The USRDS Role in Enhancing End-Stage Renal Disease Research: Interpretation of Research and Sharing of Analysis Files

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73514/1/j.1525-139X.1998.tb00305.x.pd

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

Effect of Time on Sensitivity and Specificity of Access Flow in Predicting Thrombosis

Dialysis access monitoring may help decrease thrombosis-related morbidity. We investigated the effect of time elapsed since an access flow measurement on test accuracy of a novel flow monitoring method called variable flow (VF) Doppler. A retrospective review was conducted in 36 patients with prosthetic grafts for vascular access using access thrombosis as the clinical endpoint. Receiver operator characteristic (ROC) curves and test sensitivity and specificity were determined for various follow-up time intervals. ROC analysis showed increasing test discrimination for shorter time intervals. Sensitivity and specificity for a commonly used surveillance threshold (600 ml/min) showed specificity that was little changed (88–93%) from follow-up time intervals of 15 days to 6 months. However, sensitivity was low (21%) at 6 months, increased to 50% at 2 months, 67% at 1 month, and 100% at 15 days (a single event). Low access blood flow using VF Doppler predicts near-term thrombosis. These data further imply that the discriminative value of access flow monitoring appears to be highly dependent on time from the flow measurement, improving with shorter time intervals from the measurement.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/74923/1/j.1525-139X.2003.16107.x.pd

The Sound of Silence: Observational Learning in the Us Kidney Market.

Mere observation of others' choices can be informative about product quality. This paper develops an individual-level dynamic model of observational learning and applies it to a novel data set from the U.S. kidney market, where transplant candidates on a waiting list sequentially decide whether to accept a kidney offer. We find strong evidence of observational learning: patients draw negative quality inferences from earlier refusals in the queue, thus becoming more inclined towards refusal themselves. This self-reinforcing chain of inferences leads to poor kidney utilization despite the continual shortage in kidney supply. Counterfactual policy simulations show that patients would have made more efficient use of kidneys had the concerns behind earlier refusals been shared. This study yields a set of marketing implications. In particular, we show that observational learning and information sharing shape consumer choices in markedly different ways. Optimal marketing strategies should take into account how consumers learn from others

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

End-stage renal disease preceded by rapid declines in kidney function: a case series

<p>Abstract</p> <p>Background</p> <p>Few studies have defined alternate pathways by which chronic kidney disease (CKD) patients transition into end-stage renal disease (ESRD).</p> <p>Methods</p> <p>We studied all consecutive patients initiated on maintenance hemodialysis or peritoneal dialysis over several years at two dialysis units in Northern California. Rapid decline in kidney function was considered to have occurred if a patient was documented to have estimated GFR > 30 ml/min/1.73 m²within three months prior to the initiation of chronic dialysis.</p> <p>Results</p> <p>We found that 8 out of 105 incident chronic dialysis patients one dialysis unit (7.6%; 95% confidence interval 3.4-14.5%) and 9 out of 71 incident patients at another (12.7%, 95% CI 6.0%-22.7%) suffered rapid decline in kidney function that was the immediate precipitant for the need for permanent renal replacement therapy. All these patients started hemodialysis and all relied on catheters for vascular access. Documentation submitted to United States Renal Data System did not fully reflect the health status of these patients during their "pre-ESRD" period.</p> <p>Conclusions</p> <p>A sizeable minority of ESRD cases are preceded by rapid declines in kidney function. The importance of these periods of rapid decline may have been under-appreciated in prior studies of the natural history of CKD and ESRD.</p