Awareness of kidney disease and relationship to end-stage renal disease and mortality

BackgroundOften, patients with chronic kidney disease are reported to be unaware of it. We prospectively evaluated the association between awareness of kidney disease to end-stage renal disease and mortality.MethodsWe utilized 2000-2009 data from the National Kidney Foundation's Kidney Early Evaluation Program. Mortality was determined by cross reference to the Social Security Administration Death Master File and development of end stage by cross reference with the United States Renal Data System.ResultsOf 109,285 participants, 28,244 (26%) had chronic kidney disease defined by albuminuria or estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m². Only 9% (n = 2660) reported being aware of kidney disease. Compared with those who were not aware, participants aware of chronic kidney disease had lower eGFR (49 vs 62 mL/min/1.73 m²) and a higher prevalence of albuminuria (52% vs. 46%), diabetes (47% vs 42%), cardiovascular disease (43% vs 28%), and cancer (23% vs 14%). Over 8.5 years of follow-up, aware participants compared with those unaware had a lower rate of survival for end stage (83% and 96%) and mortality (78% vs 81%), P <.001. After adjustment for demographics, socioeconomic factors, comorbidity, and severity of kidney disease, aware participants continued to demonstrate an increased risk for end-stage renal disease (hazard ratio 1.37; 95% confidence interval, 1.07-1.75; P <.0123) and mortality (hazard ratio 1.27; 95% confidence interval, 1.07-1.52; P <.0077) relative to unaware participants with chronic kidney disease.ConclusionsAmong patients identified as having chronic kidney disease at a health screening, only a small proportion had been made aware of their diagnosis previously by clinicians. This subgroup was at a disproportionately high risk for mortality and end-stage renal disease.     

Factors associated with hospital admission for exacerbation of chronic obstructive pulmonary disease

Introduction

Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) that require hospital admission have a major impact on the progression of disease and generate high health costs.

Method

A multi-center, cross-sectional, observational, study was conducted with the aim to identify factors associated with hospital admission in patients with COPD. We obtained data of socio-demographic and anthropometric characteristics, quality of life, respiratory symptoms, anxiety and depression, physical activity and pulmonary function tests. We analyzed their association with hospital admission with a multivariate analysis using a logistic regression model.

Results

We analyzed 127 patients, 50 (39%) of whom had been hospitalized. 93.7% were men, mean age 67 years (SD = 9) and a FEV1 of 41.9% (SD = 15.3). In the first model obtained, the baseline SpO2, the BODE index and emergency room (ER) visits were associated with hospital admission and the area under the ROC curve (AUC) was 0.809. In a second model we included only variables readily available (without the 6 minutes walking test) and only the SpO2 and previous visits to the ER weresignificant with an AUC ROC 0.783.

Conclusions

hospital admission for exacerbation of COPD is associated with poor SpO2, higher BODE index score and a greater number of visits to the ER. In case you do not have the 6 minutes walking test, the other two variables offer a similar discriminative ability.     

Smoking: relationship to chronic bronchitis, chronic obstructive pulmonary disease and mortality

PURPOSE OF REVIEW: To describe the recent findings concerning the relationship between smoking, chronic bronchitis, chronic obstructive pulmonary disease and mortality. RECENT FINDINGS: During their lifetime, over 40% of smokers develop chronic bronchitis. Chronic bronchitis is associated with an accelerated decline in lung function - a risk of developing chronic obstructive pulmonary disease and mortality. Approximately one-quarter of smokers can be affected by clinically significant chronic obstructive pulmonary disease. The incidence of chronic obstructive pulmonary disease is also substantial in young adults. Smokers may reduce their risk of developing chronic obstructive pulmonary disease by physical activity and increase their survival by smoking reduction. In adults and the elderly population, severe chronic obstructive pulmonary disease is associated with the most rapid decline in lung function, which is, in turn, associated with chronic obstructive pulmonary disease-related hospitalization and mortality. Using a fixed forced expiratory volume in 1 s/force vital capacity ratio (0.7) to define obstruction in chronic obstructive pulmonary disease at old age is acceptable. In chronic obstructive pulmonary disease patients, the disease is still underreported on death certificates. Chronic mucus production and being a female are associated with chronic obstructive pulmonary disease mentioned on death certificates. SUMMARY: Chronic bronchitis is a marker identifying high-risk individuals. With respect to chronic obstructive pulmonary disease and mortality, interventions to promote smoking cessation are important to reduce these risks.     

The diagnosis of acute pulmonary embolism in patients with chronic obstructive pulmonary disease.

