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Allan J Collins

Publications and source records attributed to Allan J Collins.

At least 55 records · Page 3Linked to original sources
PubMed2005

Does predialysis nephrology care influence patient survival after initiation of dialysis?

BACKGROUND: Early nephrology referral of patients with chronic kidney disease (CKD) has been suggested to reduce mortality after initiation of dialysis. This retrospective cohort study of incident dialysis patients between 1995 and 1998 was performed to address the association between frequency of nephrology care during the 24 months before initiation of dialysis and first-year mortality after initiation of dialysis. METHODS: Patient data were obtained from the Centers for Medicare & Medicaid Services. Patients who started dialysis between 1995 and 1998, and were Medicare-eligible for at least 24 months before initiation of dialysis, were included. One or more nephrology visits during a month was considered a month of nephrology care (MNC). RESULTS: Of the total 109,321 patients, only 50% had received nephrology care during the 24 months before initiation of dialysis. Overall, first-year mortality after initiation of dialysis was 36%. Cardiac disease was the major cause of mortality (46%). After adjusting for comorbidity, higher mortality was associated with increasing age (HR, 1.04 per year increase; 95% CI, 1.03 to 1.04) and more frequent visits to generalists (HR, 1.009 per visit increase; 95% CI, 1.003 to 1.014) and specialists (HR, 1.012 per visit increase; 95% CI, 1.011 to 1.013). Compared to patients with >/=3 MNC in the six months before initiation of dialysis, higher mortality was observed among those with no MNC during the 24 months before initiation of dialysis (HR, 1.51; 95% CI, 1.45 to 1.58), no MNC during the six months before initiation of dialysis (HR, 1.28; 95% CI, 1.20 to 1.36), and one or two MNC during the six months before initiation of dialysis (HR, 1.23; 95% CI, 1.18 to 1.29). CONCLUSION: Nephrology care before dialysis is important, and consistency of care in the immediate six months before dialysis is a predictor of mortality. Consistent nephrology care may be more important than previously thought, particularly because the frequency and severity of CKD complications increase as patients approach dialysis.

Aged↗
PubMed2005

Atherosclerotic renovascular disease in United States patients aged 67 years or older: risk factors, revascularization, and prognosis.

BACKGROUND: Although atherosclerotic renovascular disease is increasingly recognized in chronic kidney disease, few national level studies have examined its clinical epidemiology. METHODS: Claims data from a 5% random sample of the United States Medicare population were used to select patients without atherosclerotic renovascular disease in the 2 years preceding December 31, 1999 (N= 1,085,250), followed until December 31, 2001. RESULTS: The incidence of atherosclerotic renovascular disease was 3.7 per 1000 patient-years. Major antecedent associations [P < 0.05, with adjusted hazards ratios (HR) > 1.5] included chronic kidney disease (adjusted HR 2.54), hypertension (2.42), peripheral vascular disease (2.00), and atherosclerotic heart disease (1.70). Adverse event rates after incident atherosclerotic renovascular disease greatly exceeded those in the general population (P < 0.0001): atherosclerotic heart disease, 303.9 per 1000 patient-years (vs. 73.5 in the general population); peripheral vascular disease, 258.6 (vs. 52.2); congestive heart failure, 194.5 (vs. 56.3); cerebrovascular accident or transient ischemic attack, 175.5 (vs. 52.9); death, 166.3 (vs. 63.3); and renal replacement therapy, 28.8 (vs. 1.3). Among atherosclerotic renovascular disease patients, 16.2% underwent a renal revascularization procedure, percutaneously in 96%. Revascularization was not associated with renal replacement therapy, congestive heart failure, or death but was associated with atherosclerotic heart disease (adjusted HR 1.42) (P= 0.004) and peripheral vascular disease (adjusted HR 1.38) (P= 0.002). CONCLUSION: Atherosclerotic renovascular disease is strongly associated with cardiovascular disease, both past and future. Absolute cardiovascular risk exceeds that of renal replacement therapy. Renal revascularization is used selectively and shows inconsistent associations with cardiovascular outcomes, renal replacement therapy, and death.

Aged↗
PubMed2005

Septicemia, access and cardiovascular disease in dialysis patients: the USRDS Wave 2 study.

