Alcohol Consumption Patterns for Excessive Drinkers in a Multi-Ethnic Society Short Running Title: Drinking Patterns and Health Education.

Objective: Culture and eating habits, which vary greatly across different ethnic groups, have a substantial impact on drinking behavior. This study aimed to examine whether the drinking patterns and reasons differ by ethnic groups, and provide useful insights for multi-ethnic areas that seek to cut down alcohol intake. Methods: We recruited excessive drinkers and collected the drinking patterns and motivations by questionnaire in a multi-ethnic society. Multiple linear regressions were used to evaluate the variations in drinking characteristics among different ethnic groups. Results: We recruited 1287 participants through convenience sampling (a non-probability sampling technique used in research where the researcher selects participants or units for a study based on their accessibility and proximity), among whom 439 excessive drinkers were eligible. The mean age was 38 years for the 439 participants, 92.9% were men, 36.0% were Han, and 64.0% were minorities mainly composed of the Yi. The majority of the participants were married (75.9%) and did physical work (58.1%). Ethnic minorities consumed more alcohol on a single occasion than Han people did (47.3 vs 41.8g/session) while drinking less frequently. For the minority and Han participants, 67% and 42% were not used to drinking with food, respectively. Peer pressure and fostering a good atmosphere were the most common drinking reasons for the minority and Han, respectively. Conclusion: We found substantial differences in drinking patterns and reasons between ethnic minorities and Han ethnicity, attributable to their culture and customs. Findings highlight the importance of drinking habits and motivations in exploring alcohol control education strategies in the context of ethnic integration and population immigration.

Prescription medication use among patients with type 2 diabetes in the United States: 1999-2020.

AIMS: We aimed to examine trends in overall prescription medication use among patients with type 2 diabetes in the United States to provide insights for patient care. MATERIALS AND METHODS: We used nationally representative data from the National Health and Nutrition Examination Survey from 1999 to 2020 and included adult patients with type 2 diabetes. We examined the use of prescription drugs, overall and by drug class, polypharmacy (use of ≥5 medications), and number of medications attributed to specific classes. RESULTS: In the period 2015-2020, the mean patient age was 59.6 (51.0-70.0) years, with 46.8% (43.6-49.9) being female and 57.8% (52.8-62.8) being non-Hispanic White. Among 9489 adults with type 2 diabetes, the prevalence of polypharmacy was high and increased from 35.1% (31.6-38.6) in 1999-2002 to 47.2% (43.7-50.7) in 2003-2006, and further to 51.1% (48.3-53.9) in 2015-2020 (p for trend <0.001). Increasing trends of polypharmacy were found across all population subgroups and across the majority of therapeutic classes. Use of non-cardiometabolic medications was common. Among them, the most common were antidepressants (19.8%), proton pump inhibitors (19.0%) and analgesics (16.2%). Among patients with polypharmacy, approximately 40% of medication use was attributed to non-cardiometabolic medications. CONCLUSIONS: Prescription medication burden and complexity increased substantially among patients with type 2 diabetes, with more than 50% of patients with polypharmacy. Attention should be paid to this escalating medication use and regimen complexity, which requires multidisciplinary and coordinated care.

Trends in Number and Appropriateness of Prescription Medication Utilization Among Community-Dwelling Older Adults in the United States: 2011-2020.

BACKGROUND: Contemporary data on the quantity and quality of medication use among older adults are lacking. This study examined recent trends in the number and appropriateness of prescription medication use among older adults in the United States. METHODS: Data from the National Health and Nutrition Examination Survey (NHANES) between 2011 and March 2020 were used, and 6 336 adult participants aged 65 and older were included. We examined the number of prescription medication, prevalence of polypharmacy (≥5 prescription drugs), use of potentially inappropriate medication (PIM), and use of recommended medications (angiotensin-converting enzyme inhibitor [ACEI]/angiotensin receptor blockers [ARBs] plus beta-blockers among patients with heart failure and ACEI/ARBs among patients with albuminuria). RESULTS: There has been a slight increase in the prevalence of polypharmacy (39.3% in 2011-2012 to 43.8% in 2017-2020, p for trend = .32). Antihypertensive, antihyperlipidemic, antidiabetic medications, and antidepressants are the most commonly used medications. There was no substantial change in the use of PIM (17.0% to 14.7%). Less than 50% of older adults with heart failure received ACEI/ARBs plus beta-blockers (44.3% in 2017-2020) and approximately 50% of patients with albuminuria received ACEI/ARBs (54.0% in 2017-2020), with no improvement over the study period. Polypharmacy, older age, female, and lower socioeconomic status were generally associated with greater use of PIM but lower use of recommended medications. CONCLUSIONS: The medication burden remained high among older adults in the United States and the appropriate utilization of medications did not improve in the recent decade. Our results underscore the need for greater attentions and interventions to the quality of medication use among older adults.

