J. Michael Soucie

Risk Factors for Candidal Bloodstream Infections in Surgical Intensive Care Unit Patients: The NEMIS Prospective Multicenter Study

To assess risk factors for development of candidal blood stream infections (CBSIs), a prospective cohort study was performed at 6 sites that involved all patients admitted to the surgical intensive care unit (SICU) for >48 h over a 2-year period. Among 4276 such patients, 42 CBSIs occurred (9.82 CBSIs per 1000 admissions). The overall incidence was 0.98 CBSIs per 1000 patient days and 1.42 per 1000 SICU days with a central venous catheter in place. In multivariate analysis, factors independently associated with increased risk of CBSI included prior surgery (relative risk [RR], 7.3), acute renal failure (RR, 4.2), receipt of parenteral nutrition (RR, 3.6), and, for patients who had undergone surgery, presence of a triple lumen catheter (RR, 5.4). Receipt of an antifungal agent was associated with decreased risk (RR, 0.3). Prospective clinical studies are needed to identify which antifungal agents are most protective and which high-risk patients will benefit from antifungal prophylaxis.

Familial clustering of end-stage renal disease in blacks with HIV-associated nephropathy

Human immunodeficiency virus-associated nephropathy (HIVAN) develops more often in HIV-infected blacks than whites. Blacks also show marked familial clustering of other causes of end-stage renal disease (ESRD), particularly diabetes mellitus-, hypertension-, and systemic lupus erythematosus-associated ESRD. We compared the family history of ESRD in 201 blacks with ESRD caused by HIVAN (cases) to that of 50 HIV-infected blacks without renal disease (controls) to determine whether HIV-associated ESRD shows familial aggregation. Cases were identified using the Southeastern Kidney Council/ESRD Network 6 Family History of ESRD database. Cases initiated dialysis between September 1993 and October 1998. Controls were consecutively identified, HIV-infected blacks with serum creatinine concentrations of 1.3 mg/dL or less and no proteinuria, treated in an infectious disease clinic during September 1998. Cases and controls had similar mean ages and family sizes. First- or second-degree relatives with ESRD were reported by 24.4% of the cases compared with 6% of the controls (P = 0.004). Logistic regression analysis, controlling for sex, family size, and age, showed cases were 5.4 times more likely than controls to have close relatives with ESRD (P = 0.007). The 49 HIVAN cases who reported a positive family history had a mean of 1.2 additional relatives with ESRD per case (60 total relatives with ESRD). HIVAN was not listed as the cause of ESRD in any of the 27 relatives who underwent dialysis in Network 6 facilities. We conclude that ESRD clusters in the families of nearly 25% of blacks initiating renal replacement therapy for HIVAN. This familial aggregation of ESRD appears to be independent of HIV infection. Although environmental factors cannot be excluded, it is possible an inherited susceptibility to renal failure is present in many blacks with HIV infection who subsequently develop nephropathy.

Race and Sex Differences in the Identification of Candidates for Renal Transplantation

The availability of renal transplantation to individuals with end-stage renal disease (ESRD) is an issue of considerable concern. The role of age, race, sex, socioeconomic status, illness severity, and comorbidity in determining access to this therapy remains unclear. We examined the influence of these factors on transplant candidacy in 8,315 patients receiving dialysis treatment for ESRD in North Carolina, South Carolina, and Georgia. We found important race-sex differences in the likelihood of being identified as a transplant candidate. These differences persisted after adjustment for other patient characteristics, including illness severity and certain comorbid conditions. Characteristics found to be positively associated with candidacy included age less than 30 years (P less than 0.00001), living with a spouse and children (P = 0.004), and employment status (P = 0.006). Characteristics and comorbid conditions that were negatively associated with candidacy included 8 years or less of formal education (P = 0.001), cancer (P = 0.0006), visual impairment (P = 0.006), congestive heart failure (P = 0.008), and peripheral vascular disease (P = 0.01). Compared with white males, after adjustment for these factors, the likelihood (95% confidence interval) of being identified as a transplant candidate was: white females, 0.88 (0.65 to 1.18); black males, 0.77 (0.59 to 0.99); and black females, 0.66 (0.51 to 0.87). We conclude that although socioeconomic and medical factors are strongly associated with transplant candidacy, these associations do not adequately explain the observed race-sex differences in transplant candidacy status.

Population-Based Screening for Family History of End-Stage Renal Disease among Incident Dialysis Patients

Background: We determined the familial aggregation of end-stage renal disease (ESRD) in a large, population-based sample of incident ESRD cases to assess the feasibility of developing a targeted screening and prevention program directed at members of families at high risk for kidney disease. Methods: Between January 1, 1995, and December 31, 2003, incident dialysis patients in ESRD Network 6 facilities were asked to complete a voluntary questionnaire on family history (FH) of ESRD. Cases with ESRD attributed to Mendelian diseases or urologic causes were excluded. FH was considered present if first- or second-degree relatives had ESRD. De-identified FH data were collated with demographic data at dialysis initiation. Results: More than 46% of eligible patients (25,883/55,929) provided FH information and 22.8% (5,901/25,883) of these reported having a FH of ESRD. FH of ESRD was positively associated with female gender, earlier age at ESRD onset, and primary cause of ESRD, and negatively associated with white race. FH associations with age, race, gender, and primary cause of renal failure remained statistically significant after simultaneous adjustment in a multivariate logistic regression model. Conclusions: Approximately23% of incident dialysis patients have close relatives with ESRD. Far more are likely to have relatives with clinically silent proteinuria or chronic kidney disease (CKD), both risk factors for future cardiovascular events and ESRD. Physicians caring for patients with CKD should be aware of the marked familial aggregation of ESRD and consider focusing screening efforts on high-risk family members in an attempt to slow the exponential growth rate of kidney disease.

