Hepatitis B and C in dialysis units in Iran: changing the epidemiology

Hepatitis B (HBV) and C (HCV) viruses are the most important infections transmitted by the parenteral route in patients receiving maintenance dialysis. The prevalence varies markedly from country to country. The aim of this study is to review the efficacy of the strategies to reduce the incidence of these infections and the trend of results in Iran. As a routine, all hemodialysis patients in Iran have biannual blood samples for assessment of serum HBSAg, HBS Abs, and HCV Abs. The data are collected in the Ministry of Health. For statistical analysis, prevalence, and incidence were calculated. There is an increasing prevalence/incidence of end-stage renal disease (ESRD) in Iran, from 238/49.9 pmp in 2000 to 357/63.8 pmp in 2006. The prevalence of positive HBSAg and HCV Abs decreased from 3.8% and 14.4% in 1999 to 2.6% and 4.5% in 2006, respectively. Regarding the genotype distribution in Iran, no one was found with genotype 2. On the subject of decreasing HBV infection, our next strategy should be mandatory vaccination in dialysis centers and in the pre-ESRD period. Concerning HCV infection prevention, 2 approaches may be recommended: the first is decrease of duration of the hemodialysis period by possible early transplantation of suitable patients. The next is a strictly enforced isolation policy for HCV-positive patients, which may play a role in limiting HCV transmission in HD units, and universal precaution in dialysis units should be under constant close surveillance.     

Hyponatremia in patients with chronic kidney disease

Hyponatremia is a common condition encountered in clinical practice. A number of studies have associated low serum sodium levels with increased mortality in various patient populations, such as hospitalized patients and patients with various comorbid conditions; recent studies have shown that individuals with chronic kidney disease also are afflicted by hyponatremia. However, few studies have focused on patients with hemodialysis. Evidence supporting the incidence and prevalence of hyponatremia, clinical characteristics and the association with patient outcomes with hemodialysis is limited. In the present review, we examined the physiology and pathophysiology of water and sodium balance with a special emphasis on changes occurring during end‐stage renal disease. The outcomes in patients undergoing hemodialysis were associated with low serum sodium. We evaluated the associations between hyponatremia and mineral bone abnormalities and discussed the elevated incidence and prevalence of difficult clinical outcomes associated with hyponatremia. We also provided specific recommendations for hemodialysis treatment in hyponatremic patients.     

Thyroid function in end stage renal disease and effects of frequent hemodialysis

Introduction: End‐stage renal disease (ESRD) is associated with perturbations in thyroid hormone concentrations and an increased prevalence of hypothyroidism. Few studies have examined the effects of hemodialysis dose or frequency on endogenous thyroid function. Methods: Within the Frequent Hemodialysis Network (FHN) trials, we examined the prevalence of hypothyroidism in patients with ESRD. Among those with endogenous thyroid function (without overt hyper/hypothyroidism or thyroid hormone supplementation), we examined the association of thyroid hormone concentration with multiple parameters of self‐reported health status, and physical and cognitive performance, and the effects of hemodialysis frequency on serum thyroid stimulating hormone (TSH), free thyroxine (FT4), and free tri‐iodothyronine (FT3) levels. Conventional thrice‐weekly hemodialysis was compared to in‐center (6 d/wk) hemodialysis (Daily Trial) and Nocturnal (6 nights/wk) home hemodialysis (Nocturnal Trial) over 12 months. Findings: Among 226 FHN Trial participants, the prevalence of hypothyroidism was 11% based on thyroid hormone treatment and/or serum TSH ≥8 mIU/mL. Among the remaining 195 participants (147 Daily, 48 Nocturnal) with endogenous thyroid function, TSH concentrations were modestly (directly) correlated with age (r = 0.16, P = 0.03) but not dialysis vintage. Circulating thyroid hormone levels were not associated with parameters of health status or physical and cognitive performance. Furthermore, frequent in‐center and nocturnal hemodialysis did not significantly change (baseline to month 12) TSH, FT4, or FT3 concentrations in patients with endogenous thyroid function. Discussion: Among patients receiving hemodialysis without overt hyper/hypothyroidism or thyroid hormone treatment, thyroid indices were not associated with multiple measures of health status and were not significantly altered with increased dialysis frequency.     