Glucagon-like peptide-1 receptor agonists and the risk of atrial fibrillation in adults with diabetes: a real-world study.

BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1RA) have cardiovascular benefits in type 2 diabetes, but none of the cardiovascular trials studied atrial fibrillation/atrial flutter (AF) as a primary endpoint. Data from post-marketing surveillance studies remains sparse. OBJECTIVE: To examine the real-world risk of AF comparing GLP-1RA with other non-insulin glucose-lowering agents. DESIGN: Cohort study using de-identified electronic health record data from the Optum Labs Data Warehouse. PARTICIPANTS: Adult patients with diabetes who were newly prescribed add-on non-insulin glucose-lowering agents and were on metformin between 2005-2020. EXPOSURES: New users of GLP-1RA were separately compared with new users of dipeptidyl peptidase-4 inhibitors (DPP4i) and sodium-glucose cotransporter 2 inhibitors (SGLT2i), using 1:1 propensity score matching to adjust for differences in patient characteristics. MAIN MEASURES: The primary outcome was incident AF, defined and captured by diagnosis code for AF. Incidence rate difference (IRD) and hazard ratio (HR) were estimated in the matched cohorts. KEY RESULTS: In the matched cohort of 14,566 pairs of GLP-1RA and DPP4i followed for a median of 3.8 years, GLP-1RA use was associated with a lower risk of AF (IRD, -1.0; 95% CI, -1.8 to -0.2 per 1000 person-years; HR, 0.82; 95% CI, 0.70 to 0.96). In the matched cohort of 9,424 pairs of patients on GLP-1RA and SGLT2i with a median follow-up of 2.9 years, there was no difference in the risk for AF (IRD, 0.4; 95% CI -0.7 to 1.5 per 1000 person-years; HR, 1.12; 95% CI, 0.89 to 1.42). CONCLUSIONS: In this real-word study, GLP-1RA was associated with a lower risk of AF compared with DPP4i, but no difference compared with SGLT2i, suggesting that cardiovascular benefits of GLP-1RA use may extend to prevention for AF in patients with diabetes. Our findings call for future randomized controlled trials to focus on the effects of GLP-1RA on AF prevention.

HLA-DR Helps to Differentiate Erythrodermic Cutaneous T-cell Lymphoma from Erythrodermic Inflammatory Dermatoses in Flow Cytometry.

Differential diagnosis of erythroderma is challenging in dermatology, especially in differentiating erythrodermic cutaneous T-cell lymphoma from erythrodermic inflammatory dermatoses. This study retrospectively reviewed the peripheral blood flow cytometric results of 73 patients diagnosed with erythroderma at Peking University First Hospital from 2014 to 2019. The flow cytometry antibody panel included white blood cell markers, T-cell markers, B-cell markers, T-cell activation markers, and T helper cell differentiation markers. Features of the cell surface antigens were compared between 34 patients with erythrodermic cutaneous T-cell lymphoma and 39 patients with erythrodermic inflammatory dermatoses. The percentage of HLA-DR+/CD4+T cells was the most pronounced marker to distinguish erythrodermic cutaneous T-cell lymphoma from erythrodermic inflammatory dermatoses, with a threshold of 20.85% (sensitivity 96.77%, specificity 70.37%, p = 0.000, area under the curve (AUC) 0.882), suggesting its potential capability in the differential diagnosis of erythrodermic cutaneous T-cell lymphoma from erythrodermic inflammatory dermatoses. Moreover, in contrast to erythrodermic inflammatory dermatoses, the percentage of Th17 cells was significantly downregulated in erythrodermic cutaneous T-cell lymphoma (p = 0.001), demonstrating a dysregulated immune environment in erythrodermic cutaneous T-cell lymphoma.