BACKGROUND: Microinflammation is linked to cardiovascular disease, and is highly prevalent in dialysis patients. It is logical to postulate that septicemia, a common macroinflammatory occurrence in dialysis patients, contributes to their large burden of cardiovascular disease. METHODS: The Dialysis Morbidity and Mortality Wave 2 was a randomly selected prospective cohort of incident dialysis patients. Admission claims data were used to define and calculate rates of septicemia or bacteremia and cardiovascular events in those with Medicare as the primary payer. Utilizing Cox proportional hazard models we determined the association between baseline access and the development of bacteremia or sepsis, and also the association between bacteremia or sepsis episodes and subsequent cardiovascular events. RESULTS: The 2358 (59%) patients with Medicare as primary payer were older and more likely to have heart failure than those with other payers, but had similar comorbidity-adjusted mortality hazards. Rates of first septicemia, bacteremia, or either condition, were 7.0, 5.9 and 10.4 events per 100-patient years, respectively. Cox regression identified initial dialysis access as the main antecedent of septicemia or bacteremia. Hazards ratios for hemodialysis with permanent catheters, temporary catheters, and grafts were 1.95 (95% CI 1.47-2.57), 1.76 (95% CI 1.29-2.41), and 1.05 (95% CI 0.82-1.35), respectively, while that for peritoneal dialysis was 0.96 (95% CI 0.75-1.23) (reference arteriovenous fistula). After adjustment for baseline factors, septicemia or bacteremia, as a time-dependent covariate, was associated with subsequent death [hazards ratio (HR) 2.33, 95% CI 1.38-2.28], myocardial infarction (HR 1.78, 95% CI 1.38-2.28), heart failure (HR 1.64, 95% CI 1.39-1.95), peripheral vascular disease (HR 1.64, 95% CI 1.34-2.0), and stroke (HR 2.04, 95% CI 1.27-3.28). CONCLUSION: Septicemia appears to be an important, potentially preventable, cardiovascular risk factor in dialysis patients.

Adult↗
PubMed2005

Cardiovascular risk factor profiles and kidney function stage in the US general population: the NHANES III study.

OBJECTIVE: To determine the prevalence of cardiovascular risk factors in the general population based on kidney function. SUBJECTS AND METHODS: We retrospectively analyzed data from the Third National Health and Nutrition Examination Survey of noninstitutionalized US adults, which was conducted from 1988 to 1994. Data were gathered on 9 cardiovascular risk factors (smoking; obesity; hypertension; high total cholesterol, C-reactive protein, glycosylated hemoglobin, and homocysteine levels; low hemoglobin level; and high urinary albumin-to-creatinine ratio) and estimated glomerular filtration rate (GFR). RESULTS: For the 15,837 subjects, the estimated GFR was at least 90 mL/min per 1.73 m2 (normal) in 65.4%, 60 to 89.9 mL/ min per 1.73 m2 (stage 2 kidney function) in 27.9%, 30 to 59.9 mL/min per 1.73 m2 (stage 3 kidney function) in 6.2%, and less than 30 mL/min per 1.73 m2 (stages 4 and 5 kidney function) In 0.5%. The number of cardiovascular risk factors Increased with stage of kidney dysfunction. Of subjects with a normal GFR, 30.4% had no risk factors, 34.9% had 1 risk factor, and 34.7% had 2 or more risk factors. Of subjects with stage 2 kidney function, 24.8% had no risk factors, 30.3% had 1 risk factor, and 44.9% had 2 or more risk factors. Of subjects with stage 3 kidney function, 1.4% had no risk factors, 14.9% had 1 risk factor, and 83.6% had 2 or more risk factors. All subjects with stages 4 and 5 kidney function had 2 or more risk factors. After covariate adjustment, odds ratios for having an estimated GFR lower than 60 mL/min per 1.73 m2 were 1, 3.7 (95% confidence interval, 1.2-11.3), and 10.4 (95% confidence interval, 3.9-27.8) times greater in subjects with 0, 1, and 2 or more cardiovascular risk factors, respectively (P<.001). CONCLUSION: Persons with chronic kidney disease are much more likely to need multiple cardiovascular risk factor interventions than those without chronic kidney disease.

Adult↗
PubMed2004

Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999.

