Jenna Krisher

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.

Variation in Dialysis Facility Referral for Kidney Transplantation Among Patients With End-Stage Renal Disease in Georgia

IMPORTANCE Dialysis facilities in the United States are required to educate patients with end-stage renal disease about all treatment options, including kidney transplantation. Patients receiving dialysis typically require a referral for kidney transplant evaluation at a transplant center from a dialysis facility to start the transplantation process, but the proportion of patients referred for transplantation is unknown. OBJECTIVE To describe variation in dialysis facility-level referral for kidney transplant evaluation and factors associated with referral among patients initiating dialysis in Georgia, the US state with the lowest kidney transplantation rates. DESIGN, SETTING, AND PARTICIPANTS Examination of United States Renal Data System data from a cohort of 15,279 incident, adult (18-69 years) patients with end-stage renal disease from 308 Georgia dialysis facilities from January 2005 to September 2011, followed up through September 2012, linked to kidney transplant referral data collected from adult transplant centers in Georgia in the same period. MAIN OUTCOMES AND MEASURES Referral for kidney transplant evaluation within 1 year of starting dialysis at any of the 3 Georgia transplant centers was the primary outcome; placement on the deceased donor waiting list was also examined. RESULTS The median within-facility percentage of patients referred within 1 year of starting dialysis was 24.4% (interquartile range, 16.7%-33.3%) and varied from 0% to 75.0%. Facilities in the lowest tertile of referral (<19.2%) were more likely to treat patients living in high-poverty neighborhoods (absolute difference, 21.8% [95% CI, 14.1%-29.4%]), had a higher patient to social worker ratio (difference, 22.5 [95% CI, 9.7-35.2]), and were more likely nonprofit (difference, 17.6% [95% CI, 7.7%-27.4%]) compared with facilities in the highest tertile of referral (>31.3%). In multivariable, multilevel analyses, factors associated with lower referral for transplantation, such as older age, white race, and nonprofit facility status, were not always consistent with the factors associated with lower waitlisting. CONCLUSIONS AND RELEVANCE In Georgia overall, a limited proportion of patients treated with dialysis were referred for kidney transplant evaluation between 2005 and 2011, but there was substantial variability in referral among facilities. Variables associated with referral were not always associated with waitlisting, suggesting that different factors may account for disparities in referral.

Mortality of Dialysis Patients According to Influenza and Pneumococcal Vaccination Status

BACKGROUND Data from an immunocompromised subpopulation in which both vaccine recipients and nonrecipients have frequent opportunities for vaccination can help determine the associations between vaccination against seasonal influenza and pneumococcal disease and all-cause mortality. STUDY DESIGN We surveyed dialysis centers and performed a retrospective analysis of health status at dialysis therapy initiation, vaccination for influenza and pneumococcal disease, laboratory results, and mortality associated with the 2005-2006 influenza season for patients in 3 End-Stage Renal Disease Networks across the United States. SETTING & PARTICIPANTS Of 1,033 dialysis facilities considered, 903 centers with a total patient population of 54,734 reported vaccination data. Analysis was limited to 36,966 patients on dialysis treatment for at least 1 year as of December 31, 2005. PREDICTOR Vaccination status. OUTCOMES OR for all-cause mortality (vaccinated vs unvaccinated patients). RESULTS The estimated adjusted OR for mortality was significantly less than 1.0 for patient who received either vaccination and was lower for patients who had received both vaccinations than for those who had received either. Survival analysis confirmed these findings. LIMITATIONS Possible misclassification due to self-report of vaccination for some patients. Lack of vaccination date. CONCLUSIONS Vaccination against influenza and pneumococcal disease is associated with improved survival in dialysis patients. The 2 vaccinations have independent effects on mortality.

Individuals With a Family History of ESRD Are a High-Risk Population for CKD: Implications for Targeted Surveillance and Intervention Activities

Activities intended to improve the detection, treatment, and control of chronic kidney disease (CKD) should be incorporated into existing health care systems and targeted to high-risk populations to avoid redundancy and waste of resources. One high-risk population consists of first- or second-degree family members of patients with end-stage renal disease (ESRD), who are 2 to 3 times as likely to have incident ESRD, have high rates of impaired kidney function and undetected and uncontrolled high blood pressure, and are more likely to be obese. These individuals usually are unaware of their underlying CKD and may discount their own risk of ESRD. The ESRD Network 6 Family History Project shows that the ESRD Networks, which constitute a national CKD surveillance system for patients with stage 5 CKD, may be an existing resource that can be used to identify relatives of incident patients with ESRD and provide these families with information about CKD. Nationally available resources have been developed by the National Kidney Disease Education Program for use with these at-risk families. Individuals interested in population-based CKD control activities should be aware of and use these resources.

