Predictors of Chain Acquisition among Independent Dialysis Facilities

To determine the predictors of chain acquisition among independent dialysis providers.Retrospective facility-level data combined from CMS Cost Reports, Medical Evidence Forms, Annual Facility Surveys, and claims for 1996–2003.Independent dialysis facilities' probability of acquisition by a dialysis chain (overall and by chain size) was estimated using a discrete time hazard rate model, controlling for financial and clinical performance, practice patterns, market factors, and other facility characteristics.The sample includes all U.S. freestanding dialysis facilities that report not being chain affiliated for at least 1 year between 1997 and 2003.Above-average costs and better quality outcomes are significant determinants of dialysis chain acquisition. Facilities in larger markets were more likely to be acquired by a chain. Furthermore, small dialysis chains have different acquisition strategies than large chains.Dialysis chains appear to employ a mix of turn-around and cream-skimming strategies. Poor financial health is a predictor of chain acquisition as in other health care sectors, but the increased likelihood of chain acquisition among higher quality facilities is unique to the dialysis industry. Significant differences among predictors of acquisition by small and large chains reinforce the importance of using a richer classification for chain status.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79093/1/j.1475-6773.2010.01081.x.pd

Chronic opioid analgesic usage post‐kidney transplantation and clinical outcomes

Chronic opioid usage ( COU ) is common among patients with end‐stage renal disease ( ESRD ) qualified for kidney transplantation and associated with inferior post‐transplant outcomes. The magnitude of COU after kidney transplantation and its impact on transplant outcomes remain unknown. We performed a single‐center retrospective study aimed to describe the prevalence of COU during the first year, to identify the predictors of COU and to determine the impact of COU on post‐transplant outcomes including the rates of hospitalization and acute rejection during the first year, as well as long‐term patient and graft survival. Among 1045 kidney transplant patients, 119 (11.4%) had required continued outpatient prescription of opioid analgesics during the first year after kidney transplantation, mostly for non‐surgery‐related pain (85%). A positive history of COU prior to transplantation was the strongest predictor of COU in the first year post‐transplantation (adjusted odds ratio [ AOR ] 4.31, p < 0.001). Patients with COU had more often hospital admission during the first year ( AOR 2.48, p = 0.001, for 1 or 2 admissions, and AOR 6.03, p < 0.001 for ≥3 admissions), but similar rate of acute rejection (19.3% vs. 15.7%, p = 0.31). During long‐term follow‐up, however, the patient and/or death‐censored kidney survival was not different. COU early post‐kidney transplantation, when clinically indicated and properly supervised, does not appear to affect the risk of death and death‐censored graft failure.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/108587/1/ctr12414.pd

Immunosuppression and the Risk of Post-Transplant Malignancy Among Cadaveric First Kidney Transplant Recipients

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73619/1/j.1600-6135.2003.00274.x.pd

Geriatric Assessment for the Nephrologist

Dialysis providers are increasingly being presented with progressively older and frailer patients, in all healthcare settings from the acute hospital to the community dialysis center. These patients commonly bring more than kidney failure with them, with a complex constellation of chronic illness, comorbidity, and functional and cognitive impairment. Navigating these challenges and coordinating the care of these highly complex patients significantly increase the work of the whole dialysis team. This article reviews the role of Comprehensive Geriatric Assessment in these patients and discusses how each of its elements interacts with routine dialysis care.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/94506/1/sdi.12027.pd

Family History of Exceptional Longevity Is Associated with Lower Serum Uric Acid Levels in A shkenazi J ews

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/91205/1/jgs3902.pd

Geographic Variation in End-Stage Renal Disease Incidence and Access to Deceased Donor Kidney Transplantation

The effect of demand for kidney transplantation, measured by end-stage renal disease (ESRD) incidence, on access to transplantation is unknown. Using data from the U.S. Census Bureau, Centers for Medicare & Medicaid Services (CMS) and the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR) from 2000 to 2008, we performed donation service area (DSA) and patient-level regression analyses to assess the effect of ESRD incidence on access to the kidney waiting list and deceased donor kidney transplantation. In DSAs, ESRD incidence increased with greater density of high ESRD incidence racial groups (African Americans and Native Americans). Wait-list and transplant rates were relatively lower in high ESRD incidence DSAs, but wait-list rates were not drastically affected by ESRD incidence at the patient level. Compared to low ESRD areas, high ESRD areas were associated with lower adjusted transplant rates among all ESRD patients (RR 0.68, 95% CI 0.66–0.70). Patients living in medium and high ESRD areas had lower transplant rates from the waiting list compared to those in low ESRD areas (medium: RR 0.68, 95% CI 0.66–0.69; high: RR 0.63, 95% CI 0.61–0.65). Geographic variation in access to kidney transplant is in part mediated by local ESRD incidence, which has implications for allocation policy development.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79376/1/j.1600-6143.2010.03043.x.pd

