Paul G. Welch

Hospitalizations for fractures after renal transplantation in the United States.

PURPOSE To investigate the incidence, risk factors, and associated mortality of fractures in renal transplant recipients. METHODS Retrospective registry study of 33,479 patients in the United States Renal Data System (USRDS) who received kidney transplants between 1 July 1994 and 30 June 1997. Associations with hospitalizations for a primary discharge diagnosis of fractures (all causes) were assessed. RESULTS Renal transplant recipients had an adjusted incidence ratio for fractures of 4.59 (95% confidence interval 3.29 to 6.31). In multivariate analysis, recipients with prevalent fractures, as well as recipients who were Caucasian, women, in the lower quartiles of recipient weight (<95.9 kg), had end stage renal disease caused by diabetes, and had prolonged pretransplant dialysis were at increased risk for hospitalization because of fractures after transplantation. Recipients hospitalized for hip fractures had decreased all-cause survival (hazard ratio for mortality 1.60, 95% CI 1.13 to 2.26) in Cox Regression analysis. CONCLUSIONS In the early post-transplant course (<3 years), renal transplant recipients had a greater incidence of fractures than the general population, which were associated with decreased patient survival. Preventive efforts should focus on recipients with the risk factors identified in this analysis, most of which can be easily obtained through history and physical examination.

Scleroderma Renal Crisis Prior to Scleroderma

SCLERODERMA renal crisis (SRC) is characterized by rapid onset of severe hypertension and rapid deterioration of renal function. Although this event usually complicates established progressive systemic sclerosis (PSS), occasionally SRC may be the mode of presentation of the illness. 1 We report a case in which renal failure occurred before skin thickening, causing other etiologies of renal failure to be considered. The diagnosis of scleroderma renal involvement was confirmed at autopsy.

A multidisciplinary program for achieving lipid goals in chronic hemodialysis patients.

BackgroundThere is little information on how target lipid levels can be achieved in end stage renal disease (ESRD) patients in a systematic, multidisciplinary fashion.MethodsWe retrospectively reviewed a pharmacist-directed hyperlipidemia management program for chronic hemodialysis (HD) patients. All 26 adult patients on chronic HD at a tertiary care medical facility were entered into the program. A clinical pharmacist was responsible for laboratory monitoring, patient counseling, and the initiation and dosage adjustment of an appropriate 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor (statin) using a dosing algorithm and monitoring guidelines. The low-density lipoprotein (LDL) cholesterol goal was ≤ 100 mg/dl. A renal dietitian provided nutrition counseling and the nephrologist was notified of potential or existing drug interactions or adverse drug reactions (ADRs). Patients received a flyer containing lipid panel results to encourage compliance. Data was collected at program initiation and for 6 months thereafter.ResultsAt the start of the program, 58% of patients were at target LDL cholesterol. At 6 months, 88% had achieved target LDL (p = 0.015). Mean LDL cholesterol decreased from 96 ± 5 to 80 ± 3 mg/dl (p < 0.01), and mean total cholesterol decreased from 170 ± 7 to 151 ± 4 mg/dl (p < 0.01). Fifteen adjustments in drug therapy were made. Eight adverse drug reactions were identified; 2 required drug discontinuation or an alternative agent. Physicians were alerted to 8 potential drug-drug interactions, and appropriate monitoring was performed.ConclusionsOur findings demonstrate both feasibility and efficacy of a multidisciplinary approach in management of hyperlipidemia in HD patients.

A Reconsideration of the Benefits of Cancer Screening in Dialysis Patients

Cancer screening is an important service provided by primary health care providers. Ideal screening programs include highly sensitive, specific, reliable, low-cost, and low-risk tests that, when performed, potentially prolong patient life and avoid morbidity and costs of advanced cancer (1). Standard screening recommendations have been established for colon, breast, ovarian, cervical, and prostate malignancies. These recommendations are based largely on studies conducted in normal populations. Health care providers of patients with chronic diseases often perform cancer-screening tests that have not been fully studied in such populations. One of the major but rarely acknowledged biases in cancer-screening recommendations is the assumption that patients screened can expect a normal life span, over which time they may benefit from screening. In a group of patients who do not have such a “normal” life expectancy, as in end-stage renal disease (ESRD), the benefit of screening may be reduced or may not be realized (2). Chronic disease populations may also have physical and social features that significantly affect the cost-benefit analysis of malignancy screening as compared to normal populations. The purpose of this editorial review is to increase awareness of the unique aspects of cancer screening in ESRD, thus facilitating decisions about screening of individual patients in this population. Few data exist that address cancer screening specifically in ESRD patients. Applying standard screening concepts to this group is problematic for several reasons. The mortality of ESRD patients is higher than in the general population, resulting in fewer life-years of potential benefit when early malignancy is discovered (2). Patients with ESRD appear to be at an increased risk of malignancy, which may change the predictive value of screening tests (3–6). The increase in malignancy rate is seen predominantly soon after the initiation of hemodialysis, suggesting a detection bias at the time of ESRD therapy initiation (7). The specificity and sensitivity of screening may be altered in ESRD patients. For example, fecal occult blood screening becomes even less specific as a screening tool when one considers the high rate of positive tests not related to malignancy in ESRD patients (8). Therefore, applying standard screening recommendations to the ESRD population is unlikely to result in outcomes similar to those reported for the general population. Furthermore, the impact of ESRD on the cancerscreening risk-benefit ratio is difficult to predict. Currently, there are no guidelines or policies from the American Society of Nephrology, the Renal Physicians Association, the National Kidney Foundation, or the National Institute of Diabetes and Digestive and Kidney Diseases. Per the National Cancer Institutes’ guidelines for the general population (9, 10), it is recommended that ESRD patients be screened routinely. This recommendation was challenged recently by Chertow et al. (11), whose group pointed out the bias in the literature supporting increased overall rates of malignancy in the ESRD population and evaluated the cost-effectiveness of a hypothetical cancer-screening program in the ESRD population versus the general population. The so-called DEALE (decliningexponentialapproximation oflife expectancy) method was used for approximating life expectancy, and assumptions were made so as to strengthen the benefits of screening. The net benefit of a cancerscreening program was shown to produce a reduction in the annual mortality—from 20% to 19.98%—in patients with ESRD. The researchers concluded that cancer screening in ESRD patients was inefficient and should not be implemented except in selected populations. Although a standard recommendation for widespread cancer screening in the ESRD population is not supported by the available data, screening may be beneficial in a subset of ESRD patients or for a subset of common malignancies. To examine this possibility, we have used the DEALE method to develop a real-time life expectancy calculator, generating multiple survival figures using available data on mortality in the ESRD population, cancer incidence and mortality in the general population, and information about the attributes of major cancerscreening programs (12; unpublished data). The DEALE method is a simplified approximation of life expectancy based on the assumption that survival follows a simple declining exponential function (11, 13, 14). In this model, if the mortality ( m) for a given patient population remains fairly linear over time, the reciprocal of this mortality will equal the life expectancy ( LE):