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Allan J Collins

Publications and source records attributed to Allan J Collins.

At least 73 records · Page 4Linked to original sources
PubMed2004

Anemia, hospitalization, and mortality in patients receiving peritoneal dialysis in the United States.

BACKGROUND: The view that hemoglobin levels in peritoneal dialysis patients should be maintained at 11 to 12 g/dL is based largely on the results of studies in hemodialysis patients. METHODS: We studied 13,974 erythropoietin-treated Medicare patients who initiated peritoneal dialysis between 1991 and 1998. Mean hemoglobin levels for the first 6 months of the study and, subsequently, time to first hospitalization and death during a 2-year follow-up were determined. RESULTS: The percentages of patients with hemoglobin levels of <10, 10 to 10.9, 11 to 11.9, and >/=12 g/dL were 24.6%, 40.6%, 27.6%, and 7.2%, respectively. First-hospitalization and death rates, respectively, were 109.5 and 21.6 per 100 patient-years in nondiabetic patients, and 152.9 and 31.5 in diabetic patients. In nondiabetic patients, adjusted hospitalization hazard ratios for hemoglobin levels of <10, 10 to 10.9, 11 to 11.9 (reference category), and >/=12 g/dL were 1.29 (P < 0.0001), 1.15 (P < 0.0001), 1, and 0.98 (NS), respectively. The corresponding adjusted mortality hazard ratios were 1.43 (P < 0.0001), 1.13 (P < 0.05), 1, and 1.14 (NS). In diabetic patients, hazard ratios of 1.26 (P < 0.0001), 1.07 (NS), 1, and 0.82 (P < 0.01) were observed for hospitalization, and 1.34 (P < 0.0001), 1.18 (P < 0.01), 1, and 0.92 (NS) for mortality. CONCLUSION: In peritoneal dialysis patients, anemia is associated with hospitalization and mortality in a manner supporting current Kidney Dialysis Outcomes Quality Initiative (K/DOQI) hemoglobin targets. In addition, hemoglobin levels of >/=12 g/dL are associated with lower hospitalization rates in diabetic patients.

Adult↗
PubMed2004

Chronic kidney disease: the distribution of health care dollars.

BACKGROUND: The cost of care for end-stage renal disease (ESRD) is known to be high. The factors responsible for higher ESRD cost develop during chronic kidney disease (CKD), where the data on distribution of cost are limited. METHODS: This retrospective cohort study of 1995 through 1998 incident dialysis patients was performed to study the distribution of costs during the 24 months prior to initiation of dialysis. Patient data were obtained from the Centers for Medicare and Medicaid Services (CMS). Patients who were Medicare eligible for at least 2 years prior to initiation of dialysis were included in the study. Financial data were obtained from Medicare Part A and Part B claims and inflationary adjustments were made. The study period was divided into four segments based on overall distribution of cost. RESULTS: The mean age was 75 years, 51% were males, 73% were white, and 22% were black. Overall, patient comorbidity increased significantly during the study years. Cost showed a sharp increase in the last 6 months prior to initiation of dialysis. Hospitalization was the major component of cost throughout study period. Patients who initiated hemodialysis incurred a higher cost compared to patients who initiated other modes of kidney replacement therapy. Patients with diabetes or cardiovascular disease incurred higher cost compared to those who had no diabetes or cardiovascular disease, respectively. CONCLUSION: These data showed that hospitalization was the major component of the sharp increase in cost around the initiation of dialysis. Increased comorbidity was associated with higher cost. A focus on timely management of CKD may prevent future morbidity and costs.

Aged↗
PubMed2004

Relationship among catheter insertions, vascular access infections, and anemia management in hemodialysis patients.