Knowledge of the excess risk posed by specific cardiovascular syndromes could help in the development of strategies to reduce premature mortality among patients with chronic kidney disease (CKD). The rates of atherosclerotic vascular disease, congestive heart failure, renal replacement therapy, and death were compared in a 5% sample of the United States Medicare population in 1998 and 1999 (n = 1,091,201). Patients were divided into the following groups: 1, no diabetes, no CKD (79.7%); 2, diabetes, no CKD (16.5%); 3, CKD, no diabetes (2.2%); and 4, both CKD and diabetes (1.6%). During the 2 yr of follow-up, the rates (per 100 patient-years) in the four groups were as follows: atherosclerotic vascular disease, 14.1, 25.3, 35.7, and 49.1; congestive heart failure, 8.6, 18.5, 30.7, and 52.3; renal replacement therapy, 0.04, 0.2, 1.6, and 3.4; and death, 5.5, 8.1, 17.7, and 19.9, respectively (P < 0.0001). With use of Cox regression, the corresponding adjusted hazards ratios were as follows: atherosclerotic vascular disease, 1, 1.30, 1.16, and 1.41 (P < 0.0001); congestive heart failure, 1, 1.44, 1.28, and 1.79 (P < 0.0001); renal replacement therapy, 1, 2.52, 23.1, and 38.9 (P < 0.0001); and death, 1, 1.21, 1.38, and 1.56 (P < 0.0001). On a relative basis, patients with CKD were at a much greater risk for the least frequent study outcome, renal replacement therapy. On an absolute basis, however, the high death rates of patients with CKD may reflect accelerated rates of atherosclerotic vascular disease and congestive heart failure.

Age Distribution↗
PubMed2004

The fall and rise of parathyroidectomy in U.S. hemodialysis patients, 1992 to 2002.

Although the therapeutic approach to managing hyperparathyroidism has changed dramatically, it is unknown whether parathyroidectomy rates continue to decline in the United States. Parathyroidectomy rates were studied in successive annual national cohorts, prevalent on hemodialysis on January 1 of 1992 to 2002, with Medicare as primary payer. Parathyroidectomy was defined as International Classification of Diseases, Ninth Revision, Clinical Modification code 068. The annual incidence of parathyroidectomy was 11.6 per 1000 patient-years in 1992. The incidence declined progressively after 1994, reaching a low of 6.8 per 1000 patient-years in 1998. Rates increased progressively after 1998, reaching 11.8 per 1000 patient-years in 2002. Using proportional hazards modeling, with adjustment for comorbidity and 1992 as the reference group, the lowest adjusted hazards ratio, 0.32 (P < 0.0001), was seen in 1998, followed by hazards ratios of 0.39 (P < 0.0001) in 1999, 0.41 (P < 0.0001) in 2000, 0.52 (P < 0.0001) in 2001, and 0.53 (P < 0.0001) in 2002. Other antecedents of parathyroidectomy in multivariate models included ESRD network, younger age, female gender, white race, absence of diabetes, longer duration of previous hemodialysis, use of intravenous vitamin D, previous renal transplantation, several comorbid conditions, and parathyroid hormone measurement in the preceding year. With a case-control method, parathyroidectomy was associated with higher mortality rates immediately after surgery, followed, subsequently, by lower long-term rates. Parathyroidectomy rates in U.S. hemodialysis patients increased between 1998 and 2002, a period in which the therapeutic armamentarium for preventing severe hyperparathyroidism expanded considerably.

Aged↗
PubMed2004

Long-term outcome of renal transplant recipients in the United States after coronary revascularization procedures.

