Comparative clinical outcomes between pediatric and young adult dialysis patients

Published data on the comparative achievement of The Kidney Disease Dialysis Outcome Quality Initative (KDOQI) recommended clinical performance targets between children and young adults on dialysis are scarce. To characterize the achievement of KDOQI targets among children (<18 years) and young adults (18–24 years) with prevalent end stage renal disease (ESRD), we performed a cross-sectional analysis of data collected by the Mid-Atlantic Renal Coalition, in conjunction with the 2007 and 2008 ESRD Clinical Performance Measures Projects. Data on all enrolled pediatric dialysis patients, categorized into three age groups (0–8, 9–12, 13–17 years), and on a random sample of 5% of patients ≥18 years in ESRD Network 5 were examined for two study periods: hemodialysis (HD) data were collected from October to December 2006 and from October to December 2007 and peritoneal dialysis (PD) data were collected from October 2006 to March 2007 and from October 2007 to March 2008. In total, 114 unique patients were enrolled the study, of whom 41.2% (47/114) were on HD and 58.8% (67/114) on PD. Compared to the pediatric patients, young adults were less likely to achieve the KDOQI recommended serum phosphorus levels and serum calcium × phosphorus product values, with less than one-quarter demonstrating values at or below each goal. Multivariate analysis revealed that both young adults and 13- to 17-year-olds were less likely to achieve target values for phosphorus [young adults: odds ratio (OR) 0.04, 95% confidence interval (95% CI) 0.01–0.19, p < 0.001; 13- to 17-year-olds: OR 0.17, 95% CI 0.04–0.77, p = 0.02] and calcium × phosphorus product (young adults: OR 0.01, 95% CI 0.002–0.09, p <  0.001; 13- to 17-year-olds: OR 0.09, 95% CI 0.02–0.56, p = 0.01) than younger children. In summary, there are significant differences in clinical indices between pediatric and young adult ESRD patients.     

Anemia in pediatric dialysis patients in End-Stage Renal Disease Network 5

To identify demographic and clinical characteristics associated with failure to achieve hemoglobin levels 11 g/dl in prevalent pediatric end-stage renal disease (ESRD) patients, a cross-sectional analysis of patient clinical data collected by the Mid-Atlantic Renal Coalition in conjunction with the 2000 and 2001 ESRD Clinical Performance Measures Projects was performed. Ninety-nine patients (mean age 12.6 years, SD 5.4) contributed 119 observations to this analysis. Of patients on hemodialysis, 36.6% were anemic, and 39.5% of patients on peritoneal dialysis (PD) were anemic. Associations between age, race, gender, assigned cause of ESRD, Kt/V, transferrin saturation, time on dialysis, serum albumin, dialysis modality, and the achievement of target hemoglobin were examined. In multivariate logistic regression analyses examining age, dialysis modality, time on dialysis, and serum albumin, each 1-year increase in age was significantly associated with hemoglobin levels <11 g/dl [adjusted odds ratio (OR) 1.18, 95% confidence interval (CI) 1.06–1.32] and PD patients were more than twice as likely to have hemoglobin levels <11 g/dl (adjusted OR 2.62, 95% CI 0.98–7.04). Patients on dialysis for 6 months or more were less likely to be anemic than those on dialysis for less than 6 months (adjusted OR 0.39, 95% CI 0.16–0.99). In conclusion, increasing age, dialysis for less than 6 months, and treatment with PD were predictive of anemia in this population.     

Hospitalization rates and clinical performance measures in U.S. adolescent hemodialysis patients

