Plant size, latitude, and phylogeny explain within-population variability in herbivory.

Interactions between plants and herbivores are central in most ecosystems, but their strength is highly variable. The amount of variability within a system is thought to influence most aspects of plant-herbivore biology, from ecological stability to plant defense evolution. Our understanding of what influences variability, however, is limited by sparse data. We collected standardized surveys of herbivory for 503 plant species at 790 sites across 116° of latitude. With these data, we show that within-population variability in herbivory increases with latitude, decreases with plant size, and is phylogenetically structured. Differences in the magnitude of variability are thus central to how plant-herbivore biology varies across macroscale gradients. We argue that increased focus on interaction variability will advance understanding of patterns of life on Earth.

Anti-Myeloperoxidase Antibodies Associate with Future Proliferative Lupus Nephritis.

BACKGROUND: The subclinical pathophysiology of proliferative lupus nephritis (PLN) has not been fully elucidated. Myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) is associated with PLN, but prediagnostic levels have not been reported. METHODS: We performed a retrospective case-control Department of Defense Serum Repository (DoDSR) study comparing MPO-ANCA levels in longitudinal prediagnostic serum samples for 23 biopsy confirmed proliferative lupus nephritis (PLN) patients to DoDSR identified age, sex, race, and age of serum matched healthy and SLE without LN disease controls. We also compared the temporal relationship of MPO-ANCA to anti-double stranded DNA antibodies (dsDNAab). RESULTS: A greater proportion of PLN patients had prediagnostic MPO-ANCA levels above ≥3 U/mL and ≥6 U/mL compared to SLE without LN (91% versus 43%, p < 0.001; 57% versus 5%, p < 0.001, resp.). In subgroup analysis, the MPO-ANCA threshold of ≥3 U/mL was significant at <1 year (88% versus 39%, p = 0.007) and 1-4 years (87% versus 38%, p = 0.009) prior to diagnosis. Statistically significant subclinical MPO-ANCA levels (≥3 U/mL) occurred prior to statistically significant dsDNAab ≥ 3 IU/ml (89% versus 11%, p = 0.003). CONCLUSIONS: Subclinical MPO-ANCA levels could distinguish future PLN from SLE without LN. MPO-ANCA manifests prior to clinical disease and subclinical dsDNAab to suggest that it may contribute directly to PLN pathogenicity.

Longitudinal plasma metanephrines preceding pheochromocytoma diagnosis: a retrospective case-control serum repository study.

OBJECTIVE: Plasma metanephrines (PMN) are highly sensitive for diagnosis of pheochromocytoma, but the natural history of PMN before pheochromocytoma diagnosis has not been previously described. The aim of the study was to compare the progression of PMN before pheochromocytoma diagnosis to matched healthy and essential hypertension disease controls. DESIGN: A retrospective case-control Department of Defense Serum Repository (DoDSR) study. METHODS: We performed a DoDSR study that compared three longitudinal pre-diagnostic PMN for 30 biopsy-proven pheochromocytoma cases to three longitudinal PMN for age, sex, race, and age of serum sample matched healthy and essential hypertension disease controls. Predominant metanephrine (MN) or normetanephrine (NMN) production was identified for each case and converted to a percentage of the upper limit of normal to allow analysis of all cases together. PMN were measured by Quest Diagnostics. RESULTS: The predominant plasma metanephrine (PPM) was >100 and 300% of the upper limit of normal a median of 6.6 and 4.1 years before diagnosis respectively. A greater percentage of pheochromocytoma patients had a PPM >100 and >300% of the upper limit of normal compared with combined healthy and essential hypertension disease controls <2, 2-8, and >8 years prior to diagnosis. For patients with a baseline PPM 90-300% of the upper limit of normal, a 25% rate of rise per year was 100% specific for pheochromocytoma. CONCLUSIONS: PPMs elevate years before diagnosis which suggests that delayed diagnoses are common. For mild PMN elevations, follow-up longitudinal PMN trends may provide a highly specific and economical diagnostic tool.

Retransplantation after BK virus nephropathy in prior kidney transplant: an OPTN database analysis.