Cultural comparison of symptoms in patients on maintenance hemodialysis

Although symptoms are common and frequently severe in patients on maintenance hemodialysis, little is known about the relationship between cultural background and symptom burden. The aim of this study was to explore differences in the prevalence and severity of symptoms between American and Italian hemodialysis patients. We administered the 30‐item Dialysis Symptom Index to American and Italian patients receiving maintenance hemodialysis during routine dialysis sessions. The prevalence and severity of individual symptoms were compared between patient populations, adjusting for multiple comparisons. Multivariable logistic regression and ordinal logistic regression were used to assess the independent associations of cultural background with the prevalence and severity of symptoms, respectively. We enrolled 75 American and 61 Italian patients. American patients were more likely to be black (36% vs. 0%, P<0.001) and diabetic (53% vs. 13%, P<0.001). Italian patients were more likely to report decreased interest in sex, decreased sexual arousal, feeling nervous, feeling irritable, and worrying (P<0.001, respectively). Adjustment for demographic and clinical variables had no impact on these cultural differences in symptom prevalence. The median severity of 11 symptoms including muscle soreness, muscle cramps, and itching was greater among Americans (P<0.001, respectively), although nearly all of these differences were rendered nonstatistically significant with adjustment for race, diabetes, and/or Kt/V. Italian patients receiving chronic hemodialysis report a greater burden of symptoms than American patients, particularly those related to sexual dysfunction and psychosocial distress. These findings suggest that cultural background may affect adaptation to chronic hemodialysis therapy.     

Pulmonary hypertension in patients on chronic hemodialysis and with heart failure

Pulmonary hypertension (PH) is linked to chronic kidney disease. However, few studies have examined the prevalence, risk factors, or outcomes of PH in patients with chronic hemodialysis and concomitant heart failure. This retrospective cohort study enrolled 160 patients with a history of acute decompensated heart failure after maintenance hemodialysis therapy. All patients were prospectively observed until December 2013 or death. PH was defined as pulmonary artery systolic pressure >35 mmHg, as determined through echocardiography. Fifty‐one (32%) patients had PH, more of whom were female (70% vs. 52%, P = 0.04). The patients with PH had a lower body mass index (21.8 vs. 23.0, P = 0.03), higher cardiothoracic ratio (55% vs. 52%, P = 0.006), larger left atrium (38.5 vs. 35.7 mm, P = 0.01), and an increased proportion of mitral regurgitation (MR) (73% vs. 38%, P < 0.001) compared with the patients who did not have PH. In the multivariate regression analysis, MR was associated most strongly with PH (odds ratio 3.75, 95% confidence interval [CI]: 1.67–8.43, P = 0.001). In the multivariate Cox proportional hazard models, PH was related independently to all‐cause mortality (hazard ratio [HR], 3.11; 95% CI, 1.53–6.31; P = 0.002) and combined cardiovascular events (HR, 2.71; 95% CI, 1.66–4.44; P < 0.001) after the model was adjusted for conventional cardiovascular risk factors. PH is related to MR and independently associated with increased all‐cause mortality and cardiovascular events in patients with chronic hemodialysis and heart failure.     

Surveillance cultures of tunneled cuffed catheter exit sites in chronic hemodialysis patients are of no benefit

Catheter-related infections are a major cause of morbidity and mortality in hemodialysis (HD) patients. This study evaluated the utility of surveillance swab cultures (Ssc) of tunneled cuffed catheter (TCC) exit sites as a prediction and prevention strategy for infection. A 6-month prospective-controlled trial with 94 chronic HD patients with a TCC who received monthly Ssc and were stratified by dialysis day into topical therapy based on Ssc results (Group A) or no therapy (Group B). Outcomes were exit site infection (ESI) and catheter-associated bacteremia (CAB). The overall monthly prevalence of positive Ssc was 14.9%. There was no difference in the number of positive Ssc (17.7% vs. 11.6%, p > 0.05) or ESI (19.6% vs.16.3%, p > 0.05) between Groups A and B, respectively. Catheter-associated bacteremia was higher in Group A (17.7% vs. 4.7%, p = 0.05). There were significantly more ESI in the patients treated for a positive Ssc. In Group A, the incidence of ESI was significantly higher in those treated for a positive vs. negative Ssc (55% vs. 12%, p = 0.009) and CAB rates trended higher with positive Ssc (22.2% vs. 16.7%, p > 0.05). The strategy of treating positive surveillance cultures is not beneficial. Positive Ssc do not predict the occurrence of catheter-related infection, and treatment of these cultures may lead to increased infection rates.     