The Centers for Medicare and Medicaid Services’ End Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) Project monitors clinical measure attainment in pediatric hemodialysis (HD) patients. Targets include hemoglobin ≥11 g/dL, albumin ≥3.5/3.2 g/dL (bromcresol green/purple), single-pooled Kt/V ≥1.2, and the use of subcutaneous access. We hypothesized that the achievement of multiple targets by adolescent HD patients is associated with decreased morbidity. Data on patients aged 12–18 years included in the ESRD CPM Project from 2000 to 2004 with Medicare as primary payer were linked to the U.S. Renal Data System data from October 1, 1999 to December 31, 2004. Hospitalization rates by number of targets achieved were determined with Poisson regression analysis adjusted for dialysis vintage, short stature, and race. A total of 1534 patients with 1774 patient-years of follow-up, with 580 hospitalizations, were included in the analysis. In their first year in the ESRD CPM Project, 22% of the patients achieved four targets, with 34 and 28% achieving three and two targets, respectively. Subcutaneous access was least frequently attained target; spKt/V ≥ 1.2 was the most frequently attained target. After adjustment, there was decreased hospitalization risk with increasing target attainment (incidence rate ratio 0.74, 95% confidence interval 0.67–0.80, p < 0.001). Based on this analysis, meeting adult-defined targets is associated with decreases in the hospitalization rate of adolescent HD patients. Tracking adult-defined HD measures is appropriate for assessing hospitalization risk in adolescent patients, although no evidence for a cause-and-effect relationship exists.     

Predictors and consequences of higher estimated glomerular filtration rate at dialysis initiation

There have been no studies in pediatric dialysis patients to evaluate the impact of higher estimated glomerular filtration rate (eGFR) at dialysis initiation on clinical outcomes. Baseline clinical and demographic information was collected for children aged 1–18 years undergoing incident dialysis from 1995–2002 within the United States Renal Data System. Baseline eGFRs calculated by the Schwartz formula were categorized as high (>15 ml/min/1.73 m²) or low (≤15 ml/min/1.73 m²). We determined predictors of eGFR at baseline, and associations between baseline eGFR and subsequent hospitalization for hypertension (HTN) or pulmonary edema (PE) in a longitudinal nonconcurrent pediatric end-stage renal disease (ESRD) cohort. Twenty percent of children had a high eGFR at initiation. Black children were less likely to initiate dialysis with a high eGFR [adjusted odds ratio (adjOR) 0.71, p < 0.001]. Girls were less likely to have a high eGFR at baseline (adjOR 0.71, p < 0.001). Children who received predialysis erythropoietin therapy were more likely to start dialysis with a high eGFR (adjOR 6.67, p < 0.001). Children with higher baseline eGFR were found to have a 21% decreased risk of hospitalization [adjusted hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.65–0.96, p = 0.02]. It is not known whether this clinical benefit will result in decreased mortality and complication rates from cardiovascular disease.     

Disparate outcomes in pediatric peritoneal dialysis patients by gender/race in the End-Stage Renal Disease Clinical Performance Measures project

Associations between achievement of adult Kidney Disease Outcomes Quality Initiative (KDOQI) targets for hemoglobin, adequacy and albumin, and race and gender were determined for pediatric peritoneal dialysis patients from the End-Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) project for the period October 2004-March 2005. Fifty-six percent (427/761) of patients were male. Sixty-six percent (500/761) of patients were White. There were no differences in achievement of targets for adults by gender, and no differences in adequacy parameters by race. Blacks had lower mean hemoglobin levels than did Whites (11.1 +/- 1.6 g/dl vs 11.8 +/- 1.4 g/dl, P < 0.0001). Blacks were more likely to have mean hemoglobin levels < 10 g/dl (24% vs 11%, P < 0.0001) and less likely to achieve mean hemoglobin > 11 g/dl (56% vs 72%, P < 0.0001). Whites were more likely to achieve mean serum albumin levels > 4.0/3.7 g/dl [bromocresol green/bromocresol purple (BCG/BCP)] than Blacks were (35% vs 26%, P = 0.0376). In multivariate logistic regression models, White race was associated with mean hemoglobin levels > 11 g/dl [adjusted odds ratio (adj OR) 2.7, 95% confidence interval (CI) 1.7, 4.3] and mean serum albumin > 4.0/3.7 g/dl (BCG/BCP) (adj OR 1.9, 95% CI 1.3, 2.9]. Further study is needed of factors associated with anemia on peritoneal dialysis and barriers to its correction.     