BK virus (BKV) has emerged as a major complication of kidney transplantation. Since June 30, 2004, the OPTN in the USA collects BKV as a primary or secondary cause of graft loss and also if treatment for BK virus (TBKV) is administered. In this study, we determined characteristics of those recipients of repeat kidney transplants from the OPTN database, where either (a) a graft loss occurred between June 30, 2004 and December 31, 2008 and database recorded prior TBKV in that allograft or (b) a graft loss between June 30, 2004 and December 31, 2008 was attributed primarily or secondarily due to BKV. In the study time period, 823 graft losses have occurred where TBKV or graft failure attributable to BKV was reported in prior transplant; of these, 126 have received a retransplant as of June 5, 2009. Induction and maintenance immunosuppression usage mirrored current trends. As of June 5, 2009, 118/126 grafts are still functioning, one graft failure attributed to BKV. TBKV was reported in 17.5% of the retransplants. In the retransplants performed through December 31, 2007, 1-year acute rejection rate was 7%, 1-year and 3-year Kaplan-Meier graft survival rates and median GFR were 98.5%, 93.6%, 65.5 and 68.4 mL/min, respectively. Retransplantation after BKV appears to be associated with good results.

Association between depression and nonadherence in recipients of kidney transplants: analysis of the United States renal data system.

INTRODUCTION: In our previous prospective single-center study, using validated self-administered instruments, we demonstrated correlation between depression and nonadherence in recipients of kidney transplants. The purpose of this study was to confirm our finding that depression was associated with nonadherence in a large database of transplant recipients for which we used the United States Renal Data System (USRDS). METHODS: We conducted a retrospective cohort study of 32,757 Medicare primary renal transplant recipients in the USRDS who underwent transplantation from January 1, 2000 to July 31, 2004 and were followed up through December 31, 2004, assessing Medicare claims showing depression and nonadherence based on codes of the International Classification of Diseases, 9th Revision. RESULTS: Logistic regression analysis (adjusted hazards ratio 1.69 with 95% confidence interval, 1.48-1.92) and log rank test (P < .0005) showed that there was a strong association of depression and nonadherence. Depression was associated with nonadherence, irrespective of the time of depression, whether it was pretransplantation (P < .001) or posttransplantation (P < .001). Nonadherence was also associated with black race (P < .001), younger age (P < .001), less HLA mismatch (P < .005), recipients of living kidneys and patients who underwent transplantation a longer time ago (P < .001). Furthermore, patients with 12 or less years of education were more nonadherent (P < .001). Among the transplant donor factors we investigated, donor black race (P < .001) and expanded criteria donor kidneys were strongly associated with nonadherence (P < .001). However, donor age and delayed graft function were not significantly associated with nonadherence. CONCLUSIONS: Future clinical trials of immunosuppressive therapy should assess the impact of depression on graft survival.

Acute kidney injury requiring hemodialysis in patients with anicteric leptospirosis.

BACKGROUND: Leptospirosis is an infrequent disease in the US, with most cases reported in the state of Hawaii. Renal involvement is common (44 - 67%), ranging from a mild prerenal azotemia in anicteric disease to renal failure requiring dialysis in Weil's syndrome (severe leptospirosis with jaundice, renal failure, and hemorrhage). METHODS: To describe the pattern of leptospiral renal disease at our institution, we performed a retrospective analysis (1992 - 2004) of all hospitalized cases of laboratory confirmed leptospirosis presenting with acute kidney injury (AKI), defined as a presenting serum creatinine > 1.5 mg/dl. RESULTS: During this time period, 18 patients were hospitalized with laboratory confirmed leptospirosis. Among these patients, 12 had AKI on presentation, and hemodialysis was required in 3 patients. Renal biopsies were performed in 2 of these patients, revealing acute tubulointerstitial nephritis. Interestingly, the patients who required dialysis did not have Weil's syndrome. They did not exhibit jaundice or hemorrhage, and serum AST (mean 51.7 U/l (range 36 - 60)), ALT (mean 51.0 U/l (range 38 - 64)), and total bilirubin (mean 1.2 mg/dl (range 0.8 - 1.8)) were either within normal limits or only slightly elevated, despite having the worst renal disease. CONCLUSIONS: This series adds to other evidence that severe AKI (requiring dialysis) can complicate anicteric leptospirosis in contrast to the notion that the AKI in anicteric disease is typically mild and prerenal. Leptospirosis should be considered in all patients who present with fever and AKI, especially if associated with thrombocytopenia or travel to an endemic area.