BACKGROUND: Arteriovenous fistulas are the recommended permanent vascular access (VA) for chronic hemodialysis. However, in the United States most patients begin chronic hemodialysis with a catheter. Recent data suggest that VA type contributes to recombinant human erythropoietin (rHuEPO) resistance. We examined catheter insertions, VA infections, and anemia management in Medicare, rHuEPO-treated, chronic hemodialysis patients. METHODS: We compared hemoglobin values and rHuEPO and intravenous iron dosing with concurrent catheter insertions and VA infections in 186,348 period-prevalent patients in 2000. We studied anemia management after catheter insertions and VA infections in 67,410 incident patients from 1997 to 1999. Multiple linear regression models examined follow-up hemoglobin and rHuEPO dose per week (rHuEPO/wk) by numbers of catheter insertions and hospitalizations for VA infection. RESULTS: In the prevalent cohort, increasing temporary and permanent catheter insertions and VA infections were associated with slightly lower hemoglobin, higher rHuEPO doses, and higher intravenous iron doses. In the incident cohort, compared to patients with no VA infections or no catheter insertions (temporary or permanent), respectively, patients with 2+ VA infections or 2+ catheter insertions had 0.12 g/dL and 0.06 g/dL lower mean hemoglobin (P = 0.0028 and P < 0.0001), and 25.7% and 12.2% higher mean rHuEPO/wk (P < 0.0001). CONCLUSION: Higher rHuEPO doses may be required to maintain similar or slightly lower mean hemoglobin values among chronic hemodialysis patients with higher numbers of catheter insertions and VA infections, compared to patients without any.

Adolescent↗
PubMed2004

The differential impact of risk factors on mortality in hemodialysis and peritoneal dialysis.

BACKGROUND: While the survival ramifications of dialysis modality selection are still debated, it seems reasonable to postulate that outcome comparisons are not the same for all patients at all times. Trends in available data indicate the relative risk of death with hemodialysis (HD) compared to peritoneal dialysis (PD) varies by time on dialysis and the presence of various risk factors. This study was undertaken to identify key patient characteristics for which the risk of death differs by dialysis modality. METHODS: Analyses utilized incidence data from 398,940 United States Medicare patients initiating dialysis between 1995 and 2000. Proportional hazards regression identified the presence of diabetes, age, and the presence of comorbidity as factors that significantly interact with treatment modality. Stratifying by these factors, proportional and nonproportional hazards models were used to estimate relative risks of death [RR (HD:PD)]. RESULTS: Of the 398,940 patients studied, 11.6% used PD as initial therapy, 45% had diabetes mellitus (DM), 51% were 65 years or older, and 55% had at least one comorbidity. Among the 178,693 (45%) patients with no baseline comorbidity, adjusted mortality rates in nondiabetic (non-DM) patients were significantly higher on HD than on PD [age 18-44: RR (95% CI) = 1.24 (1.07, 1.44); age 45-64: RR = 1.13 (1.02, 1.25); age 65+: RR = 1.13 (1.05, 1.21)]. Among diabetic (DM) patients with no comorbidity, HD was associated with a higher risk of death among younger patients [age 18-44: RR = 1.22(1.05, 1.42)] and a lower risk of death among older patients [age 45-64: RR = 0.92 (0.85, 1.00); age 65+: RR = 0.86 (0.79, 0.93)]. Within the group of 220,247 (55%) patients with baseline comorbidity, adjusted mortality rates were not different between HD and PD among non-DM patients [age 18-44: RR = 1.19 (0.94, 1.50); age 45-64: RR = 1.01 (0.92, 1.11); age 65+: RR = 0.96 (0.91, 1.01)] and younger DM patients [age 18-44: RR = 1.10 (0.92, 1.32)], but were lower with HD among older DM patients with baseline comorbidity [age 45-64: RR = 0.82 (0.77, 0.87); age 65+: RR = 0.80 (0.76, 0.85)]. CONCLUSION: Valid mortality comparisons between HD and PD require patient stratification according to major risk factors known to interact with treatment modality. Survival differences between HD and PD are not constant, but vary substantially according to the underlying cause of ESRD, age, and level of baseline comorbidity. These results may help identify technical advances that will improve outcomes of patients on dialysis.

Adolescent↗
PubMed2004

Differences in diabetes prevalence, incidence, and mortality among the elderly of four racial/ethnic groups: whites, blacks, hispanics, and asians.