Adolescent hemodialysis: results of the 2000 ESRD Clinical Performance Measures Project

In 2000, the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA) 2000 ESRD Clinical Performance Measures (CPM) Project, was expanded to obtain demographic characteristics and clinical information on all adolescent (age ≥12 years, <18 years) patients receiving in-center hemodialysis on 31 December, 1999. Of the 486 patients identified, 433 (89%) had the minimum required data submitted. Demographic characteristics included mean age of 15.8 years (±1.6 years). Forty-nine percent were white, 42% black; 21% were Hispanic. Congenital/urologic disease and focal and segmental sclerosis were the leading causes of end-stage renal disease. Forty-one percent had a catheter as their dialysis access, while 37% had an AV fistula and 22% an AV graft in place. The mean Kt/V was 1.47 (±0.38) and 79% had a mean calculated Kt/V≥1.2, although residual renal function was not included in this measurement. After multivariate logistic regression, male gender and black race were among the factors predictive of mean calculated Kt/V<1.2. The mean serum albumin was 3.85 g/dl (±0.51) in patients with bromcresol green measurements and 3.62 mg/dl (±0.52) in patients with bromcresol purple measurements. The mean hemoglobin was 10.99 g/dl (±1.6) and 55% had a mean hemoglobin ≥11 g/dl. After multivariate logistic regression, lower epoetin dose and mean serum albumin ≥3.5/3.2 g/dl (BCG/BCP) remained predictive of mean hemoglobin ≥11 g/dl. These data provide important information about the clinical status of adolescent hemodialysis patients in the United States. Continued data collection and analyses are planned to identify areas for potential improvement in patient care. Received: 21 May 2001 / Revised: 7 August 2001 / Accepted: 7 August 2001     

Persistent low albumin and temporary vascular access in pediatric patients with SLE on hemodialysis

Pediatric patients with systemic lupus erythematosus (SLE) often present with significant kidney disease. In a previous cross-sectional analysis, we showed that pediatric patients with ESRD secondary to SLE have lower serum albumin levels and less permanent vascular access for hemodialysis (HD) compared to pediatric patients on HD secondary to other causes. The goal of this longitudinal study was to determine if there was an improvement in these targets over time. To this end, we performed a longitudinal analysis of patients receiving HD in the ESRD Clinical Performance Measures Project 2000–2004 study years, comparing achievement of clinical targets between pediatric patients with SLE and pediatric patients with other causes of ESRD. In the longitudinal follow-up, pediatric patients with SLE were less likely to reach target albumin levels than other children with ESRD maintained on HD [odds ratio (OR) 0.18, 95% confidence interval (CI) 0.09, 0.35] and were less likely to have arteriovenous fistulas or grafts than other pediatric patients (OR 0.45, 95% CI 0.23, 0.89). Pediatric patients with SLE maintained on HD are at particularly high risk for failing to meet some clinical targets that have been associated with improved long-term outcomes in other populations. This is true even as they remain on dialysis over time.     

Acute dialysis-associated peritonitis in children with D+ hemolytic uremic syndrome

Acute peritoneal dialysis (PD) is the preferred therapy for renal replacement in children with post-diarrheal hemolytic uremic syndrome (D+ HUS), but peritonitis remains a frequent complication of this procedure. We reviewed data from 149 patients with D+ HUS who had undergone acute PD with the aim of determining the prevalence and risk factors for the development of peritonitis. A total of 36 patients (24.2%) presented peritonitis. The median onset of peritonitis manifestations was 6 (range 2–18) days after the initiation of dialysis treatment, and Gram-positive microorganisms were the predominant bacterial type isolated (15/36 patients). The patients were divided into two groups: with or without peritonitis, respectively. Univariate analysis revealed that a longer duration of the oligoanuric period, more days of dialysis, catheter replacement, stay in the intensive care unit, and hypoalbuminemia were significantly associated to the development of peritonitis. The multivariate analysis, controlled by duration of PD, identified the following independent risk factors for peritonitis: catheter replacement [p = 0.037, odds ratio (OR) 1.33, 95% confidence interval (CI) 1.02–1.73], stay in intensive care unit (p = 0.0001, OR 2.62, 95% CI 1.65–4.19), and hypoalbuminemia (p = 0.0076, OR 1.45, 95% CI 1.10–1.91). Based on these findings, we conclude that the optimization of the aseptic technique during catheter manipulation and early nutritional support are targets for the prevention of peritonitis, especially in critically ill patients.     