Glucose-Lowering Agents and the Risk of Hypoglycemia: a Real-world Study.

BACKGROUND: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1RA) are increasingly recommended in type 2 diabetes. Hypoglycemia is a serious adverse effect of glucose-lowering agents. Real-world comparison of hypoglycemic risks among SGLT2i, GLP1RA, dipeptidyl peptidase-4 inhibitor (DPP4i), and sulfonylureas is limited. OBJECTIVE: Quantify the risk of hypoglycemia associated with SGLT2i, GLP1RA, DPP4i, and sulfonylureas (the primary reference group). DESIGN: Retrospective cohort study conducted using electronic health records from Geisinger Health, Pennsylvania (2015-2019). PARTICIPANTS: A total of 10,713 patients with type 2 diabetes who newly received SGLT2i (n=1487), GLP1RA (n=1241), DPP4i (n=2938), or sulfonylureas (n=5047). Propensity score-based inverse probability of treatment weighting was used to balance patient characteristics across four treatment groups simultaneously. MAIN MEASURES: Hypoglycemia was defined as capillary blood glucose <70 mg/dL; severe hypoglycemia was defined as capillary blood glucose <54 mg/dL. A weighted Cox proportional hazards regression model was used to estimate the risk of outcomes for pairwise comparisons of SGTL2i, GLP1RA, DPP4i, and sulfonylureas. KEY RESULTS: Median follow-up was 21.3 months. Compared with sulfonylureas, the risk of hypoglycemia was lower with SGLT2i (hazard ratio 0.60 [95% confidence interval 0.48-0.75]), GLP1RA (0.49 [0.34-0.69]), and DPP4i (0.60 [0.48-0.78]). The risk of severe hypoglycemia was also lower with SGLT2i (0.43 [0.35-0.74]), GLP1RA (0.50 [0.28-0.87]), and DPP4i (0.64 [0.46-0.90]) compared to sulfonylureas. The risks of hypoglycemia and severe hypoglycemia were similar across the SGLT2i, GLP1RA, and DPP4i groups (SGLT2i vs. DPP4i: 0.95 [0.67-1.34]; GLP1RA vs. DPP4i: 0.81 [0.55-1.19]; SGLT2i vs. GLP1RA: 1.17 [0.76-1.82] for hypoglycemia). CONCLUSION: SGLT2i and GLP1RA confer a lower risk of hypoglycemia compared with sulfonylureas and similar risk compared with DPP4i. Given the known cardiovascular benefits associated with SGLT2i and GL1PRA, our results suggesting the safety of SGLT2i and GL1PRA further support their use.

The association between socioeconomic status and use of potentially inappropriate medications in older adults.

BACKGROUND: Potentially inappropriate medication (PIM) use is an important public health problem, particularly among older adults who may need multiple pharmacologic therapies for various chronic conditions. As socioeconomic status (SES) affects the quality of healthcare that individuals receive, SES may be associated with the use of PIM in older adults. This study aimed to determine whether low SES is associated with increased use of PIM. METHODS: We studied 4927 participants (aged 66-90 years) who were on at least one medication at visit five (2011-2013) of the Atherosclerosis Risk in Communities Study. We created a cumulative SES score categorized as high (7-9), middle (3-6), and low (0-2) based on education, income, and area deprivation index. We use multivariable logistic regression to examine the associations between SES and use of two or more PIM for older adults, defined by the 2019 Beers Criteria. RESULTS: A total of 31.0% and 6.9% of the participants used one or more PIM and two or more PIM, respectively. After adjusting for demographic characteristics and insurance type, low cumulative SES score was associated with significantly greater use of two or more PIM (odds ratio [OR] = 1.83 [95% confidence interval (CI) 1.18-2.86]), as was middle cumulative SES score (OR = 1.40 [95% CI 1.06-1.83]), compared to high cumulative SES score. The results remained significant after further adjusting for comorbidities and medication burden for low cumulative SES score (OR = 1.66 [95%CI 1.02-2.71]). CONCLUSIONS: We found that lower SES was associated with greater use of PIM among older adults independent of their medication burden and comorbidities, suggesting socioeconomic disparities in quality of medication management. Focused efforts targeting older adults with low SES to reduce PIM use may be needed to prevent adverse drug events.

