Fractional excretion of sodium after renal transplantation

Fractional excretion of sodium after renal transplantation. After renal transplantation low urinary sodium concentration (UNa) has been used to diagnose acute rejection (AR), for the early phase of AR is often associated with reduced renal perfusion. Early postoperative graft failure without low UNa favors the diagnosis of ischemic tubular damage (ATN). As fractional excretion of filtered sodium (FENa) better reflects glomerulotubular balance in renal sodium handling, FENa was analyzed during the first 2 weeks in 118 renal allografts. From data on 41 transplants with good early renal function (GEF), a temporal profile of FENa was obtained and used to evaluate the behavior of FFNa by means of standardized FENa (z score). Individual subjects followed their own profile with a small deviation (Δz < 1.4 for 2 days). In 31 instances, acute rejection was diagnosed. In 14 with AR, the z score deviated little; 2 responded to methylprednisolone given intravenously. In 17 with AR, the z score fell significantly (Δz > 1.5 for 2 days), an average of 2.6 days before the first rise in serum creatinine concentration; 15 responded to treatment. The difference between these two groups was significant (P < 0.001). This functional heterogeneity and different responses to treatment may indicate different immunologic mechanisms which damage different target cells in the graft in AR. In 46 patients with acute tubular necrosis after cadaver kidney transplantation FENa was significantly higher than it was in the GEF group as early as the first posttransplantation day and approached normal as the renal function recovered. This behavior of FENa was clearly different from that in AR.Excrétion fractionnelle du sodium après transplantation rénale. Après transplantation rénale une concentration urinaire de sodium (UNa) faible est considérée comme un signe de rejet aigu (AR), du fait que la phase précoce du rejet est souvent associée à une diminution du débit rénal. L'échec précoce d'une greffe sans abaissement de UNa est en faveur d'une tubulopathie ischémique (ATN). Puisque l'excrétion fractionnelle du sodium filtré (FENa) est le meilleur reflet de l'équilibre glomérulo-tubulaire concernant le sodium, FENa a été étudiée pendant les 2 premières semaines d'évolution de 118 allogreffes rénales. A partir de l'observation de 41 transplants ayant eu un bon fonctionnement précoce (GEF) un profil de FENa en fonction du temps a été obtenu et utilisé pour évaluer le comportement de FENa au moyen d'une FENa standardisée (test z). Les sujets ont suivi leur propre profil avec une déviation faible (Δz < 1,4 par 2 jours). Le rejet aigu a été diagnostiqué dans 31 cas. Quatorze d'entre eux avaient une déviation minime de z; deux ont répondu à la methylprednisolone i.v. Dix sept sujets avaient une déviation significative de z (Δz > 1,5 par 2 jours), 2,6 jours en moyenne avant la première augmentation de la créatinine; quinze ont répondu au traitement. La différence entre ces deux groupes est significative (P < 0,001). Cette hétérogénéité fonctionnelle et cette différence de réponse au traitement peuvent être la traduction de mécanismes immunologiques différents qui atteignent des cellules cibles de la greffe différentes au cours du rejet aigu. Chez 46 malades ayant des lésions ischémiques après transplantation de reins de cadavre, FENa était significativement plus élevée que dans le groupe GEF dès le premier jour après la transplantation et revenait vers la normale au fur et à mesure que la fonction rénale s'améliorait. Ce comportement de FENa est nettement différent de celui observé dans les rejets aigus

Effect of electronic patient record use on mortality in End Stage Renal Disease, a model chronic disease: retrospective analysis of 9 years of prospectively collected data

