Shivam Joshi

Disparities among Blacks, Hispanics, and Whites in time from starting dialysis to kidney transplant waitlisting.

Background Although a longer time on dialysis before kidney transplant waitlisting has been shown for Blacks versus non-Blacks, relatively few studies have compared this outcome between Hispanics and Whites. Methods A multivariable analysis of 1910 (684 Black, 452 Hispanic, and 774 White) consecutive patients waitlisted at our center for a primary kidney transplant between 2005 and mid-2010 was performed for time from starting dialysis to waitlisting (months), the percentage who were preemptively waitlisted (waitlisted before starting dialysis), and time from starting dialysis to waitlisting after excluding the preemptively waitlisted patients. Results The variables associated with significantly longer median times from starting dialysis to waitlisting and less preemptive waitlisting included Medicare insurance for patients ages <65 years (by far, the most significant variable in each analysis), Black race, higher percentage of households in the patient’s zip code living in poverty, being a non-U.S. citizen (for preemptive waitlisting), Medicaid insurance, waitlisted for kidney-alone (vs. kidney-pancreas) transplant, and higher body mass index (longer median times for the latter three variables). Although the effect of Black race was mostly explained by significant associations with lower socioeconomic status (Medicare insurance for patients ages <65 years and greater poverty in the patient’s zip code), an unexplained component still remained. The univariable differences showing poorer outcomes for Hispanics versus Whites were smaller and completely explained in multivariable analysis by significant associations with lower socioeconomic status and non-U.S. citizenship. Conclusion Black and Hispanic patients had significantly longer times from starting dialysis to waitlisting, in large part related to their lower socioeconomic status and less preemptive waitlisting. A greater focus on earlier nephrology care may help to erase much of these disparities.

Graft failure due to noncompliance among 628 kidney transplant recipients with long-term follow-up: a single-center observational study.

Background In adult kidney transplantation, there is no clear consensus on the incidence of graft failure-due-to noncompliance (GFNC), with some reporting it as relatively uncommon and others as a major cause of late graft failure. We suspected that GFNC was a major cause of late graft loss at our center but did not know the extent of this problem. Methods In our prospectively followed cohort of 628 adult, primary kidney-alone transplant recipients with long-term follow-up, GFNC and other graft loss causes were determined from our ongoing clinical evaluations. Using competing risks methodology, we determined the overall percentage of patients developing GFNC and the significant prognostic factors for its hazard rate and cumulative incidence (via Cox regression). Results Cumulative incidence estimates (±standard error) of GFNC (n=29), GF-with-compliance (n=46), receiving a never-functioning graft (n=7), and death-with-a-functioning-graft (n=53) at 101 months after transplant (last-observed-graft loss) were as follows: 9.8%±2.4%, 10.9%±1.7%, 1.1%±0.4%, and 13.0%±1.9%, respectively. Only three patients experienced GFNC during the first 24 months; GFNC represented 48.1% (26/54) of death-censored GFs beyond 24 months. Two baseline variables were jointly associated with a significantly higher GFNC hazard and cumulative incidence: younger recipient age (P<0.000001 each) and non-white recipient (P=0.004 and P=0.02). Estimated percentages of ever developing GFNC were 28.4%±6.5% among 79 non-whites younger than 35 years versus 0.0% (0/144) among whites 50 years or older. Among 302 recipients younger than 50 years, 18.1%±4.1% developed GFNC, representing 67.6% (25/37) of its death-censored graft failures observed beyond 24 months after transplant. Conclusions GFNC is a major cause of late GF at our center, with younger and non-white recipients at a significantly greater GFNC risk. Interventional approaches to eliminate GFNC could dramatically improve long-term kidney graft survival.

Overview of pediatric orbital fractures

Orbital fractures in children are uncommon. The pattern of orbital fractures changes as children age. Although the management of pediatric orbital fractures is evolving, a thorough clinical assessment with computed tomographic scan imaging is essential. Urgent surgical intervention is indicated in cases of entrapment or acute enophthalmos. Entrapment with oculocardiac reflex is common in the white-eyed blow-out or trapdoor fractures. Otherwise, pediatric fractures may be treated conservatively with surveillance. A variety of autogenous and allogenic materials may be used to repair the fractured orbit. Resorbable plating systems are an alternative to rigid metallic fixation and may be used on the developing craniofacial skeleton.

Review of ethnic disparities in access to renal transplantation

Renal transplantation is the gold standard treatment for patients with end‐stage renal disease and is associated with several advantages over dialysis, including increased quality of life, reduced morbidity and mortality, and lower healthcare costs. Barring the constraints of a limited organ supply, the goals of the patient care should focus on attaining renal transplantation while minimizing, or even eliminating, time spent on dialysis. Disparities in access to renal transplantation between African Americans and Caucasians have been extensively documented, with African Americans having significantly poorer access. There is a growing corpus of literature examining the determinants of reduced access among other racial ethnic minority groups, including Hispanics. These determinants include patient and physician preference, socioeconomic status, insurance type, patient education, and immunologic factors. We review these determinants in access to renal transplantation in the United States among all races and ethnicities.