The association between personal habits and bladder cancer in Turkey

Aims  In this study, we analyzed the effect of Turkish coffee and black tea consumption, alcohol intake and smoking on bladder cancer. Methods  A total of 164 patients with bladder tumors and 324 individuals without primary tumors were included in the study. The habits of coffee and tea consumption, alcohol intake and smoking were queried. Results  No association was found between bladder cancer and drinking coffee (p = 0.89) and tea (p = 0.37), but alcohol intake was found to be associated, with an odds ratio (OR) of 1.85 (95% CI 1.15–2.96; p = 0.009). While there was a relationship between bladder cancer and smoking and quitting smoking (OR: 4.84 [95% CI 2.93–8.00; p < 0.001] and OR: 4.10 [95% CI 2.41–6.97; p < 0.001] respectively), the associations between bladder cancer and smoking and quitting smoking were similar (OR: 1.18, 95% CI 0.74–1.86; p = 0.477). Smoking <10 cigarettes a day created an OR of 2.14 (95% CI 1.11–4.12; p < 0.001); 10–20 cigarettes an OR of 4.50 (95% CI 2.74–7.37; p < 0.001); >20 cigarettes an OR of 14.85 (95% CI 6.83–32.27; p < 0.001); smoking by inhaling the smoke an OR of 4.72 (95% CI 2.94–7.59; p < 0.001), and smoking by not inhaling the smoke an OR of 3.34 (95% CI 1.75–6.38; p < 0.001). The associations between bladder cancer and inhaling smoke and not inhaling smoke were similar (OR: 1.41, 95% CI 0.85–2.48; p = 0.228). Conclusion  We found that smoking and alcohol consumption are closely connected with bladder cancer. Our data showed that not inhaling the smoke was as much associated with bladder cancer as inhaling the smoke. The association between smoking and bladder cancer lasts after quitting smoking.     

Darbepoetin, effective treatment of anaemia in paediatric patients with chronic renal failure

Darbepoetin alfa (DA) is a unique long-acting treatment for anaemia in patients with chronic renal failure (CRF). This study assessed the mean dose of DA to achieve and maintain haemoglobin (Hb) levels between 11 g/dl and 13 g/dl in CRF children aged 11 years to 18 years. This observational, prospective study was conducted in 39 patients treated with DA. Twenty-nine patients were switched from recombinant human erythropoietin (r-HuEPO), and ten patients were naive to r-HuEPO. Naive patients received initial doses of 0.45 μg/kg of DA. Switched patients received a dose adjusted to the prior dose of r-HuEPO (200 IU r-HuEPO:1 μg DA). Among the switched patients, 79.3% received dialysis. No naive patients underwent dialysis. Overall, 74% of patients showed increased Hb level, with a mean value of 11.6 ± 1.6 g/dl, using a mean DA dose of 0.63 ± 0.48 μg/kg per week, and 66.7% patients reached the target Hb level. Hb increased in naive patients from 9.5 (95% CI: 7.7, 11.4) to 11.7 (95% CI: 10.9, 12.6) g/dl and in switched patients from 11.1 (95% CI: 10.6, 11.5) to 11.5 (95% CI: 10.8, 12.2) g/dl). Higher doses of DA were needed in the “switched” than in the “naive” patients to maintain Hb levels over 11 g/dl, respectively 0.73 (95% CI: 0.54, 0.92) and 0.34 (95% CI: 0.16, 0.52) μg/kg per week. Our results indicate the doses of DA necessary to treat CRF patients aged 11 years to 18 years. DA was an effective treatment to stabilise CRF patients at extended dosing intervals. A prospective observational study, on behalf of the French Society for Pediatric Nephrology. Preliminary results of this study were published in part as an abstract and presented as a poster at the European Society of Pediatric Nephrology in Istanbul 11–13 September 2005 and at the ASN Renal Week in Philadelphia (Pennsylvania) 8–13 November 2005.     