Patient and graft survival implications of simultaneous pancreas kidney transplantation from old donors.

We investigated graft and patient survival implications of simultaneous pancreas kidney (SPK) transplant from old donors. Data describing patients with type 1 diabetes mellitus listed for an SPK transplant from 1994 to 2005 were drawn from Organ Procurement and Transplant Network registries. Allograft survival, patient survival and long-term survival expectations among SPK recipients from young (age <45 years) and old (age >/=45 years) donors were modeled by multivariate regression. We also examined predictors of reduced early access to young donor transplants. Of 16 496 eligible SPK candidates, 8850 patients (53.6%) received an SPK transplant and 776 (8.8%) of these transplants were from old donors. Reasonable 5-year, death-censored kidney (77.8 %) and pancreas (71.3%) survivals were achieved with old donors. SPK transplantation from both young and old donors predicted lower mortality compared to continued waiting. An additional expected wait of 1.5 years for a young donor equalized long-term survival expectations to that achieved with use of old donors. Early allocation of young donor transplants declined in the more recent era and varied by region, candidate age, blood type and sensitization. We conclude that old SPK donors should be considered for patients with decreased access to young donor transplants. Prospective evaluation of this practice is needed.

Risk factors for hospitalization for bacterial or viral infection in renal transplant recipients--an analysis of USRDS data.

We previously showed that children are more likely to develop viral infections post-kidney transplant while adults are more likely to develop bacterial infections. In this study we determined the overall risk factors for hospitalization with either a bacterial (HBI) or a viral infection (HVI). We analyzed data from 28 924 United States Renal Data System (USRDS) Medicare primary renal transplant recipients from January 1996 to July 2000, for adjusted hazard ratio (AHR) for HBI or HVI in the first 3 years posttransplant. For HVI, significantly higher AHR was seen with (a) recipient age <18 years (AHR 1.57, 95% CI = 1.02, 2.42), (b) donor CMV positive (AHR 1.72, 95% CI = 1.34, 2.19). For HBI, significantly higher AHR was seen with (i) delayed graft function (AHR 1.28, 95% CI = 1.076, 1.518), (ii) primary renal diagnosis chronic pyelonephritis (AHR 1.71, 95% CI = 1.18, 2.49); (iii) associated pretransplant diabetes (AHR 1.80, 95% CI = 1.53, 2.12); (iv) female gender AHR 1.63, 95% CI = 1.41, 1.88). Lower AHR for HVI was seen in CMV-positive recipients and for HBI with more recent year of transplant. Other covariates did not impact significantly in either HVI or HBI.

Acute renal allograft rejection following pegylated IFN-alpha treatment for chronic HCV in a repeat allograft recipient on hemodialysis: a case report.

Interferon alpha (IFN-alpha) can be effective therapy for patients with chronic kidney disease who have chronic hepatitis C (HCV). However, acute allograft rejection has been reported in association with IFN-alpha following kidney transplantation, and therefore IFN therapy is recommended prior to, rather than after, kidney transplantation whenever feasible. The special case of repeat allograft recipients who contract HCV after the first transplantation presents special difficulties. This report features the case of a repeat allograft recipient who presented with neutropenic fevers after 5 months of pegylated IFN-alpha therapy, initiated 6 months following the functional loss of his third graft and the reinitiation of hemodialysis (HD). Physical exam, radiographic and laboratory findings led to allograft nephrectomy. The pathologic findings supported a diagnosis of acute-on-chronic rejection. This represents a rare case of IFN-alpha induced rejection following allograft failure and return to HD in a repeat allograft recipient. It also calls attention to the need for a high index of suspicion for the development of allograft rejection, which may require allograft nephrectomy even after allograft 'failure'.

