George Coritsidis

The Role of the Primary Care Physician in Managing Early Stages of Chronic Kidney Disease

Abstract Recent increases in obesity, diabetes, and hypertension, along with the aging of the US population, are driving a dramatic rise in the prevalence of chronic kidney disease (CKD). Despite this increase, the majority of Americans with early-stage CKD remain unaware of their disease. Primary care physicians are at the forefront of efforts for early recognition of CKD and management to control its progression. Patients with CKD should be referred to nephrologists no later than the point at which their estimated glomerular filtration rate reaches 30 mL/min. Nephrology evaluation at this point is essential to facilitate timely preparation for care of end-stage renal disease through preemptive transplantation or planned transition to dialysis. In addition to stringent control of underlying hypertension and/or diabetes, mineral metabolic parameters (serum parathyroid hormone, phosphorus, calcium, and bicarbonate) in patients with advancing CKD should be managed closely to avoid adverse effects on the cardiovascular and skeletal systems.

Does Timing of Dialysis in Patients with ESRD and Acute Myocardial Infarcts Affect Morbidity or Mortality

BACKGROUND AND OBJECTIVES Patients with ESRD have an increased incidence of coronary events with a relatively higher risk for mortality after acute myocardial infarction (AMI). We evaluated whether it is safer to delay dialysis in AMI or if delay poses separate risks. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective review of 131 long-term hemodialysis patients who had AMI and were admitted between 1997 and 2005 at three New York City municipal hospitals. Patients were separated into three groups on the basis of time between cardiac symptoms and first dialysis (<24 h, 24 to 48 h, and >48 h). RESULTS A total of 17 (13%) patients died, 10 (59%) of whom had either hypotension or an arrhythmia during their first cardiac care unit dialysis. Although these groups were comparable in acuity and cardiac status, there were no findings of increased morbidity (26, 36, and 20%, respectively) or mortality (11, 18, and 13%, respectively), despite differences in the timing of each groups dialysis. We found that previous cardiac disease, predialysis K+, DeltaK+ after dialysis, and APACHE scores were significantly higher in patients with peridialysis morbidity. CONCLUSIONS We conclude that there is no increased morbidity with early dialysis in AMI, but rather close attention needs to be paid to the rate of decrease in serum potassium in patients with ESRD and their level of acuity when undergoing dialysis.

Hypertonic saline infusion in traumatic brain injury increases the incidence of pulmonary infection.

We aimed to investigate the incidence of electrolyte abnormalities, acute kidney injury (AKI), deep venous thrombosis (DVT) and infections in patients with traumatic brain injury (TBI) treated with hypertonic saline (HTS) as osmolar therapy. We retrospectively studied 205 TBI patients, 96 with HTS and 109 without, admitted to the surgical/trauma intensive care unit between 2006 and 2012. Hemodynamics, electrolytes, length of stay (LOS), acute physiological assessment and chronic health evaluation II (APACHE II), injury severity scores (ISS) and mortality were tabulated. Infection, mechanical ventilation, DVT and AKI incidence were reviewed. HTS was associated with increased LOS and all infections (p=0.0001). After correction for the Glasgow coma scale (GCS) and ventilator need, pulmonary infections (p=0.001) and LOS remained higher with HTS (p=0.0048). HTS did not result in increased blood pressure, DVT, AKI or neurological benefits. HTS significantly increased the odds for all infections, most specifically pulmonary infections, in patients with GCS<8. Due to these findings, HTS in TBI should be administered with caution regardless of acuity.

Sustained Low-Efficiency Daily Dialysis as Renal Replacement Therapy for the Critically Ill:

Understanding proper management of acute kidney injury (AKI) is important given that studies consistently demonstrate an increasing incidence rate of AKI in the critically ill. AKI carries a significant risk for mortality, which only increases if dialysis becomes a necessary treatment. It is not clear whether modalities other than conventional intermittent hemodialysis improve outcomes in AKI. Sustained low-efficiency daily dialysis (SLEDD) is a more recent extracorporeal treatment whose distinguishing characteristic is its hybrid integration of both continuous and intermittent hemodialysis modalities. Besides providing comparable hemodynamic stability through its decreased blood flow rate and extended hours of use, SLEDD is less complicated, is less expensive, and is convenient for staff and patient. As a result, its use in critical care is on the rise.