OBJECTIVE: To examine diabetes prevalence, incidence, and mortality from 1993 to 2001 among fee-for-service Medicare beneficiaries > or = 67 years of age. RESEARCH DESIGN AND METHODS: This study was a retrospective analysis of a 5% random sample of Medicare fee-for-service beneficiaries > or = 65 years of age in each year. RESULTS: In 1993, the prevalence of diabetes among those > or = 67 years of age was 145 cases per 1,000 individuals. By 2001, it was 197/1,000, an increase of 36.0%. The 2001 prevalence among Hispanics (334/1,000) was significantly higher than among blacks (296/1,000), Asians (243/1,000), and whites (184/1,000, P < 0.0001). During the 7-year period the greatest increase in diabetes prevalence was among Asians (68.0%). Between 1994 and 2001, the annual rate of newly diagnosed elderly individuals with diabetes increased by 36.9%. Hispanics had the greatest increase at 55.0%. The mortality rate among individuals with diabetes decreased by approximately 5% between 1994 and 2001 from 92.1/1,000 to 87.2/1,000 (P < 0.001), due to a 6% decrease among whites. No decrease in mortality was seen among elderly individuals without diabetes, it was 55/1,000 in 1994 and 54/1,000 in 2001. CONCLUSIONS: The dramatic increase in the incidence and prevalence of diabetes likely reflect a combination of true increases, as well as changes in the diagnostic criteria and increased interest in diagnosing and appropriately treating diabetes in the elderly. Improved treatment may have had an impact on mortality rates among individuals with diabetes, although they could have been influenced by the duration of diabetes before diagnosis, which has likely decreased. Changes in incidence, prevalence, and mortality in elderly individuals with diabetes need to continue to be monitored.

Age Distribution↗
PubMed2003

Does cadaveric donor renal transplantation ever provide better outcomes than live-donor renal transplantation?

BACKGROUND: Live donor renal transplantation (LRT) now comprises more than 40% of all kidney transplants performed in the United States. Many patients on the cadaveric waiting list have a prospective live kidney donor. This study determines whether cadaveric donor renal transplantation (CRT) can demonstrate better outcomes than LRT. METHODS: From the United States Renal Data System registry, 31,909 adult recipients of a first-time kidney transplant from 1995 to 1998 were analyzed. Recipients were followed until December 31, 2000. RESULTS: CRT, more human leukocyte antigen (HLA) mismatches, increased donor age, cold ischemia time greater than 24 hr, African American recipient, and a history of diabetic nephropathy all increased the risk of graft failure, return to dialysis, and death. Nevertheless, in specific circumstances, CRT could provide better outcomes than LRT. For example, in recipients aged 18 to 59 years with a hypothetical live kidney donor aged 50 years and four HLA mismatches, the relative risk of graft loss with LRT is comparable or increased compared with CRT if the cadaveric kidney donor is much younger or with fewer HLA mismatches. On the other hand, for recipients aged 60 years or older, CRT never provides better outcomes than LRT. All analyses were adjusted for recipient race, gender, and history of diabetic nephropathy. There were no significant interactions among donor type, HLA mismatches, donor age, and cold ischemia time. CONCLUSIONS: The elderly recipient with an imminent LRT should never be offered CRT. A combination of recipient and donor factors can make CRT preferable to LRT in younger patients.

Adolescent↗
PubMed2003

Fabry disease, an under-recognized multisystemic disorder: expert recommendations for diagnosis, management, and enzyme replacement therapy.

Fabry disease (alpha-galactosidase A deficiency) is an X-linked recessive lysosomal storage disorder. Although the disease presents in childhood and culminates in cardiac, cerebrovascular, and end-stage renal disease, diagnosis is often delayed or missed. This paper reviews the key signs and symptoms of Fabry disease and provides expert recommendations for diagnosis, follow-up, medical management, and the use of enzyme replacement therapy. Recommendations are based on reviews of the literature on Fabry disease, results of recent clinical trials, and expertise of the authors, all of whom have extensive clinical experience with Fabry disease and lysosomal storage disorders and represent subspecialties involved in treatment. All males and female carriers affected with Fabry disease should be followed closely, regardless of symptoms or treatment status. Clinical trials have shown that recombinant human alpha-galactosidase A replacement therapy--the only disease-specific therapy currently available for Fabry disease--is safe and can reverse substrate storage in the lysosome, the pathophysiologic basis of the disease. Enzyme replacement therapy in all males with Fabry disease (including those with end-stage renal disease) and female carriers with substantial disease manifestations should be initiated as early as possible. Additional experience is needed before more specific recommendations can be made on optimal dosing regimens for reversal; maintenance; and prevention of disease manifestations in affected males, symptomatic carrier females, children, and patients with compromised renal function.