Weight changes following antidiabetic mediation use: Real-world evidence from health system data.

Objective: Newer antidiabetic medications such as sodium-glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP1RA) result in weight loss in clinical trials. However, the real-world effectiveness remains unclear. The magnitude of weight change associated with antidiabetic medication using real-world data was examined. Methods: Patients with diabetes who initiated SGLT2i (n = 906), GLP1RA (n = 782), dipeptidyl peptidase-4 inhibitors (DPP4i, n = 1881), or sulfonylureas (n = 3255) in Geisinger Health System were identified. Outcomes were percent weight change per year and time to 5% weight loss. Propensity scores were used to account for differences across groups. Results: The mean ± SD age of patients was 57.5 ± 14.1 years, 3381 (49.5%) were female, and 6450 (94.5%) had body mass index ≥25 kg/m2. Compared with sulfonylureas, newer antidiabetic medications were associated with significant weight loss (-3.2% [95% confidence interval: -3.8%, -2.6%] per year for SGLT2i; -2.9% [-3.6%, -2.3%] per year for GLP1RA; and -1.7% [-2.1%, -1.3%] per year for DPP4i). SGLT2i and GLP1RA were also associated with significant weight loss compared with DPP4i. Among patients with overweight or obesity, SGLT2i and GLP1RA users were more likely to achieve 5% weight loss compared with sulfonylureas and DPP4i. Conclusions: In real-world practice, SGLT2i and GLP1RA were associated with significant weight loss compared with sulfonylureas and DPP4i. These results may further motivate uptake of SGLT2i and GLP1RA, especially among patients who were overweight or had obesity.

Pharmacologic Treatment of Type 2 Diabetes in the U.S., Sweden, and Israel.

OBJECTIVE: To characterize and compare glucose-lowering medication use in type 2 diabetes in the U.S., Sweden, and Israel, including adoption of newer medications and prescribing patterns. RESEARCH DESIGN AND METHODS: We used data from the National Health and Nutrition Examination Survey (NHANES) from the U.S., the Stockholm CREAtinine Measurements (SCREAM) project from Sweden, and Maccabi Healthcare Services (Maccabi) from Israel. Specific pharmacotherapy for type 2 diabetes between 2007 and 2018 was examined. RESULTS: Use of glucose-lowering medications among patients with type 2 diabetes was substantially lower in NHANES and SCREAM than in Maccabi (66.0% in NHANES, 68.4% in SCREAM, and 88.1% in Maccabi in 2017-2018). Among patients who took at least one glucose-lowering medication in 2017-2018, metformin use was also lower in NHANES and SCREAM (74.1% in NHANES, 75.9% in SCREAM, and 92.6% in Maccabi) whereas sulfonylureas use was greater in NHANES (31.5% in NHANES, 16.0% in SCREAM, and 14.9% in Maccabi). Adoption of dipeptidyl peptidase 4 inhibitors and sodium-glucose cotransporter 2 inhibitors (SGLT2i) was slower in NHANES and SCREAM than in Maccabi. History of atherosclerotic cardiovascular disease, heart failure, reduced kidney function, or albuminuria was not consistently associated with greater use of SGLT2i or glucagon-like peptide 1 receptor agonists (GLP1RA) across the three countries. CONCLUSIONS: There were substantial differences in real-world use of glucose-lowering medications across the U.S., Sweden, and Israel, with more optimal pharmacologic management in Israel. Variation in access to care and medication cost across countries may have contributed to these differences. SGLT2i and GLP1RA use in patients at high risk was limited in all three countries during this time period.

Socioeconomic status and use of obesogenic and anti-obesity medications in the United States: A population-based study.