Acute respiratory distress syndrome after kidney transplantation: epidemiology, risk factors, and outcomes.

OBJECTIVE: To determine the rate of the acute respiratory distress syndrome (ARDS) after kidney transplantation and to identify risk factors associated with the development of ARDS after kidney transplantation and outcomes for patients diagnosed with ARDS in this setting. DESIGN: Retrospective analysis of the national registry for end-stage renal disease in the United States. PATIENTS: We studied all patients who underwent kidney transplantation between July 1, 1994 and June 30, 1998 and identified patients diagnosed with ARDS. The diagnosis of ARDS was based on coding of patients records. We also compared the rate of ARDS after kidney transplantation with the rate of ARDS in the remainder of the U.S. population based on the results of the National Hospital Discharge Survey for 1997. MEASUREMENTS AND MAIN RESULTS: During the study period, 42,190 kidney transplantations were performed in the United States and ARDS was diagnosed in 86 of these subjects (0.2%) resulting in an annualized rate of ARDS of 51.0 cases per 100,000 patients per year. The rate of ARDS after kidney transplantation was significantly higher than the reported rate of ARDS in the U.S. population (p <.050). Demographic factors, indications for transplantation, comorbid illness, antigen mismatch, cytomegalovirus status, and development of rejection did not correlate with the development of ARDS. Of the immunosuppressive agents (e.g., cyclosporine, FK-506, mycophenolate mofetil, azathioprine, OKT-3, antilymphocyte globulin), only the use of antilymphocyte globulin when used to treat rejection was linked with an increased risk for ARDS (odds ratio: 3.85; 95% confidence interval: 1.36 to 10.87). Subjects with graft failure were 2.70 (95% confidence interval: 1.33 to 5.52) times more likely to develop ARDS. The 28-day mortality in subjects with ARDS was 52.1%. The 3-yr survival after kidney transplantation was 88.9% in those without ARDS compared with 57.8% in persons with ARDS (p <.001). CONCLUSIONS: Although ARDS is a rare event after kidney transplantation, undergoing renal transplantation increases the risk for ARDS. Among patients receiving kidney transplants, graft failure and the use of antilymphocyte globulin for rejection are associated with the development of ARDS. Patients who develop ARDS after kidney transplantation face significant mortality.

Hospitalized valvular heart disease in patients on renal transplant waiting list: incidence, clinical correlates and outcomes.

BACKGROUND: Patients with ESRD are at increased risk for heart valve calcification. It has not been established whether hospitalized valvular heart disease (VHD) is a substantial barrier to renal transplantation (RT) after transplant listing, or whether VHD progresses after RT. METHODS: Using data from the USRDS, we studied 35,215 patients with ESRD enrolled on the renal transplant waiting list from July 1994 to June 1997. Cox non-proportional hazards regression models were used to calculate adjusted, time-dependent hazard ratios (HR) for RT and VHD. RESULTS: In comparison to maintenance dialysis (2.2/1,000 person years), RT was independently associated with a lower hazard for hospitalization for VHD (0.7/1,000 person years, HR 0.28, 95% confidence interval 0.17 - 0.47). Renal transplant recipients had much lower rates of VHD after transplant than before (rate ratio (RR) 0.49, 95% Cl 0.47 - 0.52). Patients with VHD were significantly less likely to receive RT (adjusted rate for RT 0.38, 95% CI 0.20 - 0.45) but patients who received valve replacement surgeries (VRS) were not affected (adjusted rate for RT 1.10, 95% CI 0.52 - 2.32, not significant). CONCLUSIONS: VHD is an uncommon but serious barrier to RT after listing, while VRS is not a significant barrier to RT. Established VHD does not appear to worsen after RT. Clinicians should consider giving increased attention to the detection and treatment of VHD during the pre-transplant evaluation.

Impact of HIV seropositivity on graft and patient survival after cadaveric renal transplantation in the United States in the pre highly active antiretroviral therapy (HAART) era: an historical cohort analysis of the United States Renal Data System.