Clinical Protocols↗
PubMed2003

Hospitalization during advancing chronic kidney disease.

BACKGROUND: The care of patients with end-stage renal disease (ESRD) is associated with substantial costs to society, much of which is accounted for by a high rate of hospitalization. However, the influence of declining kidney function on hospitalization as ESRD approaches is not well understood. METHODS: We performed a retrospective cohort study of national data to evaluate the frequency of hospitalizations among patients with chronic kidney disease (CKD) who reached ESRD and had at least 2 years of Medicare eligibility before initiation of dialysis therapy. The study period for each patient extended from 2 years before to 6 months after the initiation of dialysis therapy. RESULTS: The study cohort was composed of 109,321 patients with a mean age of 75 years, all of whom initiated long-term dialysis therapy between 1995 and 1998. Mean hospitalization rate was 134 hospitalizations/1,000 patient-months at risk (PMAR). Hospitalization rates gradually increased as ESRD approached, peaking in the 3 months immediately after the initiation of dialysis therapy at 487 hospitalizations/1,000 PMAR. Cause-specific hospitalization rates mirrored this trend and were greatest for placement of vascular access and diagnoses related to cardiovascular (CVD) and infectious disease. CONCLUSION: Hospitalizations during CKD become more frequent with the approach of ESRD. The majority of these hospitalizations, both before and after the initiation of dialysis therapy, are caused by comorbidity related to CKD. These hospitalizations may be favorably impacted on by heightened attention to the prevention and management of CVD and timely placement of vascular access during CKD.

Aged↗
PubMed2003

The association of initial hemodialysis access type with mortality outcomes in elderly Medicare ESRD patients.

BACKGROUND: Dialysis access is critical for therapy delivery. Few studies have linked type of dialysis access to patient survival in the elderly population. METHODS: We included 1995 to 1997 incidence Medicare hemodialysis patients (N = 66,595) who were 67 years and older at dialysis therapy initiation. Medicare Physician/Supplier claims were used to determine initial access type: simple fistula, autologous vein graft, synthetic graft, and hemodialysis catheter. We used International Classification of Diseases, Ninth Revision, Clinical Modification, codes to determine vascular access placement for renal failure. A Cox regression analysis assessed risk for death within 1 year, with explanatory variables of incidence year, age, sex, race, diabetes, initial access type, body mass index, days from first access placement date to initial dialysis date, and serum albumin, creatinine, and blood urea nitrogen levels. RESULTS: One-year crude death rates were 24.9%, 27.2%, 28.1%, and 41.5% for patients with simple fistulae, autologous vein grafts, synthetic grafts, and hemodialysis catheters, respectively. Patients with simple fistulae (the reference) had the lowest (P < 0.0001) likelihood of death compared with those with synthetic grafts (hazard ratio [HR], 1.160; 95% confidence interval [CI], 1.084 to 1.241) or catheters (HR, 1.696; 95% CI, 1.593 to 1.806). No difference (P > 0.09) in mortality risk was detected between simple fistulae and autologous vein grafts or between autologous vein grafts and synthetic grafts. CONCLUSION: In the US Medicare dialysis population, type of initial hemodialysis access was associated with 1-year mortality. Mortality risks were (in ascending order) fistulae, grafts, and catheters.

Aged↗
PubMed2003

Clinical factors associated with achieving K/DOQI hemoglobin targets in hemodialysis patients.