BACKGROUND: Retrospective studies in dialysis patients have reported increased survival after coronary artery bypass (CAB) compared with coronary artery stenting and PTCA. The purpose of this study was to compare the long-term outcome of renal transplant recipients after stent, PTCA, or CAB with or without internal mammary grafting (CAB [IMG+] or CAB [IMG-]). METHODS AND RESULTS: Renal transplant recipients hospitalized from 1995 to 1999 for first coronary revascularization procedure were retrospectively identified from the United States Renal Data System database. Event-free survival for the end points of all-cause death, cardiac death, acute myocardial infarction (AMI), and the combined end point of cardiac death or AMI was estimated by the life-table method. The impact of independent predictors on survival was examined in a comorbidity-adjusted Cox model. In-hospital mortality rate was 2.3% for 909 stent patients, 4.3% for 652 PTCA patients, 9.4% for 288 CAB (IMG-) patients, and 5.0% for 812 CAB (IMG+) patients. Two-year all-cause survival (+/-SE) was: stent, 82.5+/-2.8%; PTCA, 81.6+/-3.1%; CAB (IMG-), 74.4+/-5.4%; and CAB (IMG+), 82.7+/-2.8%. The relative risks of all-cause and cardiac death were not significantly different among revascularization groups. The relative risk of cardiac death or AMI (versus PTCA) was 0.90 (95% CI, 0.69 to 1.17) for stent, 0.80 (95% CI, 0.55 to 1.17) for CAB (IMG-), and 0.57 (95% CI, 0.42 to 0.76) for CAB (IMG+). CONCLUSIONS: Renal transplant recipients in the United States have comparable long-term survival after percutaneous and surgical coronary revascularization procedures. The most favorable long-term outcome occurs after surgical coronary revascularization.

Adult↗
PubMed2004

Dialyser reuse-associated mortality and hospitalization risk in incident Medicare haemodialysis patients, 1998-1999.

BACKGROUND: The reuse of haemodialysers has been practiced in the United States for >20 years. We investigated mortality and hospitalization risk according to various reuse practices, testing the hypothesis that outcomes are improved in patients treated with dialysers cleaned with bleach and sterilized with formaldehyde. METHODS: We studied 1998 and 1999 incident Medicare haemodialysis patients, with follow-up through December 31, 2000 (49 273 patients). Clinical conditions and dialysis therapy were characterized from Medicare claims data. Included were patients who could be linked to a dialysis provider. Demographic characteristics were obtained from the Centers for Medicare and Medicaid Services (CMS) Medical Evidence Report. Mortality information was obtained from the CMS ESRD Death Notification; hospitalization information, from Medicare in-patient claims files. Data on reuse practices were obtained from the annual survey of haemodialysis units conducted by the Centers for Disease Control and Prevention. RESULTS: Cox regression analyses found no significant differences in mortality or first-hospitalization risk for patients in dialysis units not using bleach as a cleaning agent. Outcomes for patients treated in units using glutaraldehyde did not vary according to use of bleach. In the analysis of first-hospitalization risk, there was no difference according to various germicide/bleach combinations. Overall, there was no significant difference in relative risk of death or in hospitalization risk among the reuse groups (including the no-reuse group). CONCLUSIONS: For the 1998-1999 period, reuse practices were not associated with a survival advantage or disadvantage. Our findings may reflect the National Kidney Foundation's 1997 introduction of clinical practice guidelines, the intent of which was to bring about increased consistency of care within the dialysis community in the United States.

Equipment Reuse↗
PubMed2004

Impact of congestive heart failure, chronic kidney disease, and anemia on survival in the Medicare population.

BACKGROUND: Congestive heart failure (CHF) is a common clinical problem in the elderly, yet few studies have focused on this population. In addition, information on mortality rates conferred by chronic kidney disease (CKD) and anemia in elderly patients with CHF is lacking. METHODS AND RESULTS: A cohort of 1,136,201 patients in the 5% Medicare database, excluding those with end-stage renal disease (ESRD), was identified for a 2-year period (1996-1997). Subgroups with CHF, CKD, and anemia were identified. The effect of each disease as an independent predictor of mortality was examined in a comorbidity-adjusted Cox model, with patients followed for 2 years and censored for death or ESRD. In the study population, 61% were women; 89% were white and 7% were black. Mean +/- SD age was 76.5 +/- 6.9 years. The annual mortality rate for patients with no CHF, CKD, or anemia was 4%. Anemia was associated with an annual mortality of 8%, which was the same as CKD (8%). The annual mortality for CHF was 13%. The highest annual mortality was found in patients with all 3 comorbid conditions; mortality in these patients was 23%. CONCLUSIONS: Elderly CHF patients are at high risk of death; this risk is magnified in the presence of CKD and anemia.

Aged↗
PubMed2004

Assessment of pure red cell aplasia in US dialysis patients: the limits of the Medicare data.