BACKGROUND: National statistics are presented for patient survival and graft survival in patients seropositive for the human immunodeficiency virus (HIV+) at the time of renal transplantation in the era prior to highly active antiretroviral therapy (HAART). METHODS: Historical cohort analysis of 63, 210 cadaveric solitary renal transplant recipients with valid HIV serology entries in the United States Renal Data System (USRDS) from 1 January 1987 to 30 June 1997. The medical evidence form was also used for additional variables but, because of fewer available values, was analyzed in a separate model. Outcomes were patient characteristics and survival associated with HIV+ status. RESULTS: Thirty-two patients (0.05%) in the study period were HIV+ at transplant. HIV+ patients were comparable to the national renal transplant population in terms of gender and ethnic distribution but were younger and had younger donors and better HLA matching than the USRDS population. Patient and graft three-year survival were significantly reduced in HIV+ recipients (53% graft, 83% patient survival) relative to the USRDS population (73% and 88%, respectively). In multivariate analysis, HIV+ status was independently associated with patient mortality and decreased graft survival in recipients of cadaveric kidney transplants. CONCLUSIONS: This analysis was retrospective and may underestimate the number of HIV+ patients transplanted in the United States. Although the clinical details of patient selection for transplant were unknown, these results show HIV+ patients can have successful outcomes after cadaveric renal transplantation, although outcomes are significantly different from HIV- recipients.

Sickle cell nephropathy at end-stage renal disease in the United States: patient characteristics and survival.

BACKGROUND: The patient characteristics, including age at presentation to end-stage renal disease (ESRD) and mortality associated with sickle cell nephropathy (SCN) have not been characterized for a national sample of patients. METHODS: 375,152 patients in the United States Renal Data System were initiated on ESRD therapy between January 1, 1992 and June 30, 1997 and analyzed in an historical cohort study of SCN. RESULTS: Of the study population, 397 (0.11%) had SCN, of whom 93% were African-American. The mean age at presentation to ESRD was 40.68+/-14.00 years. SCN patients also had an independently increased risk of mortality (hazard ratio 1.52, 95% CI: 1.27-1.82) even after adjustment for placement on the renal transplant waiting list, diabetes, hematocrit, creatinine, and body mass index. However, when receipt of renal transplantation was also included in the model, SCN was no longer significant (p = 0.51, HR = 1.10, 95% CI: 0.82-1.48). SCN patients were much less likely to be placed on the renal transplant waiting list or receive renal transplants in comparison to age and race matched controls, and results of survival analysis were similar in this model. CONCLUSIONS: SCN patients were much less likely to be listed for or receive renal transplantation than other comparable patients with ESRD. SCN patients were at independently increased of mortality compared with other patients with ESRD, including those with diabetes, but this increased risk did not persist when models adjusted for their low rates of renal transplantation.

Polycystic kidney disease at end-stage renal disease in the United States: patient characteristics and survival.

BACKGROUND: The patient characteristics and mortality associated with autosomal dominant polycystic kidney disease have not been characterized for a national sample of end-stage renal disease (ESRD) patients. METHODS: 375,152 patients in the United States Renal Data System were initiated on ESRD therapy (including patients who eventually received renal transplants) between January 1, 1992 and June 30, 1997 and analyzed in an historical cohort study of polycystic kidney disease. RESULTS: Of the study population, 5,799 (1.5%) had polycystic kidney disease. In logistic regression, polycystic kidney disease was associated with Caucasian race (odds ratio 3.31, 95% CI, 3.09-3.54), women (1.10, 1.04-1.16), receipt of renal transplant (4.15, 3.87-4.45), peritoneal dialysis (vs. hemodialysis, 1.37, 1.27-1.49), younger age, and more recent year of first treatment for ESRD. Use of pre-dialysis EPO but not the level of serum hemoglobin at initiation of ESRD was significantly higher in patients with polycystic kidney disease. Patients with polycystic kidney disease had lower mortality compared to patients with other causes of ESRD, but patients with polycystic kidney disease had a higher adjusted risk of mortality associated with hemodialysis (vs. peritoneal dialysis) compared to patients with other causes of ESRD (hazard ratio 1.40, 1.13-1.75). CONCLUSIONS: Hematocrit at presentation to ESRD was not significantly different in patients with polycystic kidney disease compared with patients with other causes of ESRD. Peritoneal dialysis is a more frequent modality than hemodialysis in patients with polycystic kidney disease, and patients with polycystic kidney disease had an adjusted survival benefit associated with peritoneal dialysis, compared to patients with other causes of renal disease.

