Cardiac complications of end-stage renal disease : identification of risk factors and design of clinical trials

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Blood pressure and long-term mortality in United States hemodialysis patients: USRDS Waves 3 and 4 Study11The data reported here were supplied by the United States Renal Data System. Interpretation of these data is the responsibility of the authors, and in no way should be seen as an official policy or interpretation of the U.S. government.

Blood pressure and long-term mortality in United States hemodialysis patients: USRDS Waves 3 and 4 Study.BackgroundThe long-term prognostic associations of pre- and post-dialysis blood pressures, interdialytic weight gain, and antihypertensive use in hemodialysis patients are unclear.MethodsThe United States Renal Data System (USRDS) Dialysis Morbidity and Mortality Waves 3 and 4 Study, a randomly generated sample of 11,142 subjects receiving hemodialysis on December 31, 1993, was examined, with vital status followed until May 2000.ResultsPre- and post-dialysis blood pressure values, interdialytic weight gain and number of antihypertensives averaged 151.8/79.7, 137.0/74, 3.6% and 0.76, respectively. Prognostic discrimination was maximized by considering pre- and post-systolic and diastolic blood pressure values simultaneously, in a pattern suggesting that wide pulse pressures were associated with mortality (P < 0.0001). Comorbidity adjustment markedly affected associations, with low pre-dialysis diastolic (P < 0.05), low post-dialysis dialysis diastolic pressure (P < 0.05), high post-dialysis dialysis systolic pressure (P < 0.05), and high interdialytic weight gains (P = 0.005) associated with mortality. Each class of antihypertensive drug, except angiotensin-converting enzyme (ACE)-inhibitors, was associated with lower mortality in unadjusted models, an effect most pronounced for beta-blockers (hazards ratio 0.72, 95% CI 0.66 to 0.79, P < 0.0001). Comorbidity adjustment eliminated survival associations for each antihypertensive class except beta-blockers.ConclusionsPre- and post-dialysis blood pressure values have independent associations with mortality, in a way that implicates wide pulse pressures. Much of the adverse prognosis of wide pulse pressures probably reflects older age and cardiovascular comorbidity. Large interdialytic weight gains are associated with shorter survival when comorbidity is taken into account. Beta-blocker use shows a robust association with survival, and may be protective

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

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

SN 2006bt: A Perplexing, Troublesome, and Possibly Misleading Type Ia Supernova

SN 2006bt displays characteristics unlike those of any other known Type Ia supernova (SN Ia). We present optical light curves and spectra of SN 2006bt which demonstrate the peculiar nature of this object. SN 2006bt has broad, slowly declining light curves indicative of a hot, high-luminosity SN, but lacks a prominent second maximum in the i band as do low-luminosity SNe Ia. Its spectra are similar to those of low-luminosity SNe Ia, containing features that are only present in cool SN photospheres. Light-curve fitting methods suggest that SN 2006bt is reddened by a significant amount of dust; however, it occurred in the outskirts of its early-type host galaxy and has no strong Na D absorption in any of its spectra, suggesting a negligible amount of host-galaxy dust absorption. C II is possibly detected in our pre-maximum spectra, but at a much lower velocity than other elements. The progenitor was likely very old, being a member of the halo population of a galaxy that shows no signs of recent star formation. SNe Ia have been very successfully modeled as a one-parameter family, and this is fundamental to their use as cosmological distance indicators. SN 2006bt is a challenge to that picture, yet its relatively normal light curves allowed SN 2006bt to be included in cosmological analyses. We generate mock SN Ia datasets which indicate that contamination by similar objects will both increase the scatter of a SN Ia Hubble diagram and systematically bias measurements of cosmological parameters. However, spectra and rest-frame i-band light curves should provide a definitive way to identify and eliminate such objects.Comment: ApJ, accepted. 13 pages, 13 figure

Patterns of Natural and Human-Caused Mortality Factors of a Rare Forest Carnivore, the Fisher (Pekania pennanti) in California.

Wildlife populations of conservation concern are limited in distribution, population size and persistence by various factors, including mortality. The fisher (Pekania pennanti), a North American mid-sized carnivore whose range in the western Pacific United States has retracted considerably in the past century, was proposed for threatened status protection in late 2014 under the United States Endangered Species Act by the United States Fish and Wildlife Service in its West Coast Distinct Population Segment. We investigated mortality in 167 fishers from two genetically and geographically distinct sub-populations in California within this West Coast Distinct Population Segment using a combination of gross necropsy, histology, toxicology and molecular methods. Overall, predation (70%), natural disease (16%), toxicant poisoning (10%) and, less commonly, vehicular strike (2%) and other anthropogenic causes (2%) were causes of mortality observed. We documented both an increase in mortality to (57% increase) and exposure (6%) from pesticides in fishers in just the past three years, highlighting further that toxicants from marijuana cultivation still pose a threat. Additionally, exposure to multiple rodenticides significantly increased the likelihood of mortality from rodenticide poisoning. Poisoning was significantly more common in male than female fishers and was 7 times more likely than disease to kill males. Based on necropsy findings, suspected causes of mortality based on field evidence alone tended to underestimate the frequency of disease-related mortalities. This study is the first comprehensive investigation of mortality causes of fishers and provides essential information to assist in the conservation of this species

An Observed Correlation Between Thermal and Non-Thermal Emission in Gamma-Ray Bursts

Recent observations by the $Fermi$ Gamma-ray Space Telescope have confirmed the existence of thermal and non-thermal components in the prompt photon spectra of some Gamma-ray bursts (GRBs). Through an analysis of six bright Fermi GRBs, we have discovered a correlation between the observed photospheric and non-thermal $\gamma$-ray emission components of several GRBs using a physical model that has previously been shown to be a good fit to the Fermi data. From the spectral parameters of these fits we find that the characteristic energies, $E_{\rm p}$ and $kT$, of these two components are correlated via the relation $E_{\rm p} \propto T^{\alpha}$ which varies from GRB to GRB. We present an interpretation in which the value of index $\alpha$ indicates whether the jet is dominated by kinetic or magnetic energy. To date, this jet composition parameter has been assumed in the modeling of GRB outflows rather than derived from the data

Detection of a Thermal Spectral Component in the Prompt Emission of GRB 100724B

Observations of GRB 100724B with the Fermi Gamma-Ray Burst Monitor (GBM) find that the spectrum is dominated by the typical Band functional form, which is usually taken to represent a non-thermal emission component, but also includes a statistically highly significant thermal spectral contribution. The simultaneous observation of the thermal and non-thermal components allows us to confidently identify the two emission components. The fact that these seem to vary independently favors the idea that the thermal component is of photospheric origin while the dominant non-thermal emission occurs at larger radii. Our results imply either a very high efficiency for the non-thermal process, or a very small size of the region at the base of the flow, both quite challenging for the standard fireball model. These problems are resolved if the jet is initially highly magnetized and has a substantial Poynting flux.Comment: 6 pages, 3 figures, 1 table, Accepted for publication in the Astrophysical Journal Letters November, 23 2010 (Submitted October, 20 2010