Clinical characteristics and outcomes of new uremic patients with extreme azotemia in southern Taiwan

Serum creatinine (SCr) had been considered to be an important predictor of mortality in end-stage renal disease (ESRD) patients at the start of renal replacement therapy (RRT). However, the data were limited about initially extreme azotemia (EA), exclusively defined as blood urea nitrogen (BUN) > or = 300 mg/dL, SCr > or = 30 mg/dL, or both. This retrospective study was conducted to clarify the characteristics and outcome in our EA patients. We had 1682 new ESRD patients from July 1988 to December 1996. With frequency match for age, gender, and starting RRT in the same period, 20 EA patients and 60 controls were included. Fifty percent of our EA patients had unknown etiology. The EA patients had significantly lower prevalence of underlying diabetic nephropathy, and comorbid hypertension. All the EA patients had late referral to nephrologists within 4 weeks before the initiation of RRT, and 90% of them had taken Chinese herbals. The EA group had significantly higher BUN, SCr, and iron storage as well as a higher prevalence of severe anemia, hyperkalemia, hypocalcemia, and acidemia. However, the similar prevalence of cardiomegaly and left ventricular hypertrophy as well as the similar early mortality rate and long-term survival were noted. Age over 40 years, comorbid diabetes mellitus, and hypoalbuminemia were independent predictors of poor survival. Our EA patients had different initial presentations from other uremic ones at the start of RRT. However, the short-term and long-term mortality rates were similar. The lower prevalence of underlying diabetic nephropathy and comorbid hypertension among the EA patients might contribute to their fair outcome.     

Gender,low Kt/V,and mortality in Japanese hemodialysis patients: Opportunities for improvement through modifiable practices

Guidelines have recommended single pool Kt/V > 1.2 as the minimum dose for chronic hemodialysis (HD) patients on thrice weekly HD. The Dialysis Outcomes and Practice Patterns Study (DOPPS) has shown that “low Kt/V” (<1.2) is more prevalent in Japan than many other countries, though survival is longer in Japan. We examined trends in low Kt/V, dialysis practices associated with low Kt/V, and associations between Kt/V and mortality overall and by gender in Japanese dialysis patients. We analyzed 5784 HD patients from Japan DOPPS (1999–2011), restricted to patients dialyzing for >1 year and receiving thrice weekly dialysis. Logistic regression models estimated the relationships of patient characteristics with Kt/V. Logistic models also were used to estimate the proportion of low Kt/V cases attributable to various treatment practices. Multivariable Cox regression was used to estimate the associations of low Kt/V, blood flow rate (BFR), and treatment time (TT), with all‐cause mortality. From 1999 to 2009, the prevalence of low Kt/V declined in men (37–27%) and women (15–10%). BFR <200 mL/min, TT <240 minutes, and dialyzate flow rate (DFR) < 500 mL/min were common (35, 13, and 19% of patients, respectively) and strongly associated with low Kt/V. Fifteen percent of low Kt/V cases were attributable to BFR <200 and 13% to TT <240, compared to only 3% for DFR <500. Lower Kt/V was associated with elevated mortality, more so among women (hazard ratio [HR] = 1.13 per 0.1 lower Kt/V, 95% CI: 1.07–1.20) than among men (HR = 1.06 per 0.1 lower Kt/V, 95% CI: 1.00–1.12). The relatively large proportion of low Kt/V cases in Japanese facilities may potentially be reduced 30% by increasing BFR to 200 mL/min and TT to 4 hours thrice weekly in HD patients. Associations of low Kt/V with elevated mortality suggest that modification of these practices may further improve survival for Japanese HD patients.     

