Experiences of Kidney Transplant Recipients as Patient Navigators.

BACKGROUND AND OBJECTIVE: The use of trained kidney transplant recipients as patient navigators resulted in increased completion of the steps in the transplant process by dialysis patients. We sought to understand the experiences of these patient navigators. SETTING AND PARTICIPANTS: Six kidney transplant recipients were hired and employed by transplant centers in Ohio, Kentucky, and Indiana. The transplant navigators received formal training as peer educators, met with dialysis patients on a regular basis, and provided tailored education and assistance about transplantation to each patient. They worked closely with the pretransplant coordinators and social workers to learn the details of each patient's transplant work-up. METHODOLOGY: We queried navigators using open-ended questions to learn about their experiences. Navigator responses were coded and common themes identified. A thematic auditor reviewed and refined the coding. RESULTS: Two primary categories of themes emerged about the navigator experience: 1. practical comments that supported programmatic or implementation observations of the navigators, and 2. affective comments that reflected a shared experience among the navigators and patients. The navigators were able to fill voids in the transplant process that were not fulfilled by other caregivers. This was accomplished by a natural bond based upon a shared experience (of dialysis and kidney failure) between the navigator and the patient. The patient and navigator became experiential partners. CONCLUSION: Kidney transplant recipients trained as patient navigators fill the role of a nontraditional medical provider, offer support during the transplant process, and provide an added benefit to complement routine dialysis and nephrology care.

You eat what you are: autophagy inhibition as a therapeutic strategy in leukemia.

A deeper understanding of the role of autophagy, literally 'self-eating', in normal and cancer cell biology has emerged over the last few years. Autophagy serves as a vehicle for cells to respond to various stressors including genomic, hypoxic and nutrient stress, and to oppose mechanisms of 'programmed' cell death. Here, we review not only mechanisms of cell death and cell survival but also the early successes in applying autophagy inhibition strategies in solid tumors using the only currently available clinical inhibitor, oral hydroxychloroquine. In acute leukemia, currently available chemotherapy drugs promote cell death and demonstrate clinical benefit, but relapse and subsequent chemotherapy resistance is common. Increasing preclinical data suggest that autophagy is active in leukemia as a means of promoting cell survival in response to chemotherapy. We propose coupling autophagy inhibition strategies with current cytotoxic chemotherapy and discuss synergistic combinations of available anti-leukemic therapies with autophagy inhibition. Furthermore, novel autophagy inhibitors are in development and promise to provide new therapeutic opportunities for patients with leukemia.

DNMT3A and IDH mutations in acute myeloid leukemia and other myeloid malignancies: associations with prognosis and potential treatment strategies.

The development of effective treatment strategies for most forms of acute myeloid leukemia (AML) has languished for the past several decades. There are a number of reasons for this, but key among them is the considerable heterogeneity of this disease and the paucity of molecular markers that can be used to predict clinical outcomes and responsiveness to different therapies. The recent large-scale sequencing of AML genomes is now providing opportunities for patient stratification and personalized approaches to treatment that are based on individual mutational profiles. It is particularly notable that studies by The Cancer Genome Atlas and others have determined that 44% of patients with AML exhibit mutations in genes that regulate methylation of genomic DNA. In particular, frequent mutation has been observed in the genes encoding DNA methyltransferase 3A (DNMT3A), isocitrate dehydrogenase 1 (IDH1) and isocitrate dehydrogenase 2 (IDH2), as well as Tet oncogene family member 2. This review will summarize the incidence of these mutations, their impact on biochemical functions including epigenetic modification of genomic DNA and their potential usefulness as prognostic indicators. Importantly, the presence of DNMT3A, IDH1 or IDH2 mutations may confer sensitivity to novel therapeutic approaches, including the use of demethylating agents. Therefore, the clinical experience with decitabine and azacitidine in the treatment of patients harboring these mutations will be reviewed. Overall, we propose that understanding the role of these mutations in AML biology will lead to more rational therapeutic approaches targeting molecularly defined subtypes of the disease.

Prominent impact of community risk factors on kidney transplant candidate processes and outcomes.

Numerous factors impact patients' health beyond traditional clinical characteristics. We evaluated the association of risk factors in kidney transplant patients' communities with outcomes prior to transplantation. The primary exposure variable was a community risk score (range 0-40) derived from multiple databases and defined by factors including prevalence of comorbidities, access and quality of healthcare, self-reported physical and mental health and socioeconomic status for each U.S. county. We merged data with the Scientific Registry of Transplant Recipients (SRTR) and utilized risk-adjusted models to evaluate effects of community risk for adult candidates listed 2004-2010 (n = 209 198). Patients in highest risk communities were associated with increased mortality (adjusted hazard ratio [AHR] = 1.22, 1.16-1.28), decreased likelihood of living donor transplantation (adjusted odds ratio [AOR] = 0.90, 0.85-0.94), increased waitlist removal for health deterioration (AHR = 1.36, 1.22-1.51), decreased likelihood of preemptive listing (AOR = 0.85, 0.81-0.88), increased likelihood of inactive listing (AOR = 1.49, 1.43-1.55) and increased likelihood of listing for expanded criteria donor kidneys (AHR = 1.19, 1.15-1.24). Associations persisted with adjustment for rural-urban location; furthermore the independent effects of rural-urban location were largely eliminated with adjustment for community risk. Average community risk varied widely by region and transplant center (median = 21, range 5-37). Community risks are powerful factors associated with processes of care and outcomes for transplant candidates and may be important considerations for developing effective interventions and measuring quality of care of transplant centers.

