Linda W. Moore

Cross-sectional and case-control analyses of the association of kidney function staging with adverse postoperative outcomes in general and vascular surgery.

Objective:This study aimed to assess kidney dysfunction in general surgical patients and examine the effect on postoperative mortality and morbidity. Background:An estimated 13% of the US population has chronic kidney disease (CKD), but awareness among patients and caregivers is lacking. Methods:The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data sets for 2005–2007 were analyzed. Preoperative kidney function was assessed by the Modification of Diet in Renal Disease formula for estimated glomerular filtration rate (eGFR) and staged according to National Kidney Foundation. Cross-sectional analyses were performed for 30-day mortality (Cox proportional hazard) and incidence of major complications (nominal logistic regression). A case-control cohort of colectomy cases was analyzed comparing patients in the stage 4 CKD group and the no CKD group (no-CKD). Results:Sixty-four percent of evaluable patients had reduced eGFR, but eGFR was not evaluable in 28% of the surgical cases. In the 260,352 evaluable cases, adjusted hazard ratio for 30-day mortality was 2.30 [95% confidence interval (CI), 2.11–2.51] for stage 3 CKD; 3.37 (95% CI, 3.01–3.76) for stage 4 CKD; and 3.05 (95% CI, 2.68–3.47) for stage 5 CKD compared with no-CKD (P < 0.0001). CKD was an independent risk factor for having major complications postsurgery [stage 3, odds ratio (OR) = 1.24 (95% CI, 1.19–1.29); stage 4, OR = 1.65 (95% CI, 1.52–1.78); and stage 5 CKD, OR = 1.40 (95% CI, 1.30–1.51); P < 0.0001]. The case-control for colectomy was confirmatory: increased 30-day mortality in stage 4 CKD versus no-CKD (hazard ratio = 2.58, 95% CI, 1.13–5.92; P = 0.025). Conclusions:Renal insufficiency may be underrecognized in the general and vascular (noncardiac) surgery population, is a leading independent predictor of poor early postoperative outcomes, and should be routinely assessed in the preoperative setting.

The mean dietary protein intake at different stages of chronic kidney disease is higher than current guidelines

The actual dietary protein intake of adults without and with different stages of chronic kidney disease is not known. To evaluate this we performed cross-sectional analyses of 16,872 adults (20 years of age and older) participating in the National Health and Nutrition Examination Survey 2001-2008 who completed a dietary interview by stage of kidney disease. Dietary protein intake was assessed from 24-h recall systematically collected using the Automated Multiple Pass Method. Complex survey analyses were used to derive population estimates of dietary protein intake at each stage of chronic kidney disease. Using dietary protein intake of adults without chronic kidney disease as the comparator, and after adjusting for age, the mean dietary protein intake was 1.30 g/kg ideal body weight/day (g/kgIBW/d) and was not different from stage 1 or stage 2 (1.28 and 1.25 g/kgIBW/d, respectively), but was significantly different in stage 3 and stage 4 (1.22 and 1.13 g/kgIBW/d, respectively). These mean values appear to be above the Institute of Medicine requirements for healthy adults and the NKF-KDOQI guidelines for stages 3 and 4 chronic kidney disease. Thus, the mean dietary protein intake is higher than current guidelines, even after adjusting for age.

A role for oral nutrition supplements in the malnutrition of renal disease

Abstract Objective : To review information regarding the incidence, causes, and effects of malnutrition in patients with end-stage renal disease (ESRD) and to discuss the current studies of oral enteral nutrition supplementation in this patient population. Data Sources : Published references, conference proceedings, and personal observation. Conclusions : Individuals with ESRD have significant malnutrition, and the negative results of this malnutrition contributes to the morbidity and mortality associated with renal disease. Preliminary studies indicate that oral nutritional supplementation has a positive effect on nutritional status of patients with ESRD and could potentially decrease Medicare costs in this population. The role of the renal dietitian in evaluating and counseling these patients regarding nutrition places this profession in a forward role for preventing and intervening malnutrition. Therefore, continued research to determine the impact of oral nutritional supplements requires the involvement of renal dietitians and will establish justifications for Medicare reimbursement. The Council on Renal Nutrition actively promotes research regarding oral nutritional supplements in patients requiring renal replacement therapy.