Trauma care in a multiethnic population: effects of being undocumented

BACKGROUND Epidemiologic studies have shown that undocumented immigrants (UIs) display characteristics of having a low socioeconomic status and are primarily of ethnic minorities. These social determinants of health are known to be associated with diminished health care access and poor clinical outcomes. We therefore investigated the impact of documentation status on the clinical outcomes of patients with traumatic injuries. MATERIALS AND METHODS We conducted a retrospective review of the trauma registry at our safety net institution for all adult patients who were admitted from 2010 to 2014. UIs were identified by the absence of a valid social security number within their medical records. Multivariate regression analysis was used to determine the impact of documentation status on in-hospital mortality, length of stay (LOS), and the odds of rehab placement. RESULTS 4924 trauma patients met the study criteria, of which 1050 (21.3%) were UIs. There was no significant difference in mortality rates between the two populations. Multivariate regression analyses revealed a longer average LOS and a decreased likelihood for placement in an in-patient rehabilitation facility following hospitalization for UIs, even after accounting for insurance, age, injury severity, and other possible confounders known to affect these outcomes. CONCLUSIONS There was no association between in-hospital mortality and documentation status; however, UIs had a longer average LOS and were less likely to be placed into rehab following their hospitalization. A longer LOS and a decreased likelihood for rehabilitation placement suggest that disparities in trauma care exist for UIs, putting them at risk for worse clinical and functional outcomes.

Anemia management trends in hospital-based dialysis centers (HBDCs), 2010 to 2013.

BACKGROUND Few data have been reported on anemia management practices in hospital-based dialysis centers (HBDCs), which are uniquely different from other freestanding dialysis centers. Examining data from HBDCs would help determine if HBDCs and the general US dialysis population have similar trends related to how anemia is managed in dialysis patients. OBJECTIVE Given recent changes in the prescribing information of erythropoiesis-stimulating agents (ESAs) and in end-stage renal disease-related health policy and reimbursement, this study describes trends in anemia management practices in HBDCs from January 2010 through March 2013. METHODS Electronic medical records of 5404 adult hemodialysis patients in 50 US-based HBDCs were analyzed retrospectively. Patients included in the study cohort were aged ≥18 years and had at least 1 hemoglobin (Hb) measurement and 1 dose of an ESA between January 2010 and March 2013. End points included Hb concentration, darbepoetin alfa dosing, epoetin alfa dosing, and iron biomarkers (transferrin saturation and ferritin) and dosing. RESULTS From 2010 to 2013, mean monthly Hb levels declined from 11.4 to 10.7 g/dL; the percentage of patients with mean monthly Hb levels <10 g/dL increased from 11.3% to 24.4%; and the percentage of patients with mean monthly Hb levels >12 g/dL declined from 30.1% to 11.2%. The median darbepoetin alfa cumulative 4-week dose also declined 38.8%, and the weekly epoetin alfa dose declined 24%. From January 2010 to March 2013, the percentage of patients with transferrin saturation >30% increased from 35.8% to 43.6%, the percentage of patients with ferritin levels >500 ng/mL increased from 62.0% to 77.9%, the percentage of patients with ferritin levels ≥800 ng/mL increased from 28.9% to 47.3%, and the median cumulative 4-week intravenous iron dose increased 50%. CONCLUSIONS These study results support growing evidence that meaningful changes have occurred over the last 3 years in how anemia is clinically managed in US hemodialysis patients. Study limitations include that changes in patient clinical/demographic characteristics over time were not controlled for and that study findings may not be applicable to HBDCs that have different patient populations and/or do not use an electronic medical record system. Continuing to evaluate anemia management practices in HBDCs would provide additional information on the risks and benefits of anemia care. Consistent with national data, the findings from this study indicate that from 2010 to 2013, HBDCs modified anemia management practices for dialysis patients, as evidenced by reductions in mean monthly Hb levels and ESA dosing and by increases in iron biomarkers and dosing.

1495: MORTALITY IN SURGICAL/TRAUMA ICU PATIENTS WITH SEVERE TBI

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) were evaluated. Results: 30 extensive burn patients were included in this study. Hierarchical clustering analysis showed a cluster formed by four cytokines, including IL6,IL8,IL10 and MCP-1. Those cytokine were significantly correlated with peak SOFA score (IL6: r =0.608, p =0.001, IL8; r =0.510, p =0.005, IL10: r =0.571, p =0.001, MCP-1:r =0.445, p =0.016, respectively) Cox regression analysis showed significant correlation between those cytokines and the 28-day mortality. Conclusions: We demonstrated for the first time the cytokine network composed by IL6, IL8, IL10 and MCP-1, which associate with the prognosis and severity in extensive burn patients. This suggests that the cytokine network plays a critical role in the pathophysiological process of extensive burn.