The prognostic value of kidney transplant center report cards.

SRTR report cards provide the basis for quality measurement of US transplant centers. There is limited data evaluating the prognostic value of report cards, informing whether they are predictive of prospective patient outcomes. Using national SRTR data, we simulated report cards and calculated standardized mortality ratios (SMR) for kidney transplant centers over five distinct eras. We ranked centers based on SMR and evaluated outcomes for patients transplanted the year following reports. Recipients transplanted at the 50th, 100th and 200th ranked centers had 18% (AHR = 1.18, 1.13-1.22), 38% (AHR = 1.38, 1.28-1.49) and 91% (AHR = 1.91, 1.64-2.21) increased hazard for 1-year mortality relative to recipients at the top-ranked center. Risks were attenuated but remained significant for long-term outcomes. Patients transplanted at centers meeting low-performance criteria in the prior period had 40% (AHR = 1.40, 1.22-1.68) elevated hazard for 1-year mortality in the prospective period. Centers' SMR from the report card was highly predictive (c-statistics > 0.77) for prospective center SMRs and there was significant correlation between centers' SMR from the report card period and the year following (ρ = 0.57, p < 0.001). Although results do not mitigate potential biases of report cards for measuring quality, they do indicate strong prognostic value for future outcomes. Findings also highlight that outcomes are associated with center ranking across a continuum rather than solely at performance margins.

Overweight, obesity and intentional weight loss in chronic kidney disease: NHANES 1999-2006.

OBJECTIVE: Obesity and chronic kidney disease (CKD) have emerged as major public health problems. We aimed to examine: (a) lifestyle and behavioral factors, (b) factors related to pursuing weight loss and (c) weight loss modalities pursued by CKD and non-CKD individuals who are overweight and obese. METHODS: Cross-sectional analysis of 10,971 overweight and obese adult participants in the National Health and Nutrition Examination Surveys conducted between 1999 and 2006. We examined the differences in lifestyle and behavioral factors between CKD and non-CKD participants and factors associated with pursuing weight loss using survey regression models. RESULTS: The total daily energy intake of the CKD population was lower than the non-CKD group (1987 kcal per day versus 2063 kcal per day, P=0.02) even after adjusting for relevant covariates. However, the percentage of energy derived from protein was similar between the groups. Sixty six percent of the CKD population did not meet the minimum recommended leisure time physical activity goals compared with 57% among non-CKD (P<0.001). Fifty percent of CKD participants pursued weight loss (vs fifty-five percent of non-CKD individuals, P=0.01), but the presence of CKD was not independently associated with the pursuit of weight loss in the multivariate model. Among participants pursuing weight loss, modalities including dietary interventions utilized by CKD and non-CKD participants were similar. Eight percent of CKD participants used medications to promote weight loss. CONCLUSIONS: Among the overweight and obese population, lifestyle and behavioral factors related to obesity and weight loss are similar between CKD and non-CKD participants. Insufficient data exist on the beneficial effects of intentional weight loss in CKD and these data show that a significant proportion of the CKD population use diets that may have high-protein content and medications to promote weight loss that may be harmful. Future clinical trials evaluating the efficacy and optimal modalities to treat obesity in the CKD population are warranted.

Marked variation of the association of ESRD duration before and after wait listing on kidney transplant outcomes.

Numerous studies report a strong association between pretransplant end-stage renal disease (ESRD) duration and diminished transplant outcomes. However, cumulative waiting time may reflect distinct phases and processes related to patients' physiological condition as well as pre-existing morbidity and access to care. The relative impact of pre- and postlisting ESRD durations on transplant outcomes is unknown. We examined the impact of these intervals from a national cohort of kidney transplant recipients from 1999 to 2008 (n = 112,249). Primary factors explaining prelisting ESRD duration were insurance and race, while primary factors explaining postlisting ESRD duration were blood type, PRA% and variation between centers. Extended time from ESRD to waitlisting had significant dose-response association with overall graft loss (AHR = 1.26 for deceased donors [DD], AHR = 1.32 for living donors [LD], p values < 0.001). Contrarily, time from waitlisting (after ESRD) to transplantation had negligible effects (p = 0.10[DD], p = 0.57[LD]). There were significant associations between pre- and postlisting ESRD time with posttransplant patient survival, however prelisting time had over sixfold greater effect. Prelisting ESRD time predominately explains the association of waiting time with transplant outcomes suggesting that factors associated with this interval should be prioritized for interventions and allocation policy. The degree to which the effect of prelisting ESRD time is a proxy for comorbid conditions, socioeconomic status or access to care requires further study.