Background: The Endocrine Society Clinical Practice Guidelines recommend the avoidance of medications that may cause weight gain (i.e., obesogenic medications) in individuals with overweight or obesity. Obesity disproportionately affects people with lower socioeconomic status (SES); however, it is unknown whether the use of obesogenic medications differs by SES. Methods: We included adults with overweight or obesity and used prescription medications from 2009-2018 of the US National Health and Nutrition Examination Survey. We examined the associations between a composite measure of SES and use of obesogenic medications and anti-obesity medications. The composite SES included

Arteriovenous Access Type and Risk of Mortality, Hospitalization, and Sepsis Among Elderly Hemodialysis Patients: A Target Trial Emulation Approach.

RATIONALE & OBJECTIVE: Evidence is mixed regarding the optimal choice of the first permanent vascular access for elderly patients receiving hemodialysis (HD). Lacking data from randomized controlled trials, we used a target trial emulation approach to compare arteriovenous fistula (AVF) versus arteriovenous graft (AVG) creation among elderly patients receiving HD. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Elderly patients included in the US Renal Data System who initiated HD with a catheter and had an AVF or AVG created within 6 months of starting HD. EXPOSURE: Creation of an AVF versus an AVG as the incident arteriovenous access. OUTCOMES: All-cause mortality, all-cause and cause-specific hospitalization, and sepsis. ANALYTICAL APPROACH: Target trial emulation approach, high-dimensional propensity score and inverse probability of treatment weighting, and instrumental variable analysis using the proclivity of the operating physician to create a fistula as the instrumental variable. RESULTS: A total of 19,867 patients were included, with 80.1% receiving an AVF and 19.9% an AVG. In unweighted analysis, AVF creation was associated with significantly lower risks of mortality and hospitalization, especially within 6 months after vascular access creation. In inverse probability of treatment weighting analysis, AVF creation was associated with lower incidences of mortality and hospitalization within 6 months after creation (hazard ratios of 0.82 [95% CI, 0.75-0.91] and 0.82 [95% CI, 0.78-0.87] for mortality and all-cause hospitalization, respectively), but not between 6 months and 3 years after access creation. No association between AVF creation and mortality, sepsis, or all-cause, cardiovascular disease-related, or infection-related hospitalization was found in instrumental variable analyses. However, AVF creation was associated with a lower risk of access-related hospitalization not due to infection. LIMITATIONS: Potential for unmeasured confounding, analyses limited to elderly patients, and absence of data on actual access use during follow-up. CONCLUSIONS: Using observational data to emulate a target randomized controlled trial, the type of initial arteriovenous access created was not associated with the risks of mortality, sepsis, or all-cause, cardiovascular disease-related, or infection-related hospitalization among elderly patients who initiated HD with a catheter.

Sodium-Glucose Cotransporter 2 Inhibitors, Glucagon-Like Peptide-1 Receptor Agonists, and Dipeptidyl Peptidase-4 Inhibitors, and Risk of Hospitalization.

Clinical trials have demonstrated cardiovascular benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA). However, their impact on all-cause and cause-specific hospitalization in real-world practice remains unclear. We identified patients with diabetes who initiated SGLT2i (n = 2,492), GLP-1RA (n = 1,982), or dipeptidyl peptidase-4 inhibitors (DPP4i, n = 2,492) between 2015 and 2018 in Geisinger Health System. We examined all-cause hospitalization (net benefit indicator) and cardiovascular disease (CVD) hospitalization (CV benefit indicator), as well as non-CVD hospitalization (harm indicator), using Cox proportional hazards regression. During a median follow-up of 16 months, SGLT2i and GLP-1RA were associated with lower risk of all-cause hospitalization (hazard ratio [HR] 0.85, 95% CI 0.75 to 0.95 for SGLT2i; HR 0.89, 95% CI 0.78 to 0.98 for GLP-1RA), as well as CVD hospitalization (HR 0.61, 95% CI 0.47 to 0.79) for SGLT2i; HR 0.77, 95% CI 0.60 to 0.99 for GLP-1RA) compared with DPP4i. The risks of all-cause and CVD hospitalization were similar between SGLT2i and GLP-1RA. SGLT2i was associated with substantially lower risk of myocardial infarction and heart failure hospitalization compared with DPP4i and lower risk of heart failure hospitalization compared with GLP-1RA. The risk of non-CVD hospitalization did not differ among the treatment groups. These results from real-world comparison further encourage SGLT2i and GLP-1RA use in routine diabetes care, particularly among patients at high risk of cardiovascular events.