BACKGROUND: A report of neutralizing antibodies to recombinant human erythropoietin (rHuEPO) in European dialysis patients raised concerns that US dialysis patients may be at similar risk. We investigated the frequency of diagnosis codes that include pure red cell aplasia (PRCA) in the Medicare end-stage renal disease data. METHODS: Medicare claims data were used to identify incident dialysis patients from 1995 through 1999 aged 67 years or older who did not have a diagnosis code for aplastic anemia (AA; which includes PRCA) or were not administered rHuEPO before dialysis therapy initiation. Patients were assessed for complicating conditions, rHuEPO dose, hematocrit level, blood transfusion, bone marrow testing, and AA diagnosis (maximal follow-up, 13 months). RESULTS: Of 101,782 patients eligible for study, 9,896 patients had diagnosis codes for AA after dialysis therapy initiation, 3,894 patients underwent bone marrow tests (required for PRCA diagnosis), 19 patients had diagnosis codes for AA based on bone marrow examination and no other complicating conditions, and 5 patients were administered blood transfusion in 1 or more months during follow-up, of whom only 1 patient had persistent low hematocrit levels while being administered rHuEPO and blood transfusion. This latter patient was identified from a total of 101,782 patients, or 70,706.75 person-years of rHuEPO exposure. CONCLUSION: Diagnosis codes in the Medicare data are inadequate for the conclusive study of PRCA in US dialysis patients. Despite limitations of this study, it appears that few cases of rHuEPO-associated PRCA have occurred in US Medicare dialysis patients. Additional investigation is needed to determine whether apparent differences between US complication rates and those elsewhere result from differences in the manufacturing and/or use of erythropoietin products.

Aged↗
PubMed2004

Long-term survival of dialysis patients with bacterial endocarditis in the United States.

BACKGROUND: The incidence of bacterial endocarditis is much greater in long-term dialysis patients compared with the general population, and chronic kidney disease has been postulated as an independent host-related risk factor. Limited data are available on the long-term survival of dialysis patients with endocarditis. METHODS: Dialysis patients hospitalized for bacterial endocarditis between 1977 and 2000 were studied retrospectively using data from the US Renal Data System database. Long-term survival was estimated by means of the life-table method. A Cox proportional hazards model was used to identify the impact of demographic characteristics and comorbidity on outcome. RESULTS: A total of 13,130 dialysis patients with bacterial endocarditis were identified. The in-hospital mortality rate for the entire cohort was 23.5%. Survival rates at 1, 2, 3, and 5 years were 45.9%, 33.3%, 24.3%, and 14.7% for patients hospitalized between 1977 and 1991 and 41.0%, 29.1%, 20.6%, and 10.9% for those hospitalized between 1992 and 1996, respectively. Survival rates at 1, 2, and 3 years were 38.4%, 25.3%, and 18.3% for patients hospitalized between 1997 and 2000, respectively. The most powerful independent predictors of all-cause death were age, diabetes as cause of end-stage renal disease, and cerebrovascular accident or transient ischemic attack as a comorbid condition. CONCLUSION: Dialysis patients with bacterial endocarditis have poor long-term survival, even in the current treatment era, with survival rates changing little in the past 2 decades. Additional studies are needed to identify risk-reduction measures and develop additional treatment strategies for dialysis patients with endocarditis.

Aged↗
PubMed2004

Differences between blacks and whites in the incidence of end-stage renal disease and associated risk factors.

In the United States, the age-and-gender-adjusted incident rate of end-stage renal disease (ESRD) for blacks has been 4 times higher than that for whites. We analyzed patient information and medical services contained in the Medicare 5% random sample database. White (n = 977,436) and black (n = 77,800) Medicare enrollees who were at least 65 years old on January 1, 1997, were followed from 1999 to 2001. Hierarchical Cox regression models were used to estimate the relative risk of ESRD for blacks (with reference to whites) after adjustment for age and gender, socioeconomic status, special health conditions (anemia, chronic obstructive pulmonary disease, cardiovascular disease), primary causal diseases of ESRD (eg, diabetes, hypertension), diabetes care and preventive care (eg, hemoglobin A1c or lipid testing), and physician visits for primary or specialty care. The relative risk of ESRD for blacks (with reference to whites) was 3.52 (95% confidence interval [CI], 3.25-3.80) after adjustment for age and gender; 2.90 (95% CI, 2.67-3.15) after adjustment for socioeconomic status and special health conditions; and 2.11 (95% CI, 1.94-2.30) after further adjustment for primary causal diseases of ESRD, diabetes care and preventive care, and physician visits. We conclude that a higher prevalence of primary causal diseases of ESRD and lower access to diabetes care, preventive care, and primary physician visits in blacks compared with whites partially accounts for the racial difference in the incidence of ESRD in the elderly Medicare population. Public health policy should focus on improving access to care, which may lower the burden of ESRD in minority and other at-risk populations.