Ten‐year study of bacteremia in hemodialysis patients in a single center

Background: The incidence of infection in patients on chronic hemodialysis in higher than that of the general population. Infection is known to be a major cause of morbidity and mortality in these patients. The vascular access is important for hemodialysis, but infection through this route is the most common source of bacteremia and can be lethal to the patients. Despite the high morbidity and mortality of bacteremia in patients on chronic hemodialysis, the clinical characteristics of bacteremia in hemodialysis patients is rarely reported yet in Korea. Methods: We included 696 hemodialysis patients from January 1993 to December 2003 at Uijongbu St. Mary's Hospital. We investigated incidence, source, causative organisms, clinical manifestations, complication, and mortality of bacteremia. We compared clinical factors, morbidity, and mortality between arteriovenous fistula and central venous catheter groups. Results: Total 52 cases of bacteremia occurred in 43 patients. The major source of infection was vascular access (48%). Staphylococcus aureus was most common organism isolated. Major complications were septic shock (9.6%), pneumonia (9.6%), infective endocarditis (3.8%), and aortic pseudoaneurysm (1.9%). Nine patients died from septic shock (n = 4), aspiration pneumonia (n = 2), hypoxic brain injury (n = 1), gastrointestinal bleeding (n = 1), and rupture of aortic pseudoaneurysm. The central venous catheter group (n = 22) had higher incidences of vascular access as a source of infection (81.8% vs 23.3%, p < 0.001) and staphylococcus as a causative organism (77.2% vs 50.0%, p = 0.042) than the arteriovenous group. Conclusion: This data shows that bacteremia causes high incidence of fatal complications and mortality. Therefore, careful management of vascular access as well as early detection of bacteremia is an important factor for the prevention of infection and proper antibiotic therapy should be started early.     

Carnitine deficiency in children receiving continuous renal replacement therapy

Carnitine deficiency is known to occur in chronic hemodialysis; however, the effect of continuous renal replacement therapy (CRRT) on carnitine homeostasis has not been studied. We hypothesized that children receiving CRRT are at risk for deficiency because of continuous removal, absent intake, decreased production, and comorbidities related to critical illness. Records of patients with acute kidney injury receiving CRRT at Children's National Health System between 2011 and 2014 were reviewed for total carnitine (TC), free carnitine (FC), feeding modality, severity of illness, and survival outcome. The proportion of carnitine‐deficient patients at baseline, 1, 2, and ≥3 weeks on CRRT were compared by chi‐square, and relationships with other variables assessed by Pearson's correlation and logistic regression. The study group included 42 CRRT patients, age 7.9 + 1.1 years. At baseline, 30.7% and 35.7% of patients were TC and FC deficient. Within 1 week, 64.5% (P = 0.03) and 70% (P = 0.03) were TC and FC deficient, and prevalence of deficiency increased to 80% (P = 0.01) and 90% (P = 0.008) by 2 weeks; 100% of patients were TC and FC deficient after being on CRRT for ≥3 weeks (P = 0.005 and P = 0.01, respectively, vs. baseline). TC and FC levels negatively correlated with days on CRRT (r = ?0.39, P = 0.001 and r = ?0.35, P = 0.005). Patients with TC and FC deficiency had 5.9 and 4.9 greater odds of death than those with normal levels (P = 0.02 and P = 0.03). Carnitine is significantly and rapidly depleted with longer time on CRRT, and carnitine deficiency is associated with increased mortality. Consequences of deficiency and benefits of supplementation in the pediatric CRRT population should be investigated.     

High‐dose cefazolin on consecutive hemodialysis in anuric patients with Staphylococcal bacteremia