Acute kidney injury is independently associated with mortality in very low birthweight infants: a matched case–control analysis

The independent impact of acute kidney injury (AKI) on survival in very low birthweight (VLBW; ≤1,500 g) critically ill infants has not been studied. Cases (non-survivors n = 68) were matched to, at most, two controls (survivors n = 127) by incidence density sampling with replacement, birthweight (± 50 g), gestational age (± 1 week), and availability of serum creatinine (SCr) levels before the index patient’s time of death. Maternal/infant demographic characteristics, co-morbidities, complications and interventions were explored. No difference existed between patients and controls in mean gestational age and birthweight (the matching variables), race, or gender. Compared with the controls, cases had younger mothers, less placental separation, fewer occurrences of hyponatremia, more intra-ventricular hemorrhage, and received chest compressions and cardiac drugs. A 1 mg/dl increase in SCr was associated with almost two-times higher odds of death [odds ratio (OR) = 1.94, 95% confidence interval (95% CI) 1.13–3.32]. OR increased when confounding variables were adjusted (adjusted OR 3.44, 95% CI 1.23–9.61). Similarly, a 100% increase in SCr from trough level was associated with an increased OR = 1.53 (95% CI 1.14–2.04) and became stronger, after adjustment of variables (adjusted OR = 1.90, 95% CI 1.10–3.27). After confounding variables had been controlled for, AKI was independently associated with mortality in VLBW infants. Further prospective multi-center studies are needed to determine whether this association exists.     

Pregnancy Following Gastric Bypass Surgery for Morbid Obesity: Maternal and Neonatal Outcomes

Background The purpose of this study was to compare obstetric and neonatal outcomes after Roux-en-Y gastric bypass (RYGB) to those in women without such surgery. Methods Women with RYGB (cases) were matched for maternal age and prior cesarean to the next two consecutive women delivering without prior bariatric surgery (controls). Pregnancy and newborn outcomes were compared by univariate analysis. Outcomes approaching or reaching statistical significance were evaluated by conditional logistic regression controlling for maternal body mass index (BMI). Results Despite gastric bypass, the 38 cases were heavier (BMI 33.4 ± 7.3 vs. 28.1 ± 6.7 kg/m², p < 0.001) and more often obese (BMI ≥ 30 kg/m², 26/38 (68.4%) vs. 20/76 (26.3%), p < 0.001) than controls. Variables evaluated by logistic regression adjusted for BMI did not differ in cases versus controls, including hypertension (odds ratio [OR] 2.62, 95% confidence interval [CI] 0.66–10.50), preterm premature rupture of membranes (OR 0.24, 95% CI 0.02–3.38), oligohydramnios (OR 2.39, 95% CI 0.66–8.61), and delivery ≥41 weeks (OR 0.57, 95% CI 0.11–2.97). Discussion Obstetric and neonatal outcomes after RYGB are similar to those of our general obstetric population. Reprints unavailable.     

Growth failure,risk of hospitalization and death for children with end-stage renal disease

Growth failure remains a significant problem for children with chronic renal insufficiency and end-stage renal disease (ESRD). We examined whether growth failure is associated with more-frequent hospitalizations or higher mortality in children with kidney disease. We studied data on prevalent United States pediatric patients with ESRD in 1990 who were followed through 1995. Patients were categorized according to the standard deviation score (SDS) of their incremental growth during 1990: severe (<–3 SDS), moderate growth failure (>–3 and <–2 SDS), and normal growth (>–2 SDS). Among 1,112 prevalent pediatric dialysis and transplant patients (<17 years, Tanner I–IV), those with severe and moderate growth failure had higher hospitalization rates {relative risk (RR) 1.14 [95% confidence interval (CI) 1.1, 1.2] and 1.24 [95% CI 1.2, 1.3]} respectively than those with normal growth after adjustment for age, gender, race, cause and duration of ESRD, and treatment modality (dialysis or transplant) in 1990. Kaplan-Meier survival analysis showed 5-year survival of 85% and 90% for patients with severe and moderate growth failure, respectively, compared with 96% for patients with normal growth (P<0.001, log-rank). Cox proportional hazards analysis revealed that those with severe (RR 2.9, 95% CI 1.6, 5.3) and moderate growth failure (RR 2.01, 95% CI 1.1, 3.6) had an increased risk of death compared with youths with normal growth, after adjustment. A higher proportion of deaths in the severe and moderate growth failure groups were attributed to infectious causes (22% and 18.7%, respectively) than in the normal growth group (15.6%). We conclude that growth failure is associated with a more-complicated clinical course and increased risk of death for children with kidney failure. Received: 15 August 2001 / Revised: 14 January 2002 / Accepted: 15 January 2002     