BACKGROUND: Few studies have assessed treatable factors associated with achieving the Kidney Disease Outcomes Quality Initiative (K/DOQI) guideline of hemoglobin values of 11 to 12 g/dL in anemic hemodialysis patients. METHODS: This was a retrospective study of 30,029 prevalent hemodialysis patients with mean hemoglobin values less than 11 g/dL between January 1 and March 31, 1999. We studied the associations between demographic characteristics, comorbid conditions, disease severity, urea reduction ratio, epoetin doses, intravenous iron doses, and mean hemoglobin values in the ensuing 3 months. RESULTS: Approximately half (51.3%) of patients reached a mean hemoglobin value of at least 11 g/dL. By multiple logistic regression, the major factors showing a positive association with this outcome included a urea reduction ratio greater than 75% (odds ratio [OR], 1.23; P < 0.0001) and intravenous iron (OR: for 0 vials/month, 1; for < 1, 1.22; for 1 to 1.9, 1.36; 2 to 2.9, 1.48; for 3 to 3.9, 1.61; for > or = 4, 1.79; P < 0.0001), while a negative association with hemoglobin response, possibly representing epoetin resistance, was shown for initial severity of anemia (OR: for initial hemoglobin value < 7 g/dL, 0.06; for 7 to 7.9 g/dL, 0.12; for 8 to 8.9 g/dL, 0.23; for 9 to 9.9 g/dL, 0.45; for 10 to 10.9 g/dL, 1; P < 0.0001) and epoetin doses in the highest quintile (OR for > 38,000 units/wk, 0.76; P < 0.0001). CONCLUSION: In patients with persistently low hemoglobin values, optimizing urea clearance and a proactive approach to intravenous iron therapy may enhance epoetin responsiveness.

Adult↗
PubMed2003

Body size and outcomes on peritoneal dialysis in the United States.

BACKGROUND: Being overweight is often cited as a relative contraindication to peritoneal dialysis. Our primary objective was to determine whether actual mortality rates support this opinion. METHODS: Retrospective cohort study of United States Medicare patients initiating dialysis between 1995 and 2000 (N = 418,021; 11% peritoneal dialysis). RESULTS: Seven percent were underweight [body mass index (BMI) < 18.5 kg/m2], 27% were overweight (BMI 25.0 to 29.9 kg/m2), and 23% were obese (BMI> 29.9 kg/m2) at dialysis initiation. Compared to those with normal BMI, the adjusted odds of initiating peritoneal dialysis were 0.70 (P < 0.05) in underweight, 1.12 (P < 0.05) in overweight, and 0.87 (P < 0.05) in obese subjects. Among peritoneal dialysis patients, adjusted mortality hazard ratios in the first, second, and third year were 1.45 (P < 0.05), 1.28 (P < 0.05), and 1.17 for the underweight, respectively; 0.84 (P < 0.05), 0.89 (P < 0.05), and 0.98 for the overweight, respectively; and 0.89 (P < 0.05), 0.99, and 1.00 for the obese, respectively. Apart from higher third-year mortality in the obese, associations were similar after censoring at a switch to hemodialysis. For transplantation, the corresponding results were 0.76 (P < 0.05), 0.90 (P < 0.05), and 0.88 for the underweight, respectively; 0.95, 1.06, and 0.93 for the overweight, respectively; and 0.62 (P < 0.05), 0.68, and 0.71 for the obese, respectively. For switching to hemodialysis, hazards ratios were 0.92, 0.97, and 0.80 for the underweight, respectively; 1.07, 1.11 (P < 0.05), and 1.03 for the overweight, respectively; and 1.28 (P < 0.05), 1.29 (P < 0.05), and 1.36 (P < 0.05) for the obese, respectively. CONCLUSION: Although less likely to initiate peritoneal dialysis, overweight and obese peritoneal dialysis patients have longer survival than those with lower BMI, not adequately explained by lower transplantation and technique survival rates.

Adolescent↗
PubMed2003

Influenza vaccine delivery and effectiveness in end-stage renal disease.