Black or African American↗
PubMed2004

Hemoglobin levels and erythropoietin doses in hemodialysis and peritoneal dialysis patients in the United States.

Erythropoietic agents, a cornerstone of management, are a major component of the cost of renal replacement therapy. The objectives of this study were to compare (on a month-by-month basis) U.S. hemodialysis and peritoneal dialysis patients in terms of the proportion of patients receiving erythropoietin, erythropoietin doses, and hemoglobin levels after initiation of erythropoietin. Patients studied (hemodialysis, n = 121,970; peritoneal dialysis, n = 7129) began dialysis between 1995 and 2000, had Medicare as their primary payer, were 65 yr old or older at dialysis inception, had no erythropoietin claims before dialysis inception, and did not have a switch in dialysis modality in the first 6 mo of dialysis therapy. Total monthly erythropoietin doses and average monthly hemoglobin levels were calculated from Medicare claims. The proportion of patients who received erythropoietin plateaued at 3 mo in both groups: 25% in peritoneal dialysis patients and 80% in hemodialysis patients. However, monthly erythropoietin doses plateaued at 30,000 units in peritoneal dialysis patients and 60,000 units in hemodialysis patients, a disparity not explicable by differences in baseline characteristics. Among subjects who received erythropoietin, mean hemoglobin levels were similar at steady state in both populations and met the National Kidney Foundation Dialysis Outcomes Quality Initiative hemoglobin target level of 11 to 12 g/dl. Hemoglobin levels in U.S. hemodialysis and peritoneal populations are similar. However, erythropoietin doses are dramatically higher in hemodialysis patients.

Aged↗
PubMed2004

Septicemia in the United States dialysis population, 1991 to 1999.

The clinical epidemiology of septicemia in dialysis populations remains poorly defined. In this historical cohort study of 393,451 U.S. dialysis patients, International Classification of Disease, Ninth Revision, Clinical Modification discharge diagnosis codes were used to compare first-year septicemia admission rates in annual incident cohorts from 1991 to 1999 and to calculate subsequent cardiovascular event and mortality rates. Hemodialysis (compared with peritoneal dialysis) as initial therapy and starting dialysis in more recent years were the principal antecedents of septicemia. In hemodialysis patients, adjusted first admission rates (expressed throughout as first episodes per 100 patient-years) rose by 51%, from 11.6 in 1991 to 17.5 in 1999. In peritoneal dialysis patients, rates rose from 5.7 in 1991, peaked at 9.2 in 1997, and declined to 8.0 in 1999. Mortality rates after septicemia were similar to mortality rates after major cardiovascular events. Septicemia was associated with developing myocardial infarction, congestive heart failure, stroke, and peripheral vascular disease with adjusted risk ratios of 4.1, 5.5, 4.1, and 3.8 in the initial 6 mo after admission for septicemia and 1.7, 2.0, 2.0, and 1.6 after 5 yr, respectively. Septicemia, which is associated with increased cardiovascular and death risk, has become more common in dialysis patients in the United States.

Adult↗
PubMed2004

Prevalence of anemia in erythropoietin-treated pediatric as compared to adult chronic dialysis patients.