Clinical outcomes of elderly patients undergoing chronic peritoneal dialysis: experiences from one center and a review of the literature

Objectives The purpose of this study was to evaluate the outcome and to identify predictors of mortality in elderly patients on chronic peritoneal dialysis (CPD). Methods We retrospectively reviewed the charts of patients who started on CPD at the Division of Nephrology, University Health Network (UHN), Toronto, from 1 January 1994 to 31 December 2001. Patients were divided into three different age groups (≤64 years, 65–74 years, and ≥75 years). Baseline variables included demographics, information on primary kidney disease, comorbidities when dialysis was first started, and initial biochemical data such as serum albumin, serum calcium (corrected for protein), phosphate, hemoglobin (Hb), total cholesterol, and triglyceride. The effects of these variables on survival were studied using a univariate procedure and then analyzed using multivariate Cox proportional hazards models in order to evaluate their independent relation to mortality. Results This study included 358 patients, among whom 213 (59.5%) were ≤64 years old; 88 (24.6%) were 65–74, and 57 (15.9%) were ≥75 years old. Mean actuarial (death-censored) technique survival for the overall study population was 72.4 months (95% confidence interval [CI]: 66.3–78.5); in the ≤64, 65–74, and ≥75 year-old groups mean survivals were 74.4, 62.0, and 64.5 months, respectively. The death-censored technique survival for the elderly patients was not statistically significantly different from that in young patients (P = 0.778). In the overall study population, the mean patient survival was 70.4 months (95% CI 64.2–76.6), while the mean survivals for the ≤64, 65–74, and ≥75 year-old groups were 82.3, 54.0, and 50.0 months, respectively. The overall survival rates at 12 months were 98%, 84%, and 85% for the ≤64, 65–74, and ≥75 year-old groups, respectively. Not surprisingly, the survival of elderly patients on CPD is shorter than that of younger patients (P = 0.000). There were no significant differences between the two elderly groups (P = 0.439). Mortality was predicted by lower initial serum total cholesterol and albumin as well as higher serum calcium levels. Conclusion Our study shows that elderly patients starting CPD had a death-censored technique survival comparable to that of younger patients. As expected, the survival of elderly patients on CPD was shorter than the survival of younger patients. Lower initial serum total cholesterol and albumin as well as higher initial serum calcium were associated with mortality in the elderly population. Our findings indicate that chronic peritoneal dialysis is a successful dialysis option for elderly patients with end stage renal disease. Measures to improve their nutritional state and achieve normalization of serum calcium might improve their survival.     

Factors associated with anemia among incident pre-dialysis patients managed within a French care network

BACKGROUND AND AIMS: Despite guidelines concerning the management of renal anemia, the international literature reports that a large proportion of pre-dialysis patients have hemoglobin values lower than the recommended level. The present study analyzed the evolution of pre-dialysis Hb levels and erythropoietin use over a 4-year period and investigated factors associated with anemia. METHODS: A total of 1315 patients initiating dialysis in Lorraine, France, were enrolled since 2001-2004. For each year, anemia, defined by Hb <11 g/dl, and erythropoietin use were investigated in three groups: all patients, patients whose dialysis was planned and patients whose dialysis was unplanned. RESULTS: At initiation of dialysis, all groups showed increases over time in mean hemoglobin levels, proportion of patients without anemia and with erythropoietin therapy. Among patients whose first dialysis was planned in 2004, 43.8% had anemia and 67.9% had received erythropoietin, compared with 75.4% and 29.4%, respectively, when dialysis was unplanned. Patients receiving unplanned dialysis were more likely to have anemia (odds ratio (OR) = 2.6), as were those with a serum albumin level < 3.5 g/dl (OR = 2.1), body mass index < 30 kg/m2 (OR = 1.9) (all p < 0.001) or glomerular filtration rate < 10 ml/min/1.73 m2 (OR = 1.4, p = 0.04). The year of dialysis initiation was also associated with anemia (p = 0.024). CONCLUSION: The proportion ofpatients starting dialysis with anemia might be reduced by earlier nephrology referral leading to erythropoietin administration, planned first dialysis while residual renal function remains, and greater attention to nutritional status.     