BACKGROUND: Influenza vaccination rates in the general population have been associated with improved outcomes, yet high-risk populations, such as end-stage renal disease (ESRD) patients, have received little attention in determining the potential benefits. This report assessed the frequency and effectiveness of influenza vaccination, while also assessing disparities in vaccination rates in the ESRD population. METHODS: Using the United States Renal Data System research files containing claims for all Medicare ESRD patients, vaccination rates and outcomes among vaccinated and unvaccinated persons for the 1997 to 1998 and 1998 to 1999 influenza seasons were compared after adjustment for baseline demographic factors and health characteristics. RESULTS: Vaccination rates in the ESRD population were less than 50% for each season. Influenza vaccination rates were lower in non-whites, women, younger patients, and peritoneal dialysis patients. Influenza vaccination was associated with a lower risk for hospitalization and death. CONCLUSIONS: Despite universal coverage of free influenza vaccination, the ESRD population had a less than 50% vaccination rate for the years 1997 to 1998 and 1998 to 1999 as demonstrated by Medicare billing data. Substantial differences were found in vaccination rates among non-whites and peritoneal dialysis patients. This study confirms that the ESRD populations benefit from influenza vaccination, suggesting that dialysis providers should take advantage of all opportunities to immunize this high-risk group.

Adult↗
PubMed2003

Smoking and cardiovascular outcomes in dialysis patients: the United States Renal Data System Wave 2 study.

BACKGROUND: Smoking has received surprisingly little research attention in dialysis populations, a group at monumental cardiovascular risk. METHODS: Medicare claims data were used to study associations between smoking and new-onset cardiovascular outcomes, and death in the prospective, inception Wave 2 cohort (N = 4024), assembled in 1996 and 1997. RESULTS: Of the participants, 56.4% were lifetime nonsmokers, 3.6% were smokers with unknown current status, 20.0% had quit for more than 1 year, 5.8% had quit less than 1 year ago, and 14.2% were current smokers. Subjects with cardiovascular disease at baseline were more likely to be former smokers, less likely never to have smoked and less likely to be current smokers (P < 0.001). Patients were followed until December 31, 1998. When adjustment was made for baseline age, demographic variables, mode of dialysis therapy, and comorbidity, smoking status was associated with new-onset congestive heart failure (adjusted hazards ratio 1.59 comparing current to nonsmokers, P = 0.004), new-onset peripheral vascular disease (adjusted hazards ratio 1.68, P < 0.001), and mortality (adjusted hazards ratio 1.37, P < 0.001). Former smokers, in contrast, had adjusted event risks similar to lifelong nonsmokers. CONCLUSION: Smoking is a major, modifiable, cardiovascular risk factor in patients starting dialysis therapy.

Cardiovascular Diseases↗
PubMed2003

Chronic kidney disease and cardiovascular disease in the Medicare population.

BACKGROUND: The extent of diabetes, chronic kidney disease (CKD), and cardiovascular disease (CVD) in the Medicare population is relatively unknown. Also unknown is the effect of these diseases on patient survival before end-stage renal disease (ESRD). METHODS: Prevalent cohorts of Medicare enrollees from 1996 to 2000 were assessed for diabetes and CKD, presence of CVD, and probability of death versus ESRD in the follow-up period. Hospitalization rates and, in diabetics, lipid testing and glycemic control monitoring were also assessed. RESULTS: The prevalence of diabetes in the Medicare population increased at 4.4% per year, reaching 18.9% in the 1999-2000 cohort. Approximately 726,000 elderly Medicare enrollees carry a diagnosis code for CKD. Those with CKD are 5 to 10 times more likely to die before reaching ESRD than the non-CKD group. In CKD patients, CVD is twice as common and advances at twice the rate. Cardiovascular disease advances at a similarly higher rate in CKD patients who die and those who survive to ESRD. Heart failure hospitalizations are 5 times greater in CKD patients and only 30% less than those in dialysis patients. Only half of the CKD patients with diabetes who advance to ESRD had a lipid or glycosylated hemoglobin test done in the year before or after dialysis initiation. CONCLUSION: Diabetes, the leading cause of ESRD, is increasing in the general Medicare population at 4.4% per year. Cardiovascular disease is common, progresses at twice the rate, is associated with death before ESRD, and patients receive suboptimal risk factor monitoring. Active identification and treatment of CKD patients is needed.

Heart Failure↗
PubMed2003

The impact of residual renal function on graft and patient survival rates in recipients of preemptive renal transplants.