The clinical features and noninvasive tests, including ventilation perfusion (V/Q) lung scans, were assessed in 108 patients with chronic obstructive pulmonary disease (COPD) suspected of having pulmonary embolism (PE). Twenty-one (19 percent) of 108 patients had PE. In the majority of patients, it was impossible to distinguish between patients with and without PE by clinical assessment alone. However, when a high clinical index of suspicion was present, PE was confirmed by angiography in three of three patients, but the V/Q scan was of intermediate probability. No roentgenographic abnormalities distinguished between PE and no PE. There was no difference between the alveolar-arterial oxygen gradients in either group, nor was there evidence of a reduction in the PaCO2 in patients with PE who had prior hypercapnia. Among the 108 patients with COPD, high, intermediate, low, and normal/near normal probability scans were present in 5 percent, 60 percent, 30 percent, and 5 percent, respectively. The frequency of PE in these V/Q scan categories was five (100 percent) of five, 14 (22 percent) of 65, two (6 percent) of 33, and zero (0 percent) of five, respectively. In conclusion, in the majority of patients, the V/Q scan diagnosis is usually intermediate and such patients require further investigational studies, including angiography. However, among the few patients who demonstrated a high probability lung scan, there was a high positive predictive value for PE effectively avoiding the need for further studies. In those patients with low probability or near normal/normal V/Q scans, the negative predictive value was not lower than the general hospital population.     

The end-stage renal disease program. Experience with a chronic disease capitated health plan

The ESRD program has demonstrated the potential for a capitated, disease-oriented, total care method of patient support. Given both the increasing age and complexity of the patient population, not only has the cost per patient decreased over the life of the program, but the standardized mortality rates have also declined. Technology has bridged the gap and made the relative cost per treatment more affordable and science has developed medications and techniques that have enhanced both patient comfort and longevity. As more complex patients enter the fold of the ESRD program, an increased awareness of enhanced coordination of care needs to be recognized.     

Mortality of elderly patients in Ontario after hospital admission for chronic obstructive pulmonary disease

BACKGROUND:

Chronic obstructive pulmonary disease (COPD) is associated with significant mortality. It is currently the fourth leading cause of death in Canada and the world.

OBJECTIVES:

To describe the mortality of elderly patients in Ontario after hospital admission for COPD.

METHODS:

A retrospective cohort study was conducted using the Discharge Abstract Database from the Canadian Institute for Health Information. Patients aged 65 years and older who were admitted to hospital between 2001 and 2004 with primary discharge diagnoses labelled with International Classification of Diseases, Ninth Revision codes 491, 492 and 496 were included in the study.

RESULTS:

Mortality rates were 8.81, 12.10, 14.53 and 27.72 per 100 COPD hospital admissions at 30, 60, 90 and 365 days after hospital discharge, respectively. Mortality also increased with age, and men had higher rates than women. No significant differences in mortality rates were found between different socioeconomic groups (P>0.05). Patients with shared care of a family physician or general practitioner and a specialist had significantly lower mortality rates than the overall rate (P<0.05), and their rates were approximately one-half the rate of patients with only one physician.

CONCLUSIONS:

Hospitalization with COPD is associated with significant mortality. Patients who were cared for by both a family physician or general practitioner and a specialist had significantly lower mortality rates than those cared for by only one physician, suggesting that continuous and coordinated care results in better survival.     

Prognostic factors for hospital mortality and ICU admission in patients with ANCA-related pulmonary vasculitis

BACKGROUND: The objective of this study was to evaluate the factors predictive of 28-day mortality and admission to Intensive Care Unit (ICU) in patients with ANCA-related pulmonary vasculitis. METHODS: We reviewed the medical records and imaging studies of 65 patients diagnosed with ANCA-related vasculitis hospitalized with pulmonary complications between February 1985 and November 2002. All patients underwent open or video-assisted thoracoscopic lung biopsy, had a positive ANCA serology, and were negative for glomerular basement membrane antibodies. RESULTS: At presentation, 72% had dyspnea, 68% fever, 47% cough, 45% elevated blood pressure, 32.3% hemoptysis, 26.1% sinus involvement, 15% renal failure, and 4.6% scleritis. Pathological findings included alveolar hemorrhage (60%), granulomatous inflammation (46%), and capillaritis (38%). A significant number required mechanical ventilation (27.7%), hemodialysis (24.6%), continuous renal replacement therapy (3.1%), and plasmapheresis (3.1%). The 28-day mortality was 16.9% (11/65). Mechanical ventilation (OR 68, P < 0.005), admission to ICU (OR 18.5, P < 0.01), and blood transfusion (OR 22.4, P < 0.004) were strong predictors of increased mortality within 28 days after admission. Respiratory failure (OR 31, P < 0.0007), hemoptysis (OR 2.9, P < 0.06), smoking (OR 5.9, P < 0.02), and acute renal failure (OR 7.8, P < 0.01) were also predictors for admission to the ICU. CONCLUSION: In patients with ANCA-related pulmonary vasculitis several clinical factors, but not pathologic findings or ANCA titers, are associated with ICU admission and/or 28-day mortality.     