Epidemiology and predictors of spinal injury in adult major trauma patients: European cohort study

This is a European cohort study on predictors of spinal injury in adult (≥16 years) major trauma patients, using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Predictors for spinal fractures/dislocations or spinal cord injury were determined using univariate and multivariate logistic regression analysis. 250,584 patients were analysed. 24,000 patients (9.6%) sustained spinal fractures/dislocations alone and 4,489 (1.8%) sustained spinal cord injury with or without fractures/dislocations. Spinal injury patients had a median age of 44.5 years (IQR = 28.8–64.0) and Injury Severity Score of 9 (IQR = 4–17). 64.9% were male. 45% of patients suffered associated injuries to other body regions. Age <45 years (≥45 years OR 0.83–0.94), Glasgow Coma Score (GCS) 3–8 (OR 1.10, 95% CI 1.02–1.19), falls >2 m (OR 4.17, 95% CI 3.98–4.37), sports injuries (OR 2.79, 95% CI 2.41–3.23) and road traffic collisions (RTCs) (OR 1.91, 95% CI 1.83–2.00) were predictors for spinal fractures/dislocations. Age <45 years (≥45 years OR 0.78–0.90), male gender (female OR 0.78, 95% CI 0.72–0.85), GCS <15 (OR 1.36–1.93), associated chest injury (OR 1.10, 95% CI 1.01–1.20), sports injuries (OR 3.98, 95% CI 3.04–5.21), falls >2 m (OR 3.60, 95% CI 3.21–4.04), RTCs (OR 2.20, 95% CI 1.96–2.46) and shooting (OR 1.91, 95% CI 1.21–3.00) were predictors for spinal cord injury. Multilevel injury was found in 10.4% of fractures/dislocations and in 1.3% of cord injury patients. As spinal trauma occurred in >10% of major trauma patients, aggressive evaluation of the spine is warranted, especially, in males, patients <45 years, with a GCS <15, concomitant chest injury and/or dangerous injury mechanisms (falls >2 m, sports injuries, RTCs and shooting). Diagnostic imaging of the whole spine and a diligent search for associated injuries are substantial.     

Changes in Inflammatory Biomarkers Across Weight Classes in a Representative US Population: A Link Between Obesity and Inflammation

Background  Obesity has been linked with a chronic state of inflammation which may be involved in the development of metabolic syndrome, cardiovascular disease, non-alcoholic steatohepatitis, and even cancer. The objective of this study was to examine the association between obesity class and levels of inflammatory biomarkers from men and women who participated in the 1999–2004 National Health and Nutrition Examination Survey (NHANES). Methods  Serum concentrations of C-reactive protein (CRP) and fibrinogen were measured among US participants of the 1999–2004 NHANES. We examined biomarker levels across different weight classes with normal weight, overweight, and obesity classes 1, 2, and 3 were defined as BMI of <25.0, 25.0–29.9, 30.0–34.9, 35.0–39.9, and ≥40.0, respectively. Results  With CRP levels for normal weight individuals as a reference, CRP levels nearly doubled with each increase in weight class: +0.11 mg/dl (95% CI, 0.06–0.16) for overweight, +0.21 mg/dl (95% CI, 0.16–0.27) for obesity class 1, +0.43 mg/dl (95% CI, 0.26–0.61) for obesity class 2, and +0.73 mg/dl (95% CI, 0.55–0.90) for obesity class 3. With normal weight individuals as a reference, fibrinogen levels increase with increasing weight class and were highest for obesity class 3 individuals, +93.5 mg/dl (95% CI, 72.9–114.1). Individuals with hypertension or diabetes have higher levels of CRP and fibrinogen levels compared to individuals without hypertension or diabetes, even when stratified according to BMI. Conclusions  There is a direct association between increasing obesity class and the presence of obesity-related comorbidities such as diabetes and hypertension with high levels of inflammatory biomarkers. Presented at the 49th annual meeting of the Society for Surgery of the Alimentary Tract May 20, 2008, San Diego, CA.     