Methicillin‐sensitive Staphylococcus aureus (MSSA) bacteremia is a leading cause of infection in hemodialysis (HD) patients. Cloxacillin, cefazolin, and vancomycin are the mainstay antimicrobials. Cloxacillin administration leads to frequent drug dosing, longer length of stay (LOS), and higher cost, while resistance and poorer outcomes are associated with vancomycin use. Dosing cefazolin during HD allows for prolonged blood therapeutic levels. We assessed the outcomes and safety of a strategy of treating MSSA bacteremia with 2–3 g cefazolin on HD only. All HD patients with MSSA bacteremia admitted in June–December 2009 at our center and receiving this regime were compared with historical controls who received cloxacillin. Demographic characteristics and outcome measures like mortality, LOS, cost, recrudescence, and adverse drug reactions were assessed. Of 27 consecutive episodes reviewed, 14 and 13 patients received cefazolin and cloxacillin, respectively. Baseline demographics were comparable between the 2 treatment groups. More than one‐third of the bacteremia was related to tunneled catheter infection. The 30‐day mortality of cloxacillin‐ and cefazolin‐treated patients was 15% and 7%, respectively (P=0.14). Two of the 11 survivors treated with cloxacillin (18%) had recrudescent bacteremia while none was observed in cefazolin‐treated survivors. Cefazolin was associated with shorter LOS (10 vs. 20 days, P<0.05) and lower cost (US$8262.00 vs. US$15,367.00, P<0.05). Cefazolin use resulted in 3 idiosyncratic adverse drug reactions. Cefazolin dosed on each HD in MSSA bacteremia leads to earlier discharge and less cost. Larger prospective studies are, however, warranted to fully assess its safety and efficacy.     

CathAway fistula vascular access program achieves improved outcomes and sets a new standard of treatment for end‐stage renal disease

Hemodialysis patients using central venous catheters (CVCs) for vascular access are at greater risk of infection and death vs. arterial venous fistula (AVF). In 2008, DaVita initiated the CathAway quality improvement initiative, a multidisciplinary program to reduce CVC use in favor of AVF. Our retrospective analysis examined CVC use for incident (≤90 days) and prevalent (>90 days) patients receiving hemodialysis in the years 2006 to 2010. Outcomes included annual mean percentage of patients with CVCs, new CVC placements per 100 patient years, CVC survival, and percentage patient days with CVC. Over 152,000 patient records were reviewed. Between 76.2% and 79.7% of incident patients used a CVC annually, but for prevalent patients, the proportion decreased from 41.1% in 2006 to 33.5% in 2010. The number of new CVC placements per 100 patient years increased slightly for incident patients but fell annually from 64.8 in 2006 to 55.2 in 2010 for prevalent patients. The percentage of treatment days with CVCs was stable among incident patients (70.4%–74.3%) but fell among prevalent patients from 26.1% in 2006 to 16.5% in 2010. The mean duration of CVC use in incident patients was between 53.0 days (SD, 27.8) in 2006 and 54.1 days (SD, 28.1) in 2009, and for prevalent patients between 158.9 days (SD, 123.0) in 2006 and 128.1 days (SD, 112.0) in 2010. CathAway significantly decreased CVC use in prevalent hemodialysis patients. Decreasing incident patient use will require improvements in predialysis care.     

Survival pattern of hemodialysis patients in Kumasi, Ghana: A summary of forty patients initiated on hemodialysis at a new hemodialysis unit

To evaluate the survival pattern of hemodialysis patients at a dialysis unit in Kumasi, Ghana, through a retrospective (observational) study. Patients who were placed on hemodialysis at the dialysis unit at Komfo Anokye teaching hospital from October 25, 2006 to December 2007. The patients were followed from initiation of dialysis until December 31, 2007. The overall mortality was 14 (35.9%) on the incident population for the period and that for the first 90 days was 12 (32.4%) patients. Chronic glomerulonephritis was the underlying kidney disease in 35.9%. This was followed by hypertension (19.1%) and diabetes mellitus (15.4%), respectively. Cardiovascular diseases accounted for 42% of mortality. This was followed by septicemia (25%) from the access site and anemia (25%). Fifty percent of the patients were able to afford 20 sessions of hemodialysis before stopping. The most powerful predictors of survival were the duration of hemodialysis (P=0.05) and the number of hemodialysis sessions (P=0.02). Age at initiation of hemodialysis was not significant. First 90-day mortality of patients on hemodialysis is high in poor African countries. This is due partially to the late referral of patients and also the cost of the dialysis treatment. Efforts will have to be made to reduce the cost of the dialysis treatment. Reuse technology (of dialyzer, etc.) should be introduced to cut down the cost of hemodialysis. Peritoneal dialysis should also be introduced for highly motivated patients. Efforts should also be made to reduce the increasing incidence of kidney disease, and finally third-world countries should consider establishing kidney transplantation, that is cost effective.     