In-hospital complications among survivors of admission for congestive heart failure,chronic obstructive pulmonary disease,or diabetes mellitus

OBJECTIVE: To determine the frequency of hospital complications among survivors of inpatient treatment for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or diabetes mellitus (DM). DESIGN: Retrospective cohort study. SETTING: Nine Veterans Affairs hospitals in the southern United States. PATIENTS: 1,837 men veterans discharged alive following hospitalization for CHF, COPD, or DM between January 1987 and December 1989. This patient population represents a subset of cases gathered to study the process of care in the hospital and subsequent early readmission; thus, veterans who died in the hospital were not included. MEASUREMENTS: Medical record review to record the occurrence of any of 30 in-hospital complications such as cardiac arrest, nosocomial infections, or delirium (overall agreement between two reviewers=84%, kappa=0.37). RESISTS: Complications occurred in 15.7% of the CHF cases, 13.1% of the COPD cases, and 14.8% of the DM cases. Hypoglycemic reactions were the most frequent individual adverse events in the CHF and DM cases (3.6% and 11.4% of the cases, respectively), and theophylline toxicity was most frequent among the COPD cases (4.9%). Patient age, the presence of comorbid diseases, and the Acute Physiology Score (APS) of APACHE II were associated with complication occurrence. For each disease, the patients who had a complication had significantly longer mean hospital stays than did the patients who did not have complications (14.6 to 14.9 days vs 7.2 to 8.2 days, p<0.01). CONCLUSIONS: Complications are frequent among patients discharged alive with CHF, COPD, or DM. The patients who experienced complications were more ill on admission and had longer hospital stays. Received from the Houston Center for Quality of Care and Utilization Studies, Houston Veterans Affairs Medical Center. Baylor College of Medicine, Houston, Texas. Presented in part at the annual meeting of the American Federation for Clinical Research, Washington, DC, May 1, 1993, and the VA HSR & D Career Development Awardees Conference, Washington, DC, April 25, 1994. Supported by the Department of Veterans Affairs, Health Services Research & Development Service, VA HSR & D IIR 89.061.1 (Dr. Ashton), and by a Research Associate Career Development Award (Dr. Geraci).     

The patterns of use and factors associated with the patient admission of hospital emergencies for asthma and chronic obstructive pulmonary disease

The aim of this study was to describe the epidemiological characteristics of emergencies caused by asthma and chronic obstructive pulmonary disease (COPD) at the Hospital Clínico Universitario of Valencia (Spain) and to analyze factors related to hospital admissions for the same causes. Emergency room medical records for 1993 to 1995 of patients older than 14 years of age were examined to identify those due to asthma or COPD, according to established protocol. Demographic variables were described, followed by Poisson regression analysis of time and seasonal factors affecting emergencies. Factors related to hospital admission were analyzed by logistic regression, taking into account age group, sex, place of residence, and the year, month, day and hour of emergency room arrival. Asthma patients amounted to 1% of emergencies, while COPD patients accounted for 2%. The admission rate for women with asthma was higher than for men (F/M ratio = 0.78), whereas the rate for men with COPD was higher than for women (F/M ratio = 3.14). The largest age groups with asthma emergencies included young people aged 15 to 24 years old and those over 60. Hospital admissions or transfers to other hospitals were ordered for 17.4% of asthma patients and 38.8% of COPD patients. Nearly a third of COPD patients and a fifth of asthma patients were readmitted within the ten days following the first emergency. Clear temporal patterns of COPD emergency were observed for month (most occurring in winter), day of the week (most on Monday) and hour of the day (most during daytime hours, with fewer at midday). The time patterns were less evident for asthma emergencies, although the likelihood of admission because of asthma varied by month and day of the week. Emergency room records may be useful for studying the patterns of respiratory disease presentation. Other possible uses are epidemiologic monitoring and evaluation of health care quality.     

Treatment of end-stage chronic obstructive pulmonary disease with double lung transplantation.