Post-kidney transplant serum magnesium exhibits a U-shaped association with subsequent mortality: an observational cohort study.

Hypomagnesemia is common in kidney transplant recipients (KTRs). We sought to explore the relationship between Mg and outcomes in KTRs, which may be associated with mortality and thus may be a potential intervention target to improve outcomes. We followed KTRs performed between 01/2000 and 6/2016 at a large US transplant center from 6 months post-transplant to graft failure, death, or loss to follow-up. Using Mg as a time-dependent variable, associations between Mg and outcomes any time after 6 months post-transplant were evaluated. 3680 KTRs with 50  413 Mg measurements met inclusion criteria. 657 deaths occurred over a median follow-up of 5.1 years. Compared to Mg of 1.5-1.8 mg/dl, both lower (HR 1.17, 95% confidence interval (CI): 1.07-1.28) and higher (HR 1.16, 95% CI: 1.09-1.23) Mg levels were associated with greater risk of mortality. Similar U-shaped associations were observed for Mg and cardiovascular disease-related mortality (HR for Mg ≤1.5 mg/dl: 1.31; CI: 1.03-1.68) and infection-related mortality (HR for Mg ≤1.5 mg/dl: 1.28; CI: 1.09-1.51), although relationships for Mg >1.8 mg/dl were not statistically significant. Mg exhibits a U-shaped association with mortality in KTRs, with levels between 1.5 and 1.8 mg/dl associated with the lowest risk.

Graft Function Variability and Slope and Kidney Transplantation Outcomes.

INTRODUCTION: It is critical to identify kidney transplant recipients (KTRs) at higher risk for adverse outcomes, to focus on monitoring and interventions to improve outcomes. We examined the associations between graft function variability and long-term outcomes in KTRs in an observational study. METHODS: We identified 2919 KTRs in the Wisconsin Allograft Recipient Database (WisARD) who had a functioning allograft 2 years posttransplantation and at least 3 outpatient measurements of estimated glomerular filtration rate (eGFR) from 1 to 2 years posttransplantation. Graft function slope was calculated from a linear regression of eGFR, and variability was defined as the coefficient of variation around this regression line. Associations of eGFR variability and slope with death, graft failure, cardiovascular events, and acute rejection were estimated. RESULTS: Compared to the lowest quartile, the highest quartile of eGFR variability was associated with a higher risk of death (adjusted hazard ratio [HR] = 1.85; 95% CI = 1.23-2.76), but not with a higher risk of graft failure (subhazard ratio = 1.16; 95% CI = 0.85-1.58), independent of eGFR and slope of eGFR. Greater eGFR variability was associated with higher risk of cardiovascular- and infection-related death and cardiovascular events but not malignancy-related death or allograft rejection. Including variability of eGFR significantly improved prediction of mortality but not prediction of graft failure. CONCLUSION: Variability of eGFR is independently associated with risk of death, especially cardiovascular disease-related death and cardiovascular events, but not graft failure. Variability of eGFR may help identify KTRs at higher risk for death and cardiovascular events.

Catheter Dependence After Arteriovenous Fistula or Graft Placement Among Elderly Patients on Hemodialysis.