Proteinuria and decreased body mass index as a significant risk factor in developing end-stage renal disease

Background  Body mass index (BMI) is a significant predictor of developing end-stage renal disease (ESRD). The relation between a change in BMI (ΔBMI) and the incidence of ESRD has not been examined in any large epidemiologic studies. Methods  We determined the ΔBMI in subjects who participated in the Okinawa General Health Maintenance Association (OGHMA) screenings in 1983 and again in 1993. Screenees were free of ESRD at the 1993 screening and were then monitored until the end of 2000 to determine whether they developed ESRD. Participants were identified using ID numbers, birthdates, and other identifiers. Details of every ESRD patient treated in Okinawa are maintained in an independent community-based dialysis registry. Multivariate logistic analyses were performed to determine the significance of a ΔBMI on the incidence of ESRD using SAS. The ethics committee of the OGHMA approved the study protocol. Only coded data were used for this study. Results  Among the 92,364 subjects aged 30–89 years screened in 1983, 29,011 (31.4%) returned for the 1993 screening. The median ΔBMI was 2.1%, and the subjects were divided into two groups: ΔBMI < 2.1% (G1) and ΔBMI ≥ 2.1% (G2). The cumulative incidence of ESRD was 0.31% in G1 (ESRD in 44) and 0.14% in G2 (ESRD in 21). The odds ratio (95% confidence interval) of developing ESRD based on a ΔBMI was 2.268 (1.284–4.000, P < 0.01) after adjusting for age, sex, systolic blood pressure, BMI in 1983, and proteinuria. Conclusion  The findings of the present study suggest that a ΔBMI is an independent risk factor for the incidence of ESRD, especially for those with proteinuria. The reasons for the BMI change were not recorded in this study. Unintentional weight loss, however, might warrant evaluation for the presence or progression of chronic kidney disease.     

Darbepoetin alfa for the treatment of anemia in pediatric patients with chronic kidney disease

Darbepoetin alfa, an erythropoiesis-stimulating glycoprotein, has proved efficacious in the treatment of anemia of chronic kidney disease (CKD) in adult subjects. However, little information is available from pediatric populations. We conducted an open-label, non-inferiority, 28-week study comparing the efficacy of darbepoetin alfa with that of recombinant human erythropoietin (rHuEpo) in pediatric subjects with CKD. Subjects, aged 1–18, who were receiving stable rHuEpo treatment (n=124) were randomized (1:2) to either continue receiving rHuEpo or convert to darbepoetin alfa, with doses titrated to achieve and maintain hemoglobin (Hb) levels between 10.0 and 12.5 g/dl. Darbepoetin alfa was considered to be non-inferior to rHuEpo if the lower limit of the two-sided 95% confidence interval (CI) for the difference in the mean change in Hb between the two treatment groups was above −1.0 g/dl. The adjusted mean change in Hb between the baseline and the evaluation period for the rHuEpo and darbepoetin alfa groups was −0.16 g/dl and 0.15 g/dl, respectively, with a difference of 0.31 g/dl (95% CI: −0.45, 1.07) between the means. These results, and the comparable safety profiles, demonstrate that darbepoetin alfa is non-inferior to rHuEpo in the treatment of anemia in pediatric patients with CKD.     

Early erythropoietin reduced the need for red blood cell transfusion in childhood hemolytic uremic syndrome—a randomized prospective pilot trial

Childhood hemolytic uremic syndrome (HUS) is most often caused by enterohemorrhagic Escherichia coli (EHEC). Due to severe hemolysis, red blood cell (RBC) transfusions are often necessary, and anemia is aggravated by low erythropoietin (EPO) levels caused by acute renal failure. In a single center, prospective study, we randomized ten children with EHEC-positive HUS into two therapeutic groups: one receiving EPO treatment (median age 2 years, age range 1–3 years) and the other receiving standard therapy (median age 2 years, age range 1–6 years). Red blood cell transfusions were performed when the hemoglobin level (Hb) fell below 5 mg/dl. The number of RBC transfusions was compared in both groups. The Hb level at admission was comparable between both groups (6.4 vs. 8.1 mg/dl, P > 0.05, t-test). However, children in the EPO group required a significantly lower mean number of RBCs than those in the non-EPO group (0.2 vs. 1.4, P < 0.04, t-test). Based on these results, we suggest that the early administration of EPO at the time of hemolytic anemia and beginning renal failure may attenuate renal anemia in children with EHEC-induced HUS and thereby reduce the number of RBC transfusions required. The results of this pilot study will have to be confirmed in a larger multicenter trial.