Six patients with end-stage emphysema (age 44 +/- 2 years) underwent double lung transplantation (Tx) from June 1988 through May 1990. All suffered from severe inanition and required oxygen therapy. The ischemic time was 193 +/- 28 minutes. Post-Tx immune suppression was OKT3 (14 days), cyclosporine (trough levels of 150 +/- 25 ng/ml), azathioprine to keep WBC at 3,000 to 5,000/cu mm (1 to 3.0 mg/kg/day) and following OKT3, a tapering prednisone regimen. Two rejection episodes that occurred in two patients on post-Tx day 5 and 10 were treated with bolus doses of methylprednisolone. The mean hospital stay was 32 +/- 7 days (range, 20 to 69 days). Four patients required treatment of cytomegalovirus (CMV) infection: gastritis (+donor, +recipient) in one and CMV pneumonia in two (+donor, -recipient). A fourth (+donor, -recipient) had right-sided Candida empyema six weeks post-Tx, developed CMV and staphylococcal sepsis, and died 64 days post-Tx. One patient required pyloroplasty eight weeks post-Tx and one patient underwent tracheal suture line repair at eight weeks. During a follow-up of 81 patients months (range, 8 to 24 months), one patient had developed Epstein-Barr viral (EBV) induced lymphoproliferative disease in the lung and one patient had developed EBV lymphoma. Three patients are at work, one is continuing rehabilitation, and one is at home. Double lung Tx offers a definitive benefit to patients with emphysema; however, a prolonged postoperative course can be expected. Viral infections remain serious but treatable problems.     

Particular aspects of gastroenterological disorders in chronic kidney disease and end-stage renal disease patients: a clinically focused review

Abstract

Besides renal disease, gastrointestinal (GI) disorders are frequently reported in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Related gastrointestinal symptoms tend to increase as the renal disease progresses. Also, in patients with ESRD, the modality of dialysis is related to particular forms of GI disorders.

The kidney can interact with the digestive organs through functional endogenous systems such as the ‘kidney-colon axis’ and the ‘kidney-liver axis’. Digestive diseases are one of the visible manifestations of the disturbance between hemostatic, hemodynamic and immunological balance in such patients.

No clear management guidelines currently exist for many of the gastrointestinal problems that accompany renal failure. This review aims to describe the particular aspects of GI diseases present in CKD/ESRD. We focus our discussion in the specificities of epidemiology, diagnosis, and prognosis of such disorders between the different segments of the digestive system.     

Predictors of survival in patients with end-stage renal disease evaluated for kidney transplantation

Cardiovascular disease is the major cause of mortality in patients with end-stage renal disease (ESRD). This study examined the all-cause mortality in 3,698 patients with ESRD evaluated for kidney transplantation at our institution from 2001 to 2004. Mean age for the cohort was 48+/-12 years, and 42% were women. Stress myocardial perfusion imaging was done in 2,207 patients (60%) and coronary angiography in 260 patients (7%). There were 622 deaths (17%) during a mean follow-up period of 30+/-15 months. The presence and severity of coronary disease on angiography was not predictive of survival. Coronary revascularization did not impact survival (p=0.6) except in patients with 3-vessel disease (p=0.05). The best predictor of death was left ventricular ejection fraction, measured by gated myocardial perfusion imaging, with 2.7% mortality increase for each 1% ejection fraction decrease. In conclusion, left ventricular ejection fraction is a strong predictor of survival in patients with ESRD awaiting renal transplantation. Strategies to improve cardiac function or earlier renal transplantation deserve further studies.     

Peritoneal dialysis in end-stage renal disease patients with preexisting chronic liver disease and ascites.

PURPOSE: Hemodialysis in patients with chronic liver disease and ascites may be complicated by intradialytic hypotension, limiting the amount of ultrafiltration and resulting in massive ascites. Successful maintenance peritoneal dialysis (PD) has not been previously reported as an alternative to hemodialysis in this population. PATIENTS AND METHODS: Nine patients with chronic renal failure, chronic liver disease, and tense ascites prior to beginning PD are described. All chronic PD catheters were placed percutaneously by the nephrology staff. Seven patients were maintained primarily on continuous ambulatory peritoneal dialysis, whereas two were on intermittent peritoneal dialysis. RESULTS: PD catheters were placed without serious hemorrhage or bowel injury. PD provided adequate clearance and volume maintenance for each patient. Fifteen episodes of peritonitis occurred in 18 patient-years of PD. All episodes of peritonitis were successfully treated with intraperitoneal antibiotics without catheter removal. Only one patient had a decline in the serum albumin level of 0.5 g/dL or more during the course of chronic PD. Three of the nine patients are still alive and on PD for durations of 18 to 24 months. One patient insidiously developed sclerosing peritonitis after 8 years on PD and is now on hemodialysis, and another patient switched to hemodialysis because she was no longer able to care for herself or to manage her PD. Four patients died while maintained on PD; three deaths were due to complications of liver failure within the first 4 months of PD and the fourth was due to empyema after 4 years of PD. CONCLUSION: PD can be used successfully to treat chronic renal failure in patients with chronic liver disease and ascites when the liver disease itself is not rapidly fatal. PD may be better tolerated than hemodialysis and perhaps should be the renal replacement treatment of choice in these patients.