Dustin J. Little

Racial differences and income disparities are associated with poor outcomes in kidney transplant recipients with lupus nephritis.

Background An analysis of income and racial/ethnic disparities on renal transplant outcomes in recipients with lupus nephritis (LN) has not been reported. We analyzed the United States Renal Data System database to assess the impact of these disparities on graft loss and death in the LN and non-LN cohorts. Methods We identified 4214 patients with LN as the cause of end-stage renal disease in a retrospective cohort of 150,118 patients first transplanted from January 1, 1995 to July 1, 2006. We merged data on median household income from the United States Census based on the ZIP code. Results In multivariate Cox regression analyses, African-Americans (AF) recipients with LN (vs. non-AF) had an increased risk of graft loss (adjusted hazard ratio [AHR], 1.39; 95% confidence interval [CI], 1.21–1.60) and death (AHR, 1.33; 95% CI, 1.09–1.63). Furthermore, there were significant associations of lower-income quintiles with higher risk for graft loss and death among AF with LN. In comparison, among non-AF recipients with LN, income levels did not predict risk for transplant outcomes. The racial disparity for both graft loss and death outcomes among AF with LN was greater than among AF without LN (AHR, 1.32; 95% CI, 1.29–1.36 for graft loss and AHR, 1.02; 95% CI, 0.99–1.05 for death). Conclusions AF kidney transplant recipients with LN were at increased risk for graft loss and death compared with non-AF. Income levels were associated with the risk of graft loss and death in AF but not in non-AF recipients with LN.

Non-Adherence Codes in the New ICD-10: Need for Prospective Trials.

1. Non adherence is a significant factor in post transplant graft loss n2. The authors (e.g. Baines, Jindal) suggest that ICD-10 fails to consider the emotional and psychological issues faced by renal patients

Cost-utility analysis of sodium polystyrene sulfonate vs. potential alternatives for chronic hyperkalemia.

PURPOSEnHyperkalemia during renin-angiotensin-aldosterone system inhibition (RAAS-I) may prevent optimum dosing. Treatment options include sodium polystyrene sulfonate potassium binding resins, but safety and efficacy concerns exist, including associated colonic necrosis (CN). Alternative agents have been studied, but cost-utility has not been estimated.nnnMETHODSnWe performed a cost-utility analysis of outpatients ≥ 18 years of age receiving chronic RAAS-I, with a history of hyperkalemia or chronic kidney disease, prescribed either sodium polystyrene sulfonate or a theoretical drug X binding resin for chronic hyperkalemia. Data were obtained from existing literature. We used a decision analytic model with Monte Carlo probabilistic sensitivity analyses, from a health care payer perspective and a 12-month time horizon. Costs were measured in US dollars. Effectiveness was measured in quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).nnnRESULTSnDrug X could cost no more than

Survey of Kidney Biopsy Clinical Practice and Training in the United States

10.77 per daily dose to be cost-effective, at a willingness-to- pay (WTP) threshold of

Cost-Utility Analysis of Mycophenolate Mofetil versus Azathioprine Based Regimens for Maintenance Therapy of Proliferative Lupus Nephritis

50,000/QALY. At

Integrating Quality Improvement Education into the Nephrology Curricular Milestones Framework and the Clinical Learning Environment Review

40.00 per daily dose, drug X achieved an incremental cost effectiveness ratio of

Effects of Traumatic Amputation on β-Trace Protein and β2-Microglobulin Concentrations in Male Soldiers

26,088,369.00 per QALY gained. One-way sensitivity analysis showed sodium polystyrene sulfonate to be the cost-effective option for CN incidences ≤ 19.9%. Limitations include incomplete information on outpatient outcomes and lack of data directly comparing sodium polystyrene sulfonate to potential alternatives.nnnCONCLUSIONSnAlternatives may not be cost-effective unless priced similarly to sodium polystyrene sulfonate. This analysis may guide decisions regarding adoption of alternative agents for chronic hyperkalemia control, and suggests that sodium polystyrene sulfonate be employed as an active control in clinical trials of these agents.

Cost-effectiveness of antiplatelet therapy to prolong primary patency of hemodialysis graft.

BACKGROUND AND OBJECTIVESnPracticing clinical nephrologists are performing fewer diagnostic kidney biopsies. Requiring biopsy procedural competence for graduating nephrology fellows is controversial.nnnDESIGN, SETTING, PARTICIPANTS, & MEASUREMENTSnAn anonymous, on-line survey of all Walter Reed training program graduates (n=82; 1985-2017) and all United States nephrology program directors (n=149; August to October of 2017), regarding kidney biopsy practice and training, was undertaken.nnnRESULTSnWalter Reed graduates response and completion rates were 71% and 98%, respectively. The majority felt adequately trained in native kidney biopsy (83%), transplant biopsy (82%), and tissue interpretation (78%), with no difference for ≤10 versus >10 practice years. Thirty-five percent continued to perform biopsies (13% did ≥10 native biopsies/year); 93% referred at least some biopsies. The most common barriers to performing biopsy were logistics (81%) and time (74%). Program director response and completion rates were 60% and 77%. Seventy-two percent cited ≥1 barrier to fellow competence. The most common barriers were logistics (45%), time (45%), and likelihood that biopsy would not be performed postgraduation (41%). Fifty-one percent indicated that fellows should not be required to demonstrate minimal procedural competence in biopsy, although 97% agreed that fellows should demonstrate competence in knowing/managing indications, contraindications, and complications. Program directors citing ≥1 barrier or whose fellows did <50 native biopsies/year in total were more likely to think that procedural competence should not be required versus those citing no barriers (P=0.02), or whose fellows performed ≥50 biopsies (P<0.01).nnnCONCLUSIONSnAlmost two-thirds of graduate respondents from a single military training program no longer perform biopsy, and 51% of responding nephrology program directors indicated that biopsy procedural competence should not be required. These findings should inform discussion of kidney biopsy curriculum requirements.

Risk Factors for Future Scleroderma Renal Crisis at Systemic Sclerosis Diagnosis

Background/Aims. We aimed to examine the cost-effectiveness of mycophenolate mofetil (MMF) and azathioprine (AZA) as maintenance therapy for patients with Class III and Class IV lupus nephritis (LN), from a United States (US) perspective. Methods. Using a Markov model, we conducted a cost-utility analysis from a societal perspective over a lifetime horizon. The modeled population comprised patients with proliferative LN who received maintenance therapy with MMF (2u2009gm/day) versus AZA (150u2009mg/day) for 3 years. Risk estimates of clinical events were based on a Cochrane meta-analysis while costs and utilities were retrieved from other published sources. Outcome measures included costs, quality-adjusted life-years (QALY), incremental cost-effectiveness ratios (ICER), and net monetary benefit. Results. The base-case model showed that, compared with AZA strategy, the ICER for MMF was

Incidence of Sodium Polystyrene Sulfonate-associated Colonic Necrosis

2,630,592/QALY at 3 years. Over the patients lifetime, however, the ICER of MMF compared to AZA was