Bariatric Surgery and End-Stage Organ Failure

Morbid obesity increases the risk of complications and allograft failure in transplant patients. Bariatric surgery is both safe and effective in patients with chronic kidney disease and end-stage renal disease, improves eligibility for transplant based on body mass index, and does not affect postoperative immunosuppressant dosing regimens. Bariatric surgery in patients with liver disease has been shown to be safe and effective, although they remain at high risk in the setting of portal hypertension. Sleeve gastrectomy may become increasingly used both pretransplant and posttransplant, as it can result in low complication rates and excellent weight loss, and retains intestinal continuity.

Incidence, Causes, and Treatment of Iron Deficiency Anemia in Hemodialysis Patients

Because an important factor in response to recombinant human erythropoietin (r-HuEPO) therap is adequate iron (Fe) availability, the investigators decided to assess Fe status of their hemodialysl (HD) patients before initiating r-HuEPO therapy. Of 104 patients not receiving r-HuEPO, 72% had transferrin saturation level less than 0.20 (20%), and 69% had a serum ferritin level less than 10 μg/L (100 ng/mL). The average hematocrit was 0.22 (22%). The investigators determined that the patients lose from 2 to 5 L of blood per year, amounting to a loss of 3 to 8 mg of Fe/treatment whe hematocrit is 0.22 (22%). If hematocrit is 0.30 (30%), Fe loss will be 4 to 11 mg /treatment. The ren; diet provides approximately 14 mg of Fe per day, comparable to only about 1 to 2 mg of absorbe Fe. Therefore, these patients require significant amounts of Fe replacement therapy because of th blood loss incurred and dietary inadequacies. Thirty-two patients with Fe deficiency anemia wer studied. Each subject had Fe studies consisting of serum Fe, total Fe binding capacity, transferri saturation, serum ferritin, and hematocrit evaluated weekly. Sixteen subjects received intravenou (IV) Fe dextran (IVFe Imferon, Fisons Pharmaceuticals, Rochester, NY) administered after eac dialysis for 5 weeks totaling 1.5 g, and 16 subjects received oral (PO) ferrous gluconate (POFe approximately 5 g (72 mg daily), given over 10 weeks. IVFe subjects increased hematocrit fror 0.19 to 0.27 (19% to 27%). All subjects treated with IVFe corrected transferrin saturation, and 771, corrected serum ferritin. Subjects treated with POFe improved hematocrit from 0.20 to 0.25 (20% t 25%), and two thirds of these subjects improved Fe status. Substantial numbers of HD patient exhibiting anemia have significant Fe deficiency largely due to blood loss. The renal diet i insufficient to combat this deficiency. IVFe is more efficient than POFe in treating Fe deficiency in HD patients.

Are high flux dialysis and erythropoietin treatment in a collision course

Twenty patients treated with human recombinant erythropoietin (EPO) for 9 months were studied. The patients were randomly allocated to high flux (HF) or conventional dialysis (CD). Patients on HF used the F-60 or F-80 dialyzer, with a polysulfone membrane; QB: 470 ml/min; QD: 800 ml/min; t: 127 min; Kt/V: 1.01. Conventional dialysis patients used regenerated cellulosic membranes; QB: 297 ml/min; QD: 500 ml/min; t: 193 min; Kt/V: 1.05. Mean dose of EPO was 103 U/kg for HF patients and 112.4 U/kg for patients on CD. At 9 months, no significant differences were observed in HCT (HF 33.6% vs. CD 33.2%), BUN, serum creatinine, potassium, or phosphorus. Hemoconcentration during dialysis was 12% for HF and 17% for CD. Urea clearance decreased 7% for HF and 9% for CD, while clearance of creatinine, potassium, and phosphorus decreased between 14 and 18% with both treatments. Heparin requirements increased 10% in HF and 16% in CD. Hypertension was similar in both groups. One HF patient withdrew from the study because of hypertension and one HF patient had seizures related to hypertension. Vascular access clotting or hospitalizations were no different. High flux dialysis patients on EPO over a 9 month period did not have any catastrophic complications when HCT was maintained between 30 and 35%.