BACKGROUND: Recent guidelines recommend a target hemoglobin range of 11 to 12 g/dL in pediatric and adult dialysis patients. We compared anemia prevalence in United States Medicare pediatric and adult dialysis patients. METHODS: Prevalent hemodialysis patients (0 to 19 years, pediatric: N= 1692; adult: N= 352,291) and peritoneal dialysis patients (pediatric: N= 597; adult: N= 39,136) treated with recombinant human erythropoietin (rHuEPO) from 1996 to 2000 were selected. Mean annual hemoglobin values were calculated by modality, age, sex, and race. RESULTS: Among hemodialysis patients, mean annual hemoglobin values less than 11 g/dL were present in pediatric and adult patients during 54.1% versus 39.8% patient years, respectively (P < 0.0001); for peritoneal dialysis patients, 69.5% versus 55.1% (P < 0.0001). Mean hemoglobin values increased over time and were 11.2, 11.5, 10.8, and 11.2 g/dL for pediatric and adult hemodialysis and peritoneal dialysis patients, respectively, in 2000. Pediatric hemodialysis patients received intravenous iron less frequently than adults (66.3% vs. 82.5% patient years; P < 0.0001). CONCLUSION: Hemoglobin values in rHuEPO-treated pediatric dialysis patients lagged behind those of adult patients, with pediatric patients achieving target hemoglobin values only a minority of the time (45.9% and 30.5% patient years, respectively, for hemodialysis and peritoneal dialysis). Trends show recent improvement in anemia treatment of children on dialysis. Still, further attention to and analysis of rHuEPO and iron therapy in pediatric dialysis patients is warranted.

Adolescent↗
PubMed2004

Association of hematocrit value with cardiovascular morbidity and mortality in incident hemodialysis patients.

BACKGROUND: Associations between hematocrit values and clinical outcome have been studied with conflicting results in cardiac patients, end-stage renal disease (ESRD) patients, and ESRD patients with cardiac disease. We studied dialysis patients to determine the relationship between hematocrit value and cardiac risk under current Dialysis Outcomes Quality Initiative (DOQI) practices. METHODS; Medicare data were used to study 50,579 incident hemodialysis patients selected from January 1, 1998, to December 31, 1999, who received hemodialysis for 9 months after the onset of ESRD. Patients were divided into groups on the basis of the hematocrit value: < or =30%, >30% to < or =33%, >33% to < or =36%, >36% to < or =39%, and >39%. For hospitalization, the follow-up extended to 21/2 years; for mortality, 3 years. RESULTS: Compared to patients with hematocrit values of >33% to < or =36%, patients with values of >36% to < or =39% and those with values of >39% had risk ratios for hospitalization due to cardiac disease of 0.92 (95% CI 0.88 to 0.97) and 0.79 (95% CI 0.72 to 0.87), respectively, and risk ratios for death due to cardiac disease of 0.92 (95% CI 0.87 to 0.98) and 0.83 (95% CI 0.74 to 0.93), respectively, in the follow-up period. CONCLUSION: The significant associations we report do not establish a causal relationship between higher hematocrit values and lower risks of cardiac morbidity and mortality. A randomized clinical trial in low-risk patients is needed to establish causality.

Aged↗
PubMed2004

Cardiac medications and their association with cardiovascular events in incident dialysis patients: cause or effect?

BACKGROUND: There are no large randomized, controlled trials evaluating the efficacy of common cardioprotective medications on cardiovascular outcomes in the dialysis population. We aimed to determine the association between cardioprotective medications and a composite end point of cardiovascular events or death in an incident dialysis cohort. METHODS: Medicare claims data were utilized to determine outcomes in participants of the Dialysis Morbidity and Mortality Wave 2 cohort. Information was gathered at baseline regarding demographics, comorbidities, medication use, and lab data. Cox proportional hazard models were developed to determine the association between cardioprotective medication use at baseline and the subsequent development of a composite of cardiovascular events or death. RESULTS: Two thousand two hundred thirty-four of 3044 individuals experienced a cardiovascular event or death. Use of the following medications at baseline was associated with an increased event rate: nitrates, antiplatelet agents, and warfarin. There was no association between the use of angiotensin-converting enzyme inhibitors, beta-blockers, or 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors and a composite cardiovascular outcome or death. Only use of a calcium channel blocker at baseline was associated with a reduced risk of events. This beneficial association did not persist when death was excluded as an outcome. Many of the associations observed varied substantially depending on the outcome utilized. CONCLUSION: Use of cohort data to determine an association between medication use and outcome is difficult because the indication for the medication confounds the observed association. Before widespread practice changes, rigorous clinical trials of common cardioprotective medications on cardiovascular morbidity and mortality in dialysis should be performed.

Adrenergic beta-Antagonists↗