Biomedical subjects

L Szczech

Publications and source records attributed to L Szczech.

5 recordsLinked to original sources

PubMed2001

Evaluation of disease-state management of dialysis patients.

Dialysis patients are the only Medicare beneficiaries prohibited from joining managed care plans. Concerns have been raised about the ability of such plans to provide the comprehensive care required by patients with this complex condition. However, more than 20,000 dialysis patients belong to such plans because they were enrolled before developing end-stage renal disease (ESRD). Disease-state management, successfully applied to patients with diabetes mellitus and congestive heart failure, is now being used in patients with ESRD. Standardized mortality ratios (SMRs) and standardized hospitalization ratios (SHRs) were calculated for 1998 and 1999 in 1,541 patients enrolled in the RMS Disease Management program of renal disease-state management using US Renal Data System methods. SMRs were 0.643 and 0.806 for 1998 and 1999, respectively, significantly different from 1.0 for both years (P < 0.001). SHRs were 0.620 and 0.503 for 1998 and 1999, respectively, significantly different from 1.0 for both years (P < 0.001). Although additional studies are needed to define the aspects of care that are most important for the outcomes seen, this study shows that favorable outcomes are achievable for this vulnerable patient population within a managed care setting that applies coordinated approaches to care.

Adolescent↗

PubMed2001

IgM anticardiolipin antibodies are associated with stenosis of vascular access in hemodialysis patients but do not predict thrombosis.

AIM: The prevalence of anticardiolipin antibodies (ACA) is elevated amongst hemodialysis patients as compared with the general population. Previous studies have disagreed as to whether the presence of ACA represents a risk factor for access thrombosis. Other risk factors for access thrombosis (decreased blood flow, elevated venous pressure) have also been described. MATERIALS AND METHODS: We performed a combination retrospective and prospective cohort study of a single outpatient dialysis unit to assess the association between these potential risk factors and access thrombosis. ACA, access blood flow, presence of stenosis, and venous pressures were measured in 100 patients. Information on episodes of access thrombosis was gathered for 12 months prior to and 12 months after ACA measurement. RESULTS: ACA were present in 19% of patients with equal numbers of IgG- and IgM-ACA. The presence of IgM-ACA was significantly associated with the use of aspirin and the presence of stenosis by Doppler at the time of ACA testing (p < 0.05). A logistic regression model was used to estimate the association between clinical factors and access thrombosis. In this multivariate analysis, the presence of access stenosis and a history of access thrombosis were both significantly associated with the development of access thrombosis. Adjusted for these variables, neither IgG- nor IgM-ACA was significantly associated with access thrombosis. The presence of an ACA was not associated with episodes of access thrombosis in either the prospective or retrospective analyses. CONCLUSION: Further investigation is required to determine if the association between aspirin use and IgM-ACA, or of IgM-ACA and access stenosis, has implications for underlying pathogenetic mechanisms of access stenosis.

Adult↗

PubMed1999

National perspective on iron therapy as a clinical performance measure for maintenance hemodialysis patients.

The Health Care Financing Administration (HCFA) End-Stage Renal Disease (ESRD) Core Indicators Project collects clinical information on prevalent adult patients receiving in-center hemodialysis care in the United States to assess the quality of care delivered. Although hematocrit values, transferrin saturations (TSATs) and iron prescription practices have improved over the last 5 years, we sought to determine whether there are continued opportunities for improvement of this domain of care. A random sample of 7,292 adult in-center hemodialysis patients was selected for the period October through December 1996. Hematocrit values, TSATs, serum ferritin concentrations, epoetin-alfa dosing, and iron prescriptions were abstracted from 4,991 patient medical records to assess anemia management practices. The mean hematocrit for this cohort was 32.6% +/- 3.5%, and 72% of patients had hematocrit values greater than 30%. Ninety-four percent of patients received epoetin alfa intravenously, with a mean weekly epoetin dose of 202.4 +/- 137.2 U/kg. The mean TSAT was 27.4% +/- 12.6%; 73% of patients had TSATs >/= 20%. The mean serum ferritin concentration was 386 +/- 422 ng/mL; 79% and 12% of patients had serum ferritin concentrations greater than 100 ng/mL and greater than 800 ng/mL, respectively. Nine percent of the sample had TSATs less than 20% and serum ferritin concentrations less than 100 ng/mL. Regardless of the TSAT, approximately three fourths of patients received iron; only about half received IV iron. Of the subset of patients with TSATs less than 20% and serum ferritin concentration less than 800 ng/mL, only 53% were prescribed IV iron. Although substantial improvements have been made in anemia management in hemodialysis patients over the last 5 years, significant opportunities persist to improve iron prescription practices.

Adult↗

PubMed1998

Race and delayed kidney allograft function.

BACKGROUND: Allograft survival among black recipients is poorer than among whites. Delayed allograft function is associated with a significant reduction in renal allograft survival. The relationship between delayed allograft function and black race is incompletely specified and was the focus of this investigation. METHODS: A non-concurrent study of 325 recipients of cadaveric allografts followed for the occurrence of delayed allograft function defined as dialysis during the first week following transplantation for the principal analysis. A secondary definition of delayed allograft function was formulated based on the serum creatinine 2 weeks after transplantation. Unadjusted and adjusted logistic regression analysis were used to examine the unconfounded relationship between race and delayed allograft function. RESULTS: Fifty-seven of 91 (62.6%) black recipients experienced delayed allograft function compared to 113 of 234 (48.3%) whites. The odds ratio for black race as a predictor of delayed allograft function was 1.80, P=0.02, (95% CI, 1.09, 2.95). This finding was stable despite adjustment for other predictors of delayed allograft function in a multivariate model, but the precision of this estimate was less (P=0.10) because of missing data. Additionally, adjusted models with imputed values for missing covariates, models using a secondary definition of delayed allograft function, and models excluding patients whose cyclosporin therapy was delayed, all consistently demonstrated a similar association between black race and delayed allograft function. CONCLUSIONS: This study demonstrated an increased risk of delayed allograft function among black recipients. This relationship may play a role in the poorer allograft outcomes experienced by black recipients. Given the negative effect of delayed allograft function on allograft survival, efforts to identify its modifiable risk factors should be a high priority.

Adult↗

PubMedDate not supplied

Explaining counter-intuitive clinical outcomes predicted by Kt/V.

Population-based studies of maintenance hemodialysis patients have demonstrated a reproducible relationship between the dose of hemodialysis and mortality and morbidity outcomes. In these analyses, which have aggregated hemodialysis patient subgroups, improved outcomes are associated with greater doses of hemodialysis. However, remarkable counterintuitive findings are observed if patients are analyzed by subgroups based on their race, gender, and anthropometric and blood-based biomarkers of nutritional state. For example, blacks generally receive lower doses of hemodialysis than whites, but enjoy relatively improved survival; patients who receive the highest doses of hemodialysis have an increased death risk; and the dose response curve between hemodialysis and survival is altered based on the patients' body mass index. These seemingly paradoxical relationships between hemodialysis dose and patient survival can be explained because of the use of mathematical urea kinetic constructs as clinical outcome predictors; they integrate a measure of solute removal (K x t) with an anthropometric surrogate of nutrition, the urea distribution volume (V). Both these measures have an independent influence on patient survival and in some clinical circumstances are of unequal power as clinical outcome predictors. These complex interactions must be kept in perspective as clinical care is delivered in the context of hemodialysis dose.

Humans↗