RATIONALE & OBJECTIVE: Creation of an arteriovenous fistula (AVF), compared with an arteriovenous graft (AVG), is associated with longer initial catheter dependence after starting hemodialysis (HD) but longer access survival and lower long-term catheter dependence. The extent of these potential long-term benefits in elderly patients is unknown. We assessed catheter dependence after AVF or AVG placement among elderly patients who initiated HD without a permanent access in place. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Patients≥67 years of age identified in the US Renal Data System who had a first AVF (n=14,532) or AVG (n=3,391) placed within 1 year after HD initiation between May 2012 and May 2017. EXPOSURE: AVF versus AVG placement in the first year of HD. OUTCOME: Catheter dependence after AVF or AVG placement assessed using CROWNWeb data. ANALYTICAL APPROACH: Generalized estimating equations and negative binomial regression for catheter use over time and Cox proportional hazards models for mortality. RESULTS: Creation of an AVF versus AVG placement was associated with greater catheter dependence at 1 month (95.6% vs 92.5%) and 3 months (82.8% vs 41.2%), but lower catheter dependence at 12 months (14.2% vs 15.8%) and 36 months (8.2% vs 15.0%). Creation of an AVF, however, remained significantly associated with greater cumulative catheter-dependent days (80.1 vs 54.6 days per person-year) and a lower proportion of catheter-free survival time (78.1% vs 85.1%) after 3 years of follow-up. LIMITATIONS: Potential for unmeasured confounding and analyses limited to elderly patients. CONCLUSIONS: Creation of an AVF was associated with significantly greater cumulative catheter dependence than placement of an AVG in an elderly population initiating HD without a permanent access. As the long-term benefits in terms of catheter dependence of an AVF are not realized in many elderly patients, specific patient characteristics should be considered when making decisions regarding vascular access.

Associations between Proton Pump Inhibitor and Histamine-2 Receptor Antagonist and Bone Mineral Density among Kidney Transplant Recipients.

BACKGROUND: In the general population, use of proton pump inhibitor (PPI) has been linked to higher risk of osteoporotic fractures. PPI is commonly prescribed in kidney transplant recipients (KTRs). However, the effect of PPI on osteoporosis in KTRs is largely unstudied. METHODS: A total of 1,774 adult KTRs in the Wisconsin Allograft Recipient Database with at least one eligible bone mineral density (BMD) measurement at least 3 months after transplantation were included in the analyses. Associations between use of PPI and histamine-2 receptor antagonist (H2RA) at 3 months after transplantation and subsequent slope of T-score were assessed. RESULTS: A total of 1,478 (83.3%) participants were using a PPI at 3 months after transplantation. Compared to the use of H2RA, use of PPI was not significantly associated with annualized slope of hip T-score (ß = -0.0039, 95% CI -0.00497 to 0.0021) or annualized slope of spine T-score (ß = -0.017, 95% CI -0.049 to 0.083) after adjustment for potential confounders. Similarly, no significant association between use of PPI and slope of T-score was observed when defining PPI/H2RA exposure as use within 6 months of the initial BMD measurement, or only including participants with at least 2 BMD measurements, or stratified by different age and sex. CONCLUSIONS: Use of PPI was not associated with an increased rate of BMD loss in KTRs. Our results support previous findings that PPI use does not have a significant effect on bone mineral loss.

Proton Pump Inhibitors, But Not H2-receptor Antagonists, Are Associated With Incident Fractures Among Kidney Transplant Recipients.

BACKGROUND: Fractures are a common and burdensome problem among kidney transplant recipients (KTRs). Proton pump inhibitors (PPIs) are frequently used after kidney transplantation and have been associated with increased fracture risk in the general population. This study aimed to determine whether PPI use is associated with incidence of major fractures in KTRs. METHODS: Using the Wisconsin Allograft Recipient Database, we identified 155 KTRs with a major fracture that occurred at least 12 months after transplantation. Controls were selected using incidence-density sampling. Use of PPIs and histamine 2-receptor antagonists (H2RA) during the year before the index date were identified. RESULTS: A total of 155 cases were matched to 685 controls. Within 1 year before the index date, 68% of cases and 52% of controls used a PPI, and 16% of cases and 11% of controls used an H2RA. PPI use was associated with higher incidence of major fractures in unadjusted analysis (odds ratio [OR], 2.4; 95% CI, 1.6-3.5) and in adjusted analyses controlling for demographic and transplant-related covariates and use of corticosteroids, bisphosphonates, vitamin D and calcium supplements (OR, 1.9; 95% CI, 1.2-3.1). H2RA use was not associated with incidence of major fractures in adjusted analyses (OR, 1.0; 95% CI, 0.5-1.8). The associations between PPI use and fractures remained similar in analyses limited to spine and hip fractures. CONCLUSIONS: Use of PPIs, but not H2RAs, is associated with a higher risk of major fractures among KTRs. Clinicians should individualize PPI use in KTRs, evaluating the risks and benefits of prescribing and continuing PPIs in KTRs.