The impact of renal transplantation on the incidence of congestive heart failure in patients with end-stage renal disease due to diabetes.

BACKGROUND: Patients with end stage renal disease (ESRD) are at increased risk for cardiovascular disease. We hypothesized that the clinical incidence of congestive heart failure (CHF) would be lessened after successful renal transplantation, as many of the metabolic and intravascular volume abnormalities associated with dialysis-dependent ESRD would resolve. METHODS: Using data from the USRDS, we studied 11,369 patients with ESRD due to diabetes enrolled on the renal and renal-pancreas transplant waiting list from 1 July 1994-30 June 1997. Cox non-proportional hazards regression models were used to calculate adjusted, time-dependent hazard ratios (HR) for time to the most recent hospitalization for CHF (including acute myocardial infarction, unstable angina, or other CHF, ICD9 Code 428.x) for a given patient in the study period, controlling for both demographics and comorbidities in the medical evidence form (HCFA 2728). RESULTS: In comparison to maintenance dialysis, renal transplantation was independently associated with a lower risk for CHF (HR 0.64, 95% confidence interval, 0.54-0.77) in a model including age, gender, race, and year of first dialysis, but not in a model including comorbidities from the medical evidence form, although the sample was much smaller. CONCLUSIONS: Patients with ESRD due to diabetes on the renal transplant waiting list were much less likely to be hospitalized for congestive heart failure after renal transplantation, despite post transplant complications due to immunosuppression.

Hospitalizations for bacterial endocarditis after renal transplantation in the United States.

PURPOSE: The national rate of and risk factors for bacterial endocarditis in renal transplant recipients has not been reported. METHODS: Retrospective registry study of 33,479 renal transplant recipients in the United States Renal Data System (USRDS) between 1 July 1994 and 30 June 1997. Hospitalizations for a primary diagnosis of bacterial endocarditis (ICD-9 codes 421.x) within three years after renal transplant were assessed. RESULTS: Renal transplant recipients had an unadjusted incidence ratio for endocarditis of 7.84 (95% confidence interval 4.72-13.25) in 1996. In multivariate analysis, a history of hospitalization for valvular heart disease (adjusted odds ratio (AOR), 25.81, 95% confidence interval 11.28-59.07), graft loss (AOR, 2.81, 95% CI 1.34-5.09), and increased duration of dialysis prior to transplantation were independently associated with hospitalizations for bacterial endocarditis after transplantation. Hospitalization for endocarditis was associated with increased patient mortality in Cox Regression analysis, hazard ratio 4.79, 95% CI 2.97-6.76. CONCLUSIONS: The overall incidence of bacterial endocarditis was much greater in renal transplant recipients than in the general population, although it is still relatively infrequent. Independent risk factors for bacterial endocarditis in the renal transplant recipients were identified, the most significant of which was valvular heart disease. Endocarditis substantially impacts renal transplant recipient survival.

Human immunodeficiency virus/acquired immunodeficiency syndrome-associated nephropathy at end-stage renal disease in the United States: patient characteristics and survival in the pre highly active antiretroviral therapy era.