<p>Abstract</p> <p>Background</p> <p>In chronic disease, health information technology promises but has yet to demonstrate improved outcomes and decreased costs. The main aim of the study was to determine the effects on mortality and cost of an electronic patient record used in daily patient care in a model chronic disease, End Stage Renal Disease, treated by chronic maintenance hemodialysis. Dialysis treatment is highly regulated, and near uniform in treatment modalities and drugs used.</p> <p>Methods</p> <p>The particular electronic patient record, patient-centered and extensively coded, was used first in patient care in 3 dialysis units in New York, NY in 1998, 1999, and 2000. All data were stored "live"; none were archived. By December 31, 2006, the patients had been treated by maintenance hemodialysis for a total of 3924 years. A retrospective analysis was made using query tools embedded in the software. The United States Renal Data System dialysis population served as controls. In all there were 1790 patients, with many underlying primary diseases and multiple comorbid conditions affecting many organ systems. Year by year mortality, hospital admissions, and staffing were analyzed, and the data were compared with national data compiled by the United States Renal Data System.</p> <p>Results</p> <p>Analyzed by calendar year after electronic patient record implementation, mortality decreased strikingly. In years 3–9 mortality was lower than in years 1–2 by 23%, 48%, and 34% in the 3 units, and was 37%, 37%, and 35% less than that reported by the United States Renal Data System. Clinical staffing was 25% fewer per 100 patients than the national average, thereby lowering costs.</p> <p>Conclusion</p> <p>To our knowledge, this is the first demonstration that an electronic patient record, albeit of particular design, can have a favorable effect on outcomes and cost in chronic disease. That the population studied has many underlying diseases affecting all organ systems suggests that the electronic patient record design may enable application to many fields of medical practice.</p

Management of systemic lupus erythematosus

No Abstract.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/37693/1/1780050510_ftp.pd

The importance of iron in long-term survival of maintenance hemodialysis patients treated with epoetin-alfa and intravenous iron: analysis of 9.5 years of prospectively collected data

<p>Abstract</p> <p>Background</p> <p>In patients treated by maintenance hemodialysis the relationship to survival of hemoglobin level and administered epoetin-alfa and intravenous iron is controversial. The study aim was to determine effects on patient survival of administered epoetin-alfa and intravenous iron, and of hemoglobin and variables related to iron status.</p> <p>Methods</p> <p>The patients were 1774 treated by maintenance hemodialysis in 3 dialysis units in New York, NY from January 1998 to June, 2007. A patient-centered, coded, electronic patient record used in patient care enabled retrospective analysis of data collected prospectively. For survival analysis, patients were censored when transplanted, transferred to hemodialysis at home or elsewhere, peritoneal dialysis. Univariate Kaplan-Meier analysis was followed by multivariate analysis with Cox's regression, using as variables age, race, gender, major co-morbid conditions, epoetin-alfa and intravenous iron administered, and 15 laboratory tests.</p> <p>Results</p> <p>Median age was 59 years, epoetin-alfa (interquartile range) 18,162 (12,099, 27,741) units/week, intravenous iron 301 (202, 455) mg/month, survival 789 (354, 1489) days. Median hemoglobin was 116 (110, 120)g/L, transferrin saturation 29.7 (24.9, 35.1)%, serum ferritin 526 (247, 833) μg/L, serum albumin 39.0 (36.3, 41.5) g/L. Survival was better the higher the hemoglobin, best with > 120 g/L. Epoetin-alfa effect on survival was weak but had statistically significant interaction with intravenous iron. For intravenous iron, survival was best with 1–202 mg/month, slightly worse with 202–455 mg/month; it was worst with no intravenous iron, only slightly better with > 455 mg/month. Survival was worst with transferrin saturation ≤ 16%, serum ferritin ≤ 100 μg/L, best with transferrin saturation > 25%, serum ferritin > 600 μg/L The effects of each of hemoglobin, intravenous iron, transferrin saturation, and serum ferritin on survival were independently significant and not mediated by other predictors in the model.</p> <p>Conclusion</p> <p>Long term survival of maintenance hemodialysis patients was favorably affected by a relatively high hemoglobin level, by moderate intravenous iron administration, and by indicators of iron sufficiency. It was unfavorably influenced by a low hemoglobin level, and by indicators of iron deficiency.</p

Listening in on difficult conversations: an observational, multi-center investigation of real-time conversations in medical oncology