A Prospective Comparison of Methods for Determining if Cardiovascular Disease is a Predictor of Mortality in Dialysis Patients

A random sample of 464 dialysis patients was surveyed between December 1990 and June 1991 to compare methods for determining the relationship between cardiovascular disease (CVD) and mortality. The following three methods were used to identify the prevalence of CVD: standard epidemiologic questionnaires, recall by the patient, and a review of the medical record. The 1-year mortality rate during this prospective study (average follow-up, 17.5 months) was 19%. The measure of prevalent CVD found to be the best predictor of the risk of mortality was the review of the medical record. Specifically, after controlling for the effects on mortality of age, sex, race, cause of renal failure, serum albumin level, and performance status (determined by the Karnofsky score), a patient with a history of angina pectoris documented in the medical record had a relative risk (95% confidence interval) of mortality of 1.8 (1.1 to 2.8), and a patient with peripheral vascular disease recorded in the medical record had a relative risk of 1.6 (1.0 to 2.4). Estimates of CVD obtained from either the questionnaires or patient recall resulted in associations between CVD and mortality that were substantially weaker than those for the medical record. We conclude that at present the medical record is the best source of information for estimating the presence of CVD as a mortality risk factor in dialysis patients. We recommend inclusion of a medical record history of CVD as a mortality case-mix factor when comparing dialysis populations.

Facility Mortality Rates for New End-Stage Renal Disease Patients: Implications for Quality Improvement

End-stage renal disease networks can provide clinicians with valuable information about treatment outcome among their patients compared with those of other providers. These comparisons can help clinicians identify potential quality of care problems and efficiently allocate resources for quality improvement. We have illustrated this application of network information by examining the mortality rates for newly treated end-stage renal disease patients in 161 dialysis facilities in North Carolina, South Carolina, and Georgia. We found that mortality rates were high (an average of 19.2 deaths per 100 years of treatment) and variable (ranging from 0 to 43 deaths per 100 dialysis years). The risk of a patient dying in a facility at the 75th percentile of mortality was 50% higher than that of a patient in a facility at the 25th percentile. Adjusting for patient characteristics (case mix) left considerable variation in the risk of dying among individual dialysis facilities unexplained, suggesting that other treatment center-specific aspects of care contributed to the differences in mortality. After controlling for factors associated with increased mortality, the risk of a patient dying in a facility at the 75th percentile of mortality was 70% greater than that of a patient in a facility at the 25th percentile of mortality. Most facilities, but not all, with the highest unadjusted mortality rates also had the highest adjusted mortality. We conclude that treatment outcome comparisons that have been adjusted to account for case mix among facilities can be provided by network surveillance systems and, when properly understood by providers, might stimulate the search for facility-specific, nonpatient factors that contribute to these outcomes.

Consultants for the American Journal of Nephrology 2005

Sandra Garber Cybele Ghossein Richard Glassock Alan Go Laurence Greenbaum Karen Griffi n S. Grigoryev Krishnamurthy Gudehithlu Peter Hart Koichi Hayashi Peter Heering Susan Hou John Hoyer Randall Hudson Todd Ing Eunice John Richard Johnson Michelle Josephson Pradeep Kadambi Ramesh Khanna Orly Kohn Jeff Kopp Mark Kraus Jerome Lane Craig Langman James Lash David Leehey Oliver Lenz Edgar Lerma Jerrold Levine Wilfred Lieberthal Stuart Linas Jill Lindberg Natalia Litbarg Gerard London Rodger Loutzenhiser Friedrich Luft K. Matsumoto Peter McCullough Patrick Murray Naoyuki Nakao Kevin Abbott Rajiv Agarwal Sharon Anderson Gema Ariceta John Asplin Simon Atkinson Asad Bakir George Bakris Vinod Bansal Amelia Bartholomew Amy Barton Pai Daniel Batlle Vecihi Batuman Enrico Benedetti Angelito Bernardo Anil Bidani Peter Blake Anthony Bleyer W. Kline Bolton Michael Braun Carolyn Brecklin Harold Bregman Ellen Brooks Vito Campese Sule Cataltepe Nina Clark Jay Cohn Richard Cohn Judith Cook Andrey Cybulsky Mohamed Daha Farhard Danesh Janice Douglas George Dunea Lance Dworkin Beatrice Edwards Leon Ferder Steven Fishbane Kenneth Fisher Mary Foster Barry Freedman