BACKGROUND: Transplantation before the initiation of dialysis is associated with prolonged allograft survival. It is unclear if this benefit is attributable to greater residual renal function or to avoidance of dialysis exposure. The authors performed an analysis to determine whether higher renal function at transplant was associated with increased patient and graft survival rates. METHODS: The authors identified individuals who between 1994 and June 2000 were >or= 18 years and had undergone a living donor renal transplant (Tx) as initial form of renal replacement therapy. Pre-Tx and 6-month estimated glomerular filtration rates (eGFR) were calculated using the 4-variable Modification of Diet in Renal Disease formula. Survival was compared in those with a pre-Tx eGFR >or=15mL/min to those with an eGFR less than 15 mL/min, after adjusting for demographic variables, co-morbidities, and transplant characteristics. Survival rate then was adjusted for calculated propensity scores. RESULTS: A total of 4,046 patients were included. Mean pre-Tx eGFR was 9.9 mL/min (0.9 to 57.1 mL/min). There was no difference in graft survival rates by strata of eGFR in any of the tested models, even after correcting for propensity score (hazard ratio, 0.95; 95% confidence interval, 0.69 to 1.30). There was no correlation between pre-Tx eGFR and 6-month post-Tx eGFR (r(2) =-0.005). CONCLUSION: Recipients of preemptive transplants fare equally, regardless of the eGFR at which they receive their transplant. There was no relationship between pre-Tx eGFR and 6-month eGFR, suggesting that post-Tx renal function is independent of the level of pre-Tx renal function. These data suggest that preemptive kidney transplantation should be delayed as long as possible, provided the patient does not have uremic symptoms, and dialysis can be safely avoided.

Adult↗
PubMed2003

Cardiovascular mortality in end-stage renal disease.

Cardiovascular disease accounts for more than 50% of end-stage renal disease (ESRD) deaths. The reported cardiovascular death rates in patients receiving dialysis are substantially higher than in the general population. Cardiovascular mortality in ESRD is particularly high after acute myocardial infarction, but it is also elevated in ESRD patients with other forms of atherosclerotic vascular disease (eg, chronic coronary artery disease, strokes, transient ischemic attacks, and peripheral arterial disease). Left ventricular hypertrophy and dilation are associated with increased cardiovascular mortality, as is congestive heart failure. One of the major reasons for such high cardiovascular mortality in ESRD is the large burden of cardiovascular disease present in patients with chronic artery disease before renal replacement therapy. These observations mandate not only aggressive diagnosis and treatment of cardiovascular disease in patients with ESRD, but also active screening, diagnosis, and treatment in those with chronic kidney disease before renal replacement therapy.

Cardiovascular Diseases↗
PubMed2003

Anaemia management prior to dialysis: cardiovascular and cost-benefit observations.

Anaemia correction with recombinant human erythropoietin (rh-EPO, epoetin) in end-stage renal disease (ESRD) patients has been associated with improved survival and quality of life, as well as lower overall treatment costs. Few studies, however, have evaluated the benefits of epoetin treatment given to chronic kidney disease (CKD) patients during the pre-dialysis period. A retrospective study of 89 193 incident haemodialysis patients in the Medicare system (age > or =67 years) assessed consistency of epoetin treatment before the start of dialysis and the outcome of patients once they reached ESRD. Patients were grouped according to consistency of epoetin treatment based on the available months of treatment in the 2-year period before starting dialysis. Only 15.6% of patients in the study received any epoetin before the initiation of dialysis. Patients who received no or infrequent epoetin (i.e. received epoetin in <50% of possible months) had a significantly higher relative risk of cardiac disease and death than patients treated with epoetin more frequently. Patients who received no or infrequent epoetin also had significantly higher rates of hospitalization and overall treatment costs at the time of initial dialysis. These findings suggest that early epoetin treatment warrants further investigation in prospective, randomized studies. In summary, it is evident that the care of CKD patients can be improved. Evidence suggests that timely initiation of epoetin treatment to correct renal anaemia appears to be associated with improved survival of ESRD patients in the first year after start of dialysis and reduced costs of treatment.

Anemia↗