BACKGROUND: The patient characteristics and course of HlV/AIDS-associated nephropathy (HIVAN) are presented for a national sample of end-stage renal disease (ESRD). METHODS: 375,152 patients in the United States Renal Data System were initiated on ESRD therapy between 1 January 1992 and 30 June 1997 and analyzed in an historical cohort study of HIVAN. RESULTS: Of the study population, 3653 (0.97%) had HIVAN. Among patients with HIVAN, 87.8% were African American. HIVAN had the strongest association with African American race compared to other causes of renal failure except sickle cell anemia in logistic regression analysis (odds ratio 12.20, 95% confidence interval (CI) 10.57-14.07). In a separate logistic regression analysis, HIVAN was associated with male gender, decreased age (39.32 +/- 8.51 vs. 60.97 +/- 16.43 years, p<0.01 by Student's t-test), weight, body mass index, hemoglobin, albumin, decreased rate of pre-dialysis erythropoietin use, increased creatinine, decreased hypertension and increased rate of no medical insurance. The geographic distribution of HIVAN was similar to the distribution of HIV cases nationally. Two-year all cause unadjusted survival was 36% for HIVAN vs. 64% for all other patients with ESRD. HIVAN was associated with decreased patient survival in Cox regression analysis (hazard ratio for mortality 5.74, 95% CI, 5.40-6.10). CONCLUSIONS: HIVAN had the strongest association with African American race of all causes of renal failure among patients on maintenance dialysis. HIVAN was associated with decreased patient survival after initiation of dialysis, which may be associated with poorer medical condition at initiation of dialysis.

Risk factors for hospitalizations resulting from pulmonary embolism after renal transplantation in the United States.

BACKGROUND: Risk factors for pulmonary embolism (PE) have been identified in the general population but have not been studied in a national population of renal transplant recipients. METHODS: Therefore, 33,479 renal transplant recipients in the United States Renal Data System from 1 July 1994-30 June 1997 were analyzed in a historical cohort study of hospitalized PE (ICD9 Code 415.1x). HCFA form 2728 was used for comorbidities. RESULTS: Renal transplant recipients had an incidence of PE of 2.26 hospitalizations per 1000 patient years at risk. In multivariate analysis, polycystic kidney disease (adjusted odds ratio, 4.44, 95% confidence interval, 2.31-8.53), older recipient age, higher recipient weight, cadaveric donation, history of ischemic heart disease, and decreased serum albumin were associated with increased risk of PE. Body mass index and hemoglobin were not significant. Kidney-pancreas transplantation was also not significant. In Cox Regression analysis PE was associated with increased mortality (hazard ratio 2.06, 95% CI 1.34-3.18). CONCLUSIONS: The most important risk factors for PE in this population were polycystic kidney disease, advanced age and increased weight. The reasons for the increased risk of polycystic kidney disease remain to be determined but were independent of hematocrit level at initiation of end stage renal disease, and may result from venous compression. Prospective studies of anatomical and hemostatic changes after renal transplantation in recipients with polycystic kidney disease are warranted.

Hospitalizations for fungal infections after initiation of chronic dialysis in the United States.

AIMS: Hospitalized fungal infections are reported frequently in renal transplant recipients and peritoneal dialysis patients, but the frequency of hospitalized fungal infections in dialysis patients has not been studied in a national population. METHODS: 327,993 dialysis patients in the United States Renal Data System initiated from January 1, 1992 to June 30, 1997 were analyzed in a retrospective registry study of fungal infections (based on ICD9 Coding). RESULTS: Dialysis patients had an age-adjusted incidence ratio for fungal infections of 9.80 (95% confidence interval (CI) 6.34-15.25)) compared to the general population in 1996 (the National Hospital Discharge Survey). Candidiasis accounted for 79% of all fungal infections, followed by cryptococcosis (6.0%) and coccidioidomycosis (4.1%). In multivariate analysis, fungal infections were associated with earlier year of dialysis, diabetes, female gender, decreased weight and serum creatinine at initiation of dialysis, chronic obstructive lung disease and AIDS. In Cox regression analysis the hazard ratio for mortality of fungal infections was 1.35 (95% CI 1.28-1.42). CONCLUSIONS: Dialysis patients were at increased risk for fungal infections compared to the general population, which substantially decreased patient survival. Female and diabetic patients were at increased risk for fungal infections. Although candidiasis was the dominant etiology of fungal infections, the frequency of cryptococcosis and coccidioidomycosis were higher than previously reported.