be 136,166 incident ESRD patients per year (lower/upper limits 110,989 to 164,550), 712,290 prevalent patients (595,046 to 842,761), and 107,760 ESRD deaths annually (96,068 to 118,220). Incidence and prevalence counts are expected to increase by 44 and 85%, respectively, from 2000 to 2015 and incidence and prevalence rates per million population by 32 and 70%, respectively. The financial and human resources that will be needed to care for these patients in 2015 will be considerably greater than in 2005.

Excerpts From the US Renal Data System 2009 Annual Data Report

This 21st US Renal Data System Annual Data Report covers data through 2007, and again includes a section on chronic kidney disease (CKD) in the United States. Using NHANES and employer group health plan data, we estimate the relationship between kidney disease markers and mortality risk and the likelihood of blood pressure and lipid control by CKD stage; illustrate use of the new ICD-9-CM CKD diagnosis codes; and report on morbidity, mortality, care and costs during the transition to ESRD. New chapters address CKD patient care, the transition to ESRD, and acute kidney injury. In 2007, 111,000 patients started end-stage renal disease (ESRD) therapy, and the prevalent population reached 527,283 (including 368,544 dialysis patients); 17,513 transplants were performed, and 158,739 patients had a functioning graft at year’s end. Program expenditures reached

Long interdialytic interval and mortality among patients receiving hemodialysis.

35.3 billion, with

Propensity-Matched Mortality Comparison of Incident Hemodialysis and Peritoneal Dialysis Patients

23.9 billion from Medicare (accounting for 5.8% of total Medicare expenditures). The incident rate fell 2.1%, to 354 per million. Fistula use in prevalent patients declined 2.6 percent; catheter use continues to be a concern. The percentage of patients with hemoglobin levels above 13 g/dl has fallen since 2006, but levels in the incident population frequently exceed 12. First-year mortality and morbidity among hemodialysis patients—particularly the increasing rate of hospitalizations due to infections—continue to be major concerns, and pediatric patient survival has not improved. The public health impact of kidney disease is larger than previously appreciated, and early detection, education, intervention, and risk factor control need to address the heavy burden of cardiovascular disease and adverse events in this vulnerable population.

United States Renal Data System 2008 Annual Data Report Abstract

BACKGROUND Patients with end-stage renal disease requiring dialysis have limited tolerance of metabolic and volume-related deviations from normal ranges; in addition, the prevalence of cardiovascular disease is high among such patients. Given these problems, we hypothesized that a long interdialytic interval is associated with adverse events in patients receiving hemodialysis. METHODS We studied 32,065 participants in the End-Stage Renal Disease Clinical Performance Measures Project, a nationally representative sample of U.S. patients receiving hemodialysis three times weekly, at the end of calendar years 2004 through 2007. We compared rates of death and cardiovascular-related hospital admissions on the day after the long (2-day) interdialytic interval with rates on other days. RESULTS The mean age of the cohort was 62.2 years; 24.2% of the patients had been receiving dialysis treatment for 1 year or less. Over a mean follow-up interval of 2.2 years, the following event rates were higher on the day after the long interval than on other days: all-cause mortality (22.1 vs. 18.0 deaths per 100 person-years, P<0.001), mortality from cardiac causes (10.2 vs. 7.5, P<0.001), infection-related mortality (2.5 vs. 2.1, P = 0.007), mortality from cardiac arrest (1.3 vs. 1.0, P = 0.004), mortality from myocardial infarction (6.3 vs. 4.4, P<0.001), and admissions for myocardial infarction (6.3 vs. 3.9, P<0.001), congestive heart failure (29.9 vs. 16.9, P<0.001), stroke (4.7 vs. 3.1, P<0.001), dysrhythmia (20.9 vs. 11.0, P<0.001), and any cardiovascular event (44.2 vs. 19.7, P<0.001). CONCLUSIONS The long (2-day) interdialytic interval is a time of heightened risk among patients receiving hemodialysis. (Funded by the National Institutes of Health.).

Hemoglobin Level Variability: Associations with Comorbidity, Intercurrent Events, and Hospitalizations

Contemporary comparisons of mortality in matched hemodialysis and peritoneal dialysis patients are lacking. We aimed to compare survival of incident hemodialysis and peritoneal dialysis patients by intention-to-treat analysis in a matched-pair cohort and in subsets defined by age, cardiovascular disease, and diabetes. We matched 6337 patient pairs from a retrospective cohort of 98,875 adults who initiated dialysis in 2003 in the United States. In the primary intention-to-treat analysis of survival from day 0, cumulative survival was higher for peritoneal dialysis patients than for hemodialysis patients (hazard ratio 0.92; 95% CI 0.86 to 1.00, P = 0.04). Cumulative survival probabilities for peritoneal dialysis versus hemodialysis were 85.8% versus 80.7% (P < 0.01), 71.1% versus 68.0% (P < 0.01), 58.1% versus 56.7% (P = 0.25), and 48.4% versus 47.3% (P = 0.50) at 12, 24, 36, and 48 months, respectively. Peritoneal dialysis was associated with improved survival compared with hemodialysis among subgroups with age <65 years, no cardiovascular disease, and no diabetes. In a sensitivity analysis of survival from 90 days after initiation, we did not detect a difference in survival between modalities overall (hazard ratio 1.05; 95% CI 0.96 to 1.16), but hemodialysis was associated with improved survival among subgroups with cardiovascular disease and diabetes. In conclusion, despite hazard ratio heterogeneity across patient subgroups and nonconstant hazard ratios during the follow-up period, the overall intention-to-treat mortality risk after dialysis initiation was 8% lower for peritoneal dialysis than for matched hemodialysis patients. These data suggest that increased use of peritoneal dialysis may benefit incident ESRD patients.

Survival of dialysis patients after cardiac arrest and the impact of implantable cardioverter defibrillators

In this age of modern era, the use of internet must be maximized. Yeah, internet will help us very much not only for important thing but also for daily activities. Many people now, from any level can use internet. The sources of internet connection can also be enjoyed in many places. As one of the benefits is to get the on-line united states renal data system 2008 annual data report book, as the world window, as many people suggest.

An improved comorbidity index for outcome analyses among dialysis patients

National payment policies target a hemoglobin range of 11 to 12.5 g/dl for patients with ESRD. However, clinical complications and provider practices may contribute to wide fluctuations over time. This study evaluated the frequency with which patients maintain stable hemoglobin levels below, within, and above the Centers for Medicare & Medicaid Services target range and assessed patterns of hemoglobin level change that resulted in large fluctuations across the target range during a 6-mo period. All hemodialysis patients who survived the first 6 mo of 2003, had Medicare as primary payer, and had Medicare outpatient erythropoietin claims in each of the first 6 mo of 2003 (n = 152,846) were studied. Six patient groups were defined on the basis of patterns of hemoglobin level fluctuation: Consistently low (<11 g/dl), consistently target range (11 to 12.5 g/dl), consistently high (> or =12.5 g/dl), low-amplitude fluctuation with low hemoglobin levels, low-amplitude fluctuation with high hemoglobin levels, and high-amplitude fluctuation. Only 10.3% of patients maintained stable hemoglobin levels during the 6 mo and only 6.5% in the target range. The consistently low group had the highest percentage of hospitalizations and the highest number of comorbid conditions. High-amplitude fluctuation was the most common pattern (39.5%), with hemoglobin levels falling below and rising above the target range during the 6-mo period. Hemoglobin levels in almost 90% of patients are in some degree of flux at any point in time, and the fluctuation is highly associated with clinical complications and provider practices.