Determinants of survival in patients receiving dialysis in Libya

Maintenance dialysis is associated with reduced survival when compared with the general population. In Libya, information about outcomes on dialysis is scarce. This study, therefore, aimed to provide the first comprehensive analysis of survival in Libyan dialysis patients. This prospective multicenter study included all patients in Libya who had been receiving dialysis for >90 days in June 2009. Sociodemographic and clinical data were collected upon enrolment and survival status after 1 year was determined. Two thousand two hundred seventy‐three patients in 38 dialysis centers were followed up for 1 year. The majority were receiving hemodialysis (98.8%). Sixty‐seven patients were censored due to renal transplantation, and 46 patients were lost to follow‐up. Thus, 2159 patients were followed up for 1 year. Four hundred fifty‐eight deaths occurred, (crude annual mortality rate of 21.2%). Of these, 31% were due to ischemic heart disease, 16% cerebrovascular accidents, and 16% due to infection. Annual mortality rate was 0% to 70% in different dialysis centers. Best survival was in age group 25 to 34 years. Binary logistic regression analysis identified age at onset of dialysis, physical dependency, diabetes, and predialysis urea as independent determinants of increased mortality. Patients receiving dialysis in Libya have a crude 1‐year mortality rate similar to most developed countries, but the mean age of the dialysis population is much lower, and this outcome is thus relatively poor. As in most countries, cardiovascular disease and infection were the most common causes of death. Variation in mortality rates between different centers suggests that survival could be improved by promoting standardization of best practice.     

Effect of personalized nutritional counseling in maintenance hemodialysis patients

Monitoring nutritional parameters is an integral part of hemodialysis (HD) patient treatment program. The purpose of this study was to evaluate the impact of the personalized nutritional counseling (PNC) on calcium–phosphorus metabolism, potassium, albumin, protein intake, interdialytic weight gain (IDWG), body composition parameters and fluid overload in HD patients. This was a multicenter longitudinal intervention study with 6 months of follow‐up and 731 patients on maintenance HD from 34 dialysis units in Portugal were enrolled. Biochemical and body composition parameters were measured at baseline, 1, 3 and 6 months after the PNC. Patient's mean age was 64.9 (95% confidence interval [CI]: 63.8–66.0) years and mean HD time was 59.8 (95% CI: 55.3–64.3) months. Regarding data comparison collected before PNC vs. 6 months after, we obtained, respectively, the following results: patients with normalized protein catabolic rate (nPCR) ≥ 1 g/kg/day = 66.5% vs. 73.5% (P = 0.002); potassium > 5.5 mEq/L = 52% vs. 35.8% (P < 0.001); phosphorus between 3.5 and 5.5 mg/dL = 43.2% vs. 52.5% (P < 0.001); calcium/phosphorus (Ca/P) ratio ≤ 50 mg/dL = 73.2 % vs. 81.4% (P < 0.001); albumin ≥ 4.0 g/dL = 54.8% vs. 55% (P = 0.808); presence of relative overhydration = 22.4% vs. 25% (P = 0.283); IDWG > 4.5% = 22.3% vs. 18.2% (P = 0.068). PNC resulted in a significant decrease in the prevalence of hyperkalemia, hypophosphatemia and also showed amelioration in Ca/P ratio, nPCR and an increase in P of hyphosphatemic patients. Our study suggests that dietetic intervention contributes to the improvement of important nutritional parameters in patients receiving hemodialysis treatment.     

Intracranial arterial calcification is highly prevalent in hemodialysis patients but does not associate with acute ischemic stroke