BACKGROUND: The quality of communication in medical care has been shown to influence health outcomes. Cancer patients, a highly diverse population, communicate with their clinical care team in diverse ways over the course of their care trajectory. Whether that communication happens and how effective it is may relate to a variety of factors including the type of cancer and the patient’s position on the cancer care continuum. Yet, many of the routine needs of cancer patients after initial cancer treatment are often not addressed adequately. Our goal is to identify areas of strength and areas for improvement in cancer communication by investigating real-time cancer consultations in a cross section of patient-clinician interactions at diverse study sites. METHODS/DESIGN: In this paper we describe the rationale and approach for an ongoing observational study involving three institutions that will utilize quantitative and qualitative methods and employ a short-term longitudinal, prospective follow-up component to investigate decision-making, key topics, and clinician-patient-companion communication dynamics in clinical oncology. DISCUSSION: Through a comprehensive, real-time approach, we hope to provide the fundamental groundwork from which to promote improved patient-centered communication in cancer care

Partitioning the Heritability of Tourette Syndrome and Obsessive Compulsive Disorder Reveals Differences in Genetic Architecture

The direct estimation of heritability from genome-wide common variant data as implemented in the program Genome-wide Complex Trait Analysis (GCTA) has provided a means to quantify heritability attributable to all interrogated variants. We have quantified the variance in liability to disease explained

Effective Computerized Patient Record Improves Patient Well-Being and Financial Performance

Effective application of information technology has transformed many facets of modern life, such as manufacturing and finance, but has had little measurable effect on medicine in general, or on nephrology and dialysis in particular. The failure of information technology in medicine can, in our opinion, be traced to poor design and implementation of medical software. Even today, nurses and physicians still spend 50% and 33%, respectively, of their time on paperwork. Our approach to computerization of the patient record, begun 24 years ago, treats the patient as the central core of the computerized record system, and makes use of a comprehensive, clinically relevant, time-oriented, digitally coded database. An embedded query tool allows quick and easy organization of the database at the point of care to make knowledge available about individuals and groups of patients, and without delay. In those scenarios where effective computerization has been combined with effective clinical and administrative management, the results have been striking. Demonstrated and published results include: 1) Improved patient welfare, with a decrease in both mortality (20-25% less than the U.S. average) and in morbidity (increased serum albumin and muscle mass, and decreased blood pressure and hospitalization). 2) More efficient and effective use of personnel caring for the patient (5.9 fewer full-time staff per 100 hemodialysis patients than the national average), with consequent increase in patient satisfaction and saving of staff time. 3) Reduction and containment of costs of medical supplies. 4) Effective management of the processes involved in billing, collection, and accounts receivable. 5) Online, continuous quality improvement and effective clinical and administrative management of the dialysis unit based on timely, complete knowledge of relevant information (especially when unexpected events occur). 6) Significantly improved return on investment; net savings of at least $13.69 to$17.40 per hemodialysis treatment have been achieved

Continuous quality improvement in daily clinical practice: a proof of concept study.

Continuous Quality Improvement (CQI) is an iterative process of: planning to improve a product or process, plan implementation, analyzing and comparing results against those expected, and corrective action on differences between actual and expected results. It is little used in clinical medicine. Anemia, a complex problem in End Stage Renal Disease patients, served to test the ability of an unique electronic medical record (EMR) optimized for daily care to empower CQI in practice. We used data collected during daily care, stored in the EMR, and organized to display temporal relationships between clinical, laboratory, and therapeutic events. Our aims were optimal hemoglobin with minimum epoetin, and maintaining stable hemoglobin and epoetin. The study was done on 250 patients treated by maintenance hemodialysis (HD), receiving epoetin prior to February 1, 2010 and followed to July 31, 2011. Repleting iron, ensuring iron sufficiency, slow epoetin reduction, and decision support tools enabling data display over long periods in patient-centered reports were key elements. Epoetin dose, adjusted 6-8 weekly, was based on current clinical conditions and past responses. Hemoglobin increased by months 1-2; epoetin decreased from month 4. By months 16-18, epoetin had decreased 42% to 9,720 units/week while hemoglobin increased 8% to 123.6 g/L. Hemoglobin and epoetin were stable from month 7 onward. New epoetin orders decreased 83%. Transferrin saturation increased after the study start. Individual patient hemoglobin variation decreased by 23%, range by 27%. Mortality, 11.78 per 100 patient years, was 42% less than United States dialysis patient mortality. Allowable epoetin charges decreased by $15.33 per treatment and were$22.88 less than current Medicare allowance. The study validates the hypothesis that an EMR optimized for daily patient care can empower CQI in clinical medicine and serve to monitor medical care quality and cost