A Randomized Trial to Reduce Disparities in Referral for Transplant Evaluation

Georgia has the lowest kidney transplant rates in the United States and substantial racial disparities in transplantation. We determined the effectiveness of a multicomponent intervention to increase referral of patients on dialysis for transplant evaluation in the Reducing Disparities in Access to kidNey Transplantation Community Study (RaDIANT), a randomized, dialysis facility-based, controlled trial involving >9000 patients receiving dialysis from 134 dialysis facilities in Georgia. In December of 2013, we selected dialysis facilities with either low transplant referral or racial disparity in referral. The intervention consisted of transplant education and engagement activities targeting dialysis facility leadership, staff, and patients conducted from January to December of 2014. We examined the proportion of patients with prevalent ESRD in each facility referred for transplant within 1 year as the primary outcome, and disparity in the referral of black and white patients as a secondary outcome. Compared with control facilities, intervention facilities referred a higher proportion of patients for transplant at 12 months (adjusted mean difference [aMD], 7.3%; 95% confidence interval [95% CI], 5.5% to 9.2%; odds ratio, 1.75; 95% CI, 1.36 to 2.26). The difference between intervention and control facilities in the proportion of patients referred for transplant was higher among black patients (aMD, 6.4%; 95% CI, 4.3% to 8.6%) than white patients (aMD, 3.7%; 95% CI, 1.6% to 5.9%; P<0.05). In conclusion, this intervention increased referral and improved equity in kidney transplant referral for patients on dialysis in Georgia; long-term follow-up is needed to determine whether these effects led to more transplants.

Geographic Concentration of Poverty and Arteriovenous Fistula Use among ESRD Patients

There is substantial geographic variability in both incident and prevalent arteriovenous fistula (AVF) use among patients with ESRD. This study examined the degree to which these variations associate with poverty in the county of a patients treatment center. We performed a cross-sectional study including 28,135 patients treated by 1127 hemodialysis centers in five ESRD networks (16 states) between June 1, 2005 and May 31, 2006. We used the 2000 U.S. Census to categorize county-level poverty and ascertained incident AVF use from the Medicare CMS 2728 form. We calculated the 30-month slope of change in AVF prevalence from monthly facility reports collected between 2003 and 2005. More than 33% of treatment centers were located in high-poverty counties. County poverty inversely associated with incident AVF use (P for trend = 0.001). In contrast, substantial increases in prevalent AVF rates from 30.9 to 38.6% (P < 0.001) among treatment centers did not associate with county poverty (P = 0.9519). In conclusion, the concentration of poverty in the county where a treatment is located associates with incident AVF use by patients with ESRD but not with subsequent improvement in AVF use among prevalent patients. These results suggest that the Medicare ESRD program may mitigate poverty effects on AVF use.

Association of standing-order policies with vaccination rates in dialysis clinics: a US-based cross-sectional study.

BACKGROUND Patients with end-stage renal disease are at increased risk of morbidity and mortality because of infection. Quality improvement efforts for this patient population include assessment of institutional policies and practices that may increase vaccination rates for influenza, hepatitis B, and pneumococcal disease. STUDY DESIGN A survey of vaccination practices, beliefs, and attitudes was sent to all dialysis centers in End-Stage Renal Disease Networks 6, 11, and 15. SETTING & PARTICIPANTS Of 1,052 dialysis facilities considered, 683 returned the survey, reported vaccination rates for 2005 to 2006, and had 20 or more patients. PREDICTOR OR FACTOR Standing-order policy of the dialysis facility, categorized as facility-wide orders, preprinted admission orders for each patient (chart orders), physician-specific orders, and individual orders. OUTCOMES Vaccination rates for influenza, hepatitis B (full or partial series), hepatitis B, and pneumococcal vaccine. MEASUREMENTS Patient vaccination, given at or outside the center. RESULTS Overall vaccination rates were 76% +/- 18% (SD) for influenza, 73% +/- 22% for hepatitis B full or partial series, 62% +/- 25% for hepatitis B full series, and 44% +/- 34% for pneumococcal vaccine. Compared with individual orders, facility-wide standing orders and chart orders were not associated with greater vaccination rates for influenza (0.4%; confidence interval, -4 to 5; and 1.27%; confidence interval, -3 to 5, respectively), but were associated with greater vaccination rates for hepatitis B full or partial series (9%; confidence interval, 3 to 15; and 11%; confidence interval, 5 to 17, respectively), hepatitis B full series (11%; confidence interval, 4 to 17; and 13%; confidence interval, 7 to 19, respectively), and pneumococcal disease (21%; confidence interval, 14 to 29; and 20%; confidence interval, 13 to 27, respectively). LIMITATIONS Data are cross-sectional, and vaccinations outside the center were self-reported. CONCLUSIONS Existing facility-wide or chart-based order programs may be effective in promoting vaccination against hepatitis B and pneumococcal disease.