Development of a surgical safety checklist for the performance of radical nephrectomy and tumor thrombectomy

BackgroundThe surgical management of renal cell carcinoma with invasion of the renal vein or inferior vena cava is associated with significant rates of perioperative morbidity and mortality. In this report we propose a surgical checklist aimed at reducing adverse events associated with the resection of these tumors.MethodsThis review describes the development of an evidence- and experience-based surgical checklist aimed at improving the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy.ResultsReducing the risk of complications during the surgical management of renal tumors with venous invasion begins with appropriate pre-operative imaging aimed at defining the cranial extent of the tumor thrombus, thus facilitating accurate preoperative planning. Other key elements of the checklist are aimed at ensuring clear and precise pre-, intra- and postoperative communication between members of the multidisciplinary-care team.ConclusionA standardized surgical checklist may help to increase the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy. Future validation studies are required to determine the clinical feasibility and post-implementation safety profile of this new checklist.

Reciprocating living kidney donor generosity: tax credits, health insurance and an outcomes registry

Kidney transplantation significantly improves patient survival, and is the most cost effective renal replacement option compared with dialysis therapy. Living kidney donors provide a valuable societal gift, but face many formidable disincentive barriers that include not only short- and long-term health risks, but also concerns regarding financial expenditures and health insurance. Other than governmental coverage for their medical evaluation and surgical expenses, donors are often asked to personally bear a significant financial responsibility due to lost work wages and travel expenses. In order to alleviate this economic burden for donors, we advocate for the consideration of tax credits, lifelong health insurance coverage, and an outcomes registry as societal reciprocity to reward their altruistic act of kidney donation.

Release of the Inferior Vena Cava Ligament during Caval Thrombectomy Causing Tumor Thrombus Embolization

Intraoperative tumor embolization is a rare complication during the surgical management of renal cell carcinoma with tumor thrombus of the inferior vena cava (IVC). We present a case of pulmonary tumor embolism which occurred during liver mobilization immediately following division of the IVC ligament. We hypothesize that this patients IVC ligament acted as an external barrier to propagation of the tumor thrombus and that its release caused the tumor to rapidly expand leading to embolization. To our knowledge, this is the first report of a pulmonary tumor embolism occurring immediately following division of the IVC ligament.

8-year survival in a patient with several recurrences of renal cell carcinoma after radical nephrectomy

We describe the case of a patient with a large renal cell carcinoma (RCC) who underwent cytoreductive nephrectomy utilizing liver mobilization techniques similar to those used in transplantation. Despite recurrent metastases, our patient continues to survive eight years later with several metastasectomies and adjuvant chemotherapy. We report the case of a 48-year-old Hispanic American man who presented with a 4-month history of an enlarging right upper quadrant abdominal mass and hematuria. Computerized tomography revealed a 13 x 14 x 14 centimeter mass suspicious of RCC with possible metastasis to the lungs. The patient subsequently underwent radical nephrectomy. Pathological analysis confirmed the mass as RCC. Over the following eight years, the patient developed metastases to the pulmonary lobes, buccal mucosa, thoracic spine, and second rib, which were all treated with metastasectomy. The patient continues to survive today with a reasonable quality of life. Palliative measures in patients with large RCC tumors with distant metastases require persistent, aggressive therapeutic modalities.

IMPORTANT SURGICAL CONSIDERATIONS IN THE MANAGEMENT OF RENAL CELL CARCINOMA (RCC) WITH INFERIOR VENA CAVA (IVC) TUMOUR THROMBUS

They described the surgical team: a vascular surgery team for a level ≥ II IVC tumour thrombus, a hepatobiliary team for a level III thrombus, and a cardiovascular team for any level IV thrombus. From our experience, we suggest that having an urologist with experience in multi-organ transplantation in the team makes it more effi cient because of the better understanding of the pathophysiology of RCC with tumour thrombus. We have required the presence of a cardiothoracic team only if there was a large right atrial tumour thrombus, severe Budd-Chiari syndrome, or the presence of pulmonary arterial emboli [ 2 – 4 ] .

Quantifying US Residency Competitiveness in Different Fields—Reply

bring further humiliation and shame to the family name. Most of the time, community cannot resolve this fundamental conflict and elder abuse issues. Recreational activities help, but cannot address root problems. Chinese culture is heavily family centric, and the belief is “don’t wash your dirty linen in public.” Bringing community into family problems is not a substitute for children who are filial and not abusive or neglectful. To achieve elder rights and improve the health and well-being of older adults in China, multifaceted social and cultural issues should be addressed.