Increased mortality of solid organ transplant recipients with H1N1 infection: a single center experience

Gainer SM, Patel SJ, Seethamraju H, Moore LW, Knight RJ, Gaber AO. Increased mortality of solid organ transplant recipients with H1N1 infection: a single center experience. 
Clin Transplant 2011 DOI: 10.1111/j.1399‐0012.2011.01443.x. 
© 2011 John Wiley & Sons A/S.

Enteral Nutrition for Patients With Traumatic Brain Injury in the Rehabilitation Setting: Associations With Patient Preinjury and Injury Characteristics and Outcomes

OBJECTIVE To determine the association of enteral nutrition (EN) with patient preinjury and injury characteristics and outcomes for patients receiving inpatient rehabilitation after traumatic brain injury (TBI). DESIGN Prospective observational study. SETTING Nine rehabilitation centers. PARTICIPANTS Patients (N=1701) admitted for first full inpatient rehabilitation after TBI. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES FIM at rehabilitation discharge, length of stay, weight loss, and various infections. RESULTS There were many significant differences in preinjury and injury characteristics between patients who received EN and patients who did not. After matching patients with a propensity score of >40% for the likely use of EN, patients receiving EN with either a standard or a high-protein formula (>20% of calories coming from protein) for >25% of their rehabilitation stay had higher FIM motor and cognitive scores at rehabilitation discharge and less weight loss than did patients with similar characteristics not receiving EN. CONCLUSIONS For patients receiving inpatient rehabilitation after TBI and matched on a propensity score of >40% for the likely use of EN, clinicians should strongly consider, when possible, EN for ≥25% of the rehabilitation stay and especially with a formula that contains at least 20% protein rather than a standard formula.

Early clearance vs persistence of de novo donor-specific antibodies following lung transplantation

The natural history of de novo donor‐specific antibodies (dnDSA) after lung transplantation is not well‐described. We sought to determine the incidence and risk factors associated with dnDSA and compare outcomes between recipients with transient (or isolated) vs persistent dnDSA after transplantation.

Outcomes of living donor renal transplants with a negative cross-match and pretransplant donor-specific antibody

INTRODUCTION Management of renal transplant recipients with a negative complement-dependent cytotoxicity-antihuman globulin (CDC-AHG) cross-match and pretransplant donor-specific antibody (DSA) is controversial. We sought to compare outcomes of immunologically high-risk living donor (LD) renal transplant recipients with and without DSA. METHODS We conducted a single-center, retrospective review of all high immune-risk LD renal transplant recipients with a negative CDC-AHG cross-match performed between January 2008 and December 2010. Pretransplant desensitization for DSA was not utilized. Immunosuppression consisted of thymoglobulin induction, followed by tacrolimus, myeophenolate mofetil, and prednisone. DSA was assessed pretransplant and at 1, 3, 6, 9, and 12 months, and every 6 months thereafter. RESULTS Between January 2008 and December 2010, 44 LD renal transplants were performed in high immune-risk recipients with a negative CDC-AHG cross-match. Outcomes of 14 recipients with pretransplant DSA were compared with 30 recipients with no DSA. After a median follow-up of 26 months (range, 12-40), overall death-censored graft survival was 100%, with no acute rejection episodes in the DSA group and 1 antibody-mediated rejection in the non-DSA cohort. Mean serum creatinines of the DSA and non-DSA groups at 1 year post-transplant were 1.0 ± 0.4 and 1.2 ± 0.6 mg/dL (P = NS), respectively. Among the pretransplant DSA cohort, 5 of the 14 (36%) developed persistent post-transplant DSA at a median of 9 months (range, 3-24) versus 2 of 30 (7%; P = .025) at a median of 12 months post-transplant in the non-DSA cohort. All recipients in the pretransplant DSA group underwent renal biopsy for persistent post-transplant DSA. Three of 5 biopsies showed C4D deposition in peritubular capillaries without glomerulopathy or arteriopathy. CONCLUSIONS Early post-transplant outcomes for LD recipients with a negative cross-match and pretransplant DSA were excellent. In recipients with good and stable renal function, the significance of persistent post-transplant DSA in combination with C4D deposition on biopsy is unclear at this time.