Racial variation in autosomal dominant polycystic kidney disease

These analyses were undertaken to determine whether racial variation contributes to the risk of end-stage renal disease (ESRD) in close relatives of incident dialysis patients with autosomal dominant polycystic kidney disease (ADPKD)-associated ESRD. A family history of ESRD was recorded in 14,769 incident ESRD patients in Network 6 (Georgia, North Carolina, South Carolina) between September 1993 and November 1997. Two hundred thirty-seven patients with ADPKD-ESRD comprised the study population (180 white and 57 black). Differences in patient populations were analyzed using the chi-squared and Students t-tests, and multiple regression analysis was performed. Correlation in age at ESRD onset in families was performed by linear regression analysis. A positive family history (FH) of ESRD in first- or second-degree relatives was reported by 38.6% (22 of 57) of blacks and 55% (99 of 180) of whites (P = 0.03). The 22 blacks with a positive FH had a mean of 2.0 additional ESRD relatives and 10.4 total first-degree relatives, whereas the 99 whites with a positive FH had a mean of 2.6 additional ESRD relatives and 7.0 total first-degree relatives (P = 0.14 and P < 0.001, respectively). Mean age in years at first dialysis was similar in blacks and whites, regardless of FH (black FH positive, 63.8; black FH negative, 66.3; P = 0.66; white FH positive, 60.8; white FH negative, 62.8; P = 0. 48). On average, 57.9% of the first- and second-degree relatives of white cases had ADPKD-associated ESRD, compared with 28.6% of the relatives of black cases (P < 0.001). In the multivariate analysis, white race (P = 0.004) and increasing family size (P = 0.002) were positively correlated with the number of relatives having ADPKD-associated ESRD, whereas age at ESRD onset (P = 0.50) and gender (P = 0.94) were not. Age at onset of ESRD was correlated within members of multiply affected white (P < 0.001) but not black families (P = 0.80). We conclude that blacks with ADPKD-associated ESRD are less likely than whites to have relatives with ESRD, and there is no correlation in age at onset of ADPKD-ESRD in black families.

Impact of Birth Weight on Familial Aggregation of End-Stage Renal Disease

Background: Birth weight (BW) and family history (FH) of end-stage renal disease (ESRD) have been shown to have an independent association with development of subsequent ESRD. This study was undertaken to determine the effects of BW (low BW suggesting a congenital reduction in functional nephron number) on the observed familial aggregation of ESRD. Methods: Cases were identified from the ESRD Network 6 ‘Family History of ESRD’ Study and BW was determined from birth certificate records maintained at the Office of Vital Records, South Carolina Department of Health and Environmental Control. BW and FH of ESRD data were available in 387 patients who initiated dialysis therapy between 1993 and 1997. Multiple logistic regression analysis was performed to assess the risk of low BW (<2,500 g) and high BW (≧4,000 g) on FH of ESRD. Results: A FH of ESRD in first or second-degree relatives was present in 24% of cases. No significant differences were observed in the frequency of a positive FH of ESRD in those with low BW compared to those with normal BW. There was a significant reduction in the prevalence of a FH of ESRD in those with high BW, compared to those with a normal BW (risk ratio 0.32, CI 0.11–0.94). Conclusion: The clustering of either high BW or low BW within multiply affected ESRD families does not account for the observed familial aggregation of ESRD. In addition, high BW was associated with a reduced familial aggregation of ESRD.

Effect of Community Characteristics on Familial Clustering of End-Stage Renal Disease

Background: Lower socioeconomic status is generally associated with an increased risk of end-stage renal disease (ESRD). The relationship between community characteristics reflecting socioeconomic status and familial aggregation of common forms of ESRD has not been studied. Methods: Demographic data and family history of ESRD were collected from 23,880 incident dialysis patients in ESRD Network 6 between 1995 and 2003. Addresses were geocoded and linked to the 2000 census 5-digit zip code-level database that includes community demographic, social and economic characteristics. Clustering of patients having a family history of ESRD at the community level was accounted for using a generalized estimating equations (GEE) model. Multivariate analysis estimated associations between family history of ESRD and community-level characteristics. Results: Twenty-three percent of patients reported a family history of ESRD. After adjusting for individual demographic characteristics, multivariate analyses failed to reveal statistically significant relationships between a family history of ESRD and indicators of community socioeconomic status such as median household income, percentage high school graduates, percentage vacant housing units or ethnic composition. Conclusions: Although select community measures of lower socioeconomic status may contribute to the familial clustering of ESRD, non-socioeconomic factors, potentially inherited, appear to be more important contributors to familial aggregation of the common forms of ESRD.