Intracranial arterial calcification (IAC) is associated with ischemic stroke in the general population but this relationship has not been examined in hemodialysis patients. We examined the factors associated with IAC and its relationship with acute ischemic stroke in this population. We retrospectively studied 490 head computed tomographic scans from 2225 hemodialysis patients presenting with neurological symptoms at our center (October 2005-May 2009). Intracranial arterial calcification was graded using a validated scoring system. Multivariate regression was used to examine the factors associated with the presence of IAC, its severity, and its ability to predict acute ischemic stroke. Weibull's survival models analyzed the relationship between IAC severity and survival. Ninety-five percent of patients with ischemic stroke had IAC vs. 83% in the nonstroke group (P=0.02). Intracranial arterial calcification severity increased with age (P<0.001), hemodialysis vintage (P<0.001), serum phosphate (P<0.05), and major comorbidities. In patients with multiple computed tomographic scans during the study period, increased IAC severity at baseline was predictive of acute ischemic stroke (P=0.05) on logistic regression analysis. High-grade and not low-grade IAC was associated with worse survival (P=0.008). Intracranial arterial calcification is highly prevalent in hemodialysis patients, especially in those with acute ischemic stroke. Its severity is prognostically significant and associated with risk factors for vascular calcification and may confer a greater risk of acute ischemic stroke. The mechanisms underlying the high incidence of ischemic stroke in this patient group require further comprehensive study.     

End‐stage renal disease from hemolytic uremic syndrome in the United States, 1995–2010

Management of hemolytic uremic syndrome (HUS) has evolved rapidly, and optimal treatment strategies are controversial. However, it is unknown whether the burden of end‐stage renal disease (ESRD) from HUS has changed, and outcomes on dialysis in the United States are not well described. We retrospectively examined data for patients initiating maintenance renal replacement therapy (RRT) (n = 1,557,117), 1995–2010, to define standardized incidence ratios (SIRs) and outcomes of ESRD from HUS) (n = 2241). Overall ESRD rates from HUS in 2001–2002 were 0.5 cases/million per year and were higher for patients characterized by age 40–64 years (0.6), ≥65 years (0.7), female sex (0.6), and non‐Hispanic African American race (0.7). Standardized incidence ratios remained unchanged (P ≥ 0.05) between 2001–2002 and 2009–2010 in the overall population. Compared with patients with ESRD from other causes, patients with HUS were more likely to be younger, female, white, and non‐Hispanic. Over 5.4 years of follow‐up, HUS patients differed from matched controls with ESRD from other causes by lower rates of death (8.3 per 100 person‐years in cases vs. 10.4 in controls, P < 0.001), listing for renal transplant (7.6 vs. 8.6 per 100 person‐years, P = 0.04), and undergoing transplant (6.9 vs. 9 per 100 person‐years, P < 0.001). The incidence of ESRD from HUS appears not to have risen substantially in the last decade. However, given that HUS subtypes could not be determined in this study, these findings should be interpreted with caution.     

Improving management of atrial fibrillation and anticoagulation in a community hospital

BACKGROUND: Clinical trials have established the safety and efficacy of warfarin anticoagulation for stroke prevention in patients with atrial fibrillation. Other studies have documented patterns of underutilization and suboptimal warfarin therapy; physician underuse of warfarin may reflect the demands associated with monitoring the drug's effects. BASELINE STUDY: At Carney Hospital, a 230-bed acute care community teaching hospital in Boston, a retrospective chart review indicated that between July 1, 1995, and June 30, 1996, of 465 patients admitted with atrial fibrillation, 209 (45%) patients were discharged with warfarin therapy: 198 were receiving warfarin at admission, and 11 began therapy during hospitalization. Analysis of the admission international normalized ratios (INRs) indicated that a minority of patients on warfarin were safely anticoagulated at the time of admission. DESIGNING THE INTERVENTION: An anticoagulation clinic was established in fall 1997 to increase utilization of warfarin, standardize anticoagulation practices, and minimize physician time and effort needed to ensure safe anticoagulation. In early 1998 monitoring of hospitalized patients with chronic atrial fibrillation began. RESULTS: The proportion of patients receiving warfarin therapy at admission increased from 46% in February-May 1998 to 63% in April-June 1999. Between October 1997 and July 1998, 49.1% of the 2,738 patient visits to the anticoagulation clinic showed an INR in the desired range. For the 2,238 visits during January through August 1999, 53.7% of the INRs were in the desired range. DISCUSSION: Establishment of a clinic to oversee warfarin therapy and dissemination of indications for anticoagulation in patients with atrial fibrillation were followed by increases in the frequency of warfarin use in hospital patients and the incidence of safe therapy in ambulatory patients.