The costs in provision of haemodialysis in a developing country: A multi-centered study

<p>Abstract</p> <p>Background</p> <p>Chronic Kidney Disease is a major public health problem worldwide with enormous cost burdens on health care systems in developing countries. We aimed to provide a detailed analysis of the processes and costs of haemodialysis in Sri Lanka and provide a framework for modeling similar financial audits.</p> <p>Methods</p> <p>This prospective study was conducted at haemodialysis units of three public and two private hospitals in Sri Lanka for two months in June and July 2010. Cost of drugs and consumables for the three public hospitals were obtained from the price list issued by the Medical Supplies Division of the Department of Health Services, while for the two private hospitals they were obtained from financial departments of the respective hospitals. Staff wages were obtained from the hospital chief accountant/chief financial officers. The cost of electricity and water per month was calculated directly with the assistance of expert engineers. An apportion was done from the total hospital costs of administration, cleaning services, security, waste disposal and, laundry and sterilization for each unit.</p> <p>Results</p> <p>The total number of dialysis sessions (hours) at the five hospitals for June and July were 3341 (12959) and 3386 (13301) respectively. Drug and consumables costs accounted for 70.4-84.9% of the total costs, followed by the wages of the nursing staff at each unit (7.8-19.7%). The mean cost of a dialysis session in Sri Lanka was LKR 6,377 (US$56). The annual cost of haemodialysis for a patient with chronic renal failure undergoing 2-3 dialysis session of four hours duration per week was LKR 663,208-994,812 (US$ 5,869-8,804). At one hospital where facilities are available for the re-use of dialyzers (although not done during study period) the cost of consumables would have come down from LKR 5,940,705 to LKR 3,368,785 (43% reduction) if the method was adopted, reducing costs of haemodialysis per hour from LKR 1,327 at present to LKR 892 (33% reduction).</p> <p>Conclusions</p> <p>This multi-centered study demonstrated that the costs of haemodialysis in a developing country remained significantly lower compared to developed countries. However, it still places a significant burden on the health care sector, whilst possibility of further cost reduction exists.</p

Renal Cell Therapy and Beyond

Although current dialysis techniques have transformed acute and chronic renal failure from uniformly fatal clinical disorders into treatable diseases, these therapies replace only the water and solute clearance function of the kidney and have reached a point where little further therapeutic improvement can be anticipated. In addition to their metabolic and endocrine functions, renal tubule cells presumably play an important role in the systemic inflammatory balance by participating in the complex and dynamic network of leukocyte action and pro- and anti-inflammatory cytokines. Loss of this function may result in a propensity to develop systemic inflammatory response syndrome (SIRS), multiorgan dysfunction, and a high risk of death in acute kidney injury (AKI), and may relate to chronic inflammatory state in end-stage renal disease (ESRD). A renal tubule cell assist device (RAD) containing animal or human renal tubule cells has been recently developed with the purpose of integrating the functions of tubule cells with the filtration function of current dialysis to offer a more complete renal replacement therapy. The viability and functionality of this device were confirmed in in vitro experiments and large animal studies, and recently the RAD’s clinical therapeutic benefit was demonstrated with a series of FDA-approved human trials. Another novel synthetic membrane extracorporeal device that binds and inhibits circulating leukocytes has been developed with the purpose of reducing microvascular damage promoted primarily via activated circulating leukocytes in AKI and SIRS. This device, called a selective cytopheretic inhibitory device, mimics immunomodulation and duplicates RAD efficiency in preliminary studies. Both devices may become comprehensive treatments, replacing full renal function and correcting inflammatory imbalance in patients with acute and chronic renal disorders.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78659/1/j.1525-139X.2009.00663.x.pd