Reduced employment in caregivers of frail elders: impact of ethnicity, patient clinical characteristics, and caregiver characteristics.

BACKGROUND: Without family caregivers, many frail elders who live at home would require nursing home care. However, providing care to frail elders requires a large time commitment that may interfere with the caregiver's ability to work. Our goal was to determine the patient and caregiver characteristics associated with the reduction of employment hours in caregivers of frail elders. METHODS: This was a cross-sectional study of 2806 patients (mean age 78, 73% women, 29% African American, 12% Hispanic, 54% with dementia) with at least one potentially working caregiver (defined as one who is either currently employed or who would have been employed if they had not been providing care) and their 4592 potentially working caregivers. Patients were enrollees at 11 sites of the Program of All-Inclusive Care for the Elderly (PACE). Social workers interviewed patients and caregivers at the time of PACE enrollment. Caregivers were asked if they had reduced the hours they worked or had stopped working to care for the patient. Nurses interviewed patients and caregivers to assess independence in activities of daily living (ADLs) and the presence of behavioral disturbances. Comorbid conditions were assessed by physicians during enrollment examinations. RESULTS: A total of 604 (22%) of the 2806 patients had at least one caregiver who either reduced the number of hours they worked or quit working to care for the patient. Patient characteristics independently associated with a caregiver reducing hours or quitting work were ethnicity, 95% confidence interval [CI] 1.14-1.78 for African American;, 95% CI 1.43-2.52 for Hispanic), ADL function below the median (, 95% CI 1.44-2.15), a diagnosis of dementia (, 95% -2.17 if associated with a behavioral disturbance;, 95% CI 1.06-1.63 if not associated with a behavioral disturbance), or a history of stroke (OR = 1.42, 95% CI 1.16-1.73). After controlling for these patient characteristics, caregiver characteristics associated with reducing work hours included being the daughter or daughter-in-law of the patient (OR = 1.69, 95% CI 1.37-2.08) and living with the patient (OR = 4.66, 95% CI 3.65-5.95 if no other caregiver lived at home, OR = 2.53, 95% CI 2.03-3.14 if another caregiver lived at home). CONCLUSIONS: Many caregivers reduce the number of hours they work to care for frail elderly relatives. The burden of reduced employment is more likely to be incurred by the families of ethnic minorities and of patients with specific clinical characteristics. Daughters and caregivers who live with the patient are more likely to reduce work hours than other caregivers. Future research should examine the impact of lost caregiver employment on patients' families and the ways in which the societal responsibility of caring for frail elders can be equitably shared.

Identifying patients at risk for hemodialysis underprescription.

Underprescription of hemodialysis is an important barrier to adequate delivery of dialysis. We sought to determine which patient factors are associated with hemodialysis underprescription and to examine variation in prescription across facilities. For 721 randomly selected patients from all 22 chronic hemodialysis units in northeast Ohio, we calculated prescribed Kt/V based on dialyzer urea clearance at prescribed blood and dialysate flow (K), prescribed treatment time (t), and anthropometric volume (V). A minimum 'prescribed Kt/V' of 1.3 has been recommended to ensure an adequate 'delivered Kt/V' of 1.2. Using this criterion, 15% of patients had a low prescribed Kt/V. Prescribed Kt was strongly related to patient anthropometric volume but not to other patient characteristics (age, gender, race, cause of renal failure, number of years on dialysis, number of comorbid conditions). A 10-liter increase in V was associated with an 8.3-liter increase in prescribed Kt. However, a 13-liter increase in prescribed Kt would be needed to maintain a prescribed Kt/V of 1.3. As a result, the proportion of patients with low prescriptions increased from 2% of patients with V <35 liters to 42% of patients with V > or =50 liters. In addition, the prevalence of low prescriptions varied dramatically across facilities (range 0-47%) even after accounting for volumes of individual patients. Of the 109 patients with low prescription, 75% would achieve a prescribed Kt/V of 1.3 with less than 30 min of additional treatment time. In conclusion, large patients and patients at specific facilities are at increased risk for underprescription of hemodialysis. Most patients with low prescriptions would achieve a prescribed Kt/V of 1.3 with a modest increase in treatment time.

Morbidity and cost implications of inadequate hemodialysis.

American hemodialysis patients have short lifespans, frequent hospitalizations, and aggregate Medicare inpatient expenditures of $4 billion/year. Dose of dialysis, as quantified by the parameter, Kt/V, corresponds strongly with survival and is estimated to be inadequate (Kt/V <1.2) in one fourth of patients. However, little is known about the morbidity and cost implications of inadequate dialysis. We sought to determine the independent relationship between dose of dialysis and (1) number of hospitalizations, (2) hospital days, and (3) Medicare inpatient reimbursements. We randomly selected 674 patients from all 22 hemodialysis units in northeast Ohio and examined hospitalizations, hospital days, and Medicare inpatient reimbursements for a 6-month interval following a 90-day quantification of dialysis dose. Every 0.1 decrease in Kt/V was independently associated with more hospitalizations (rate ratio, 1.11; 95% confidence interval [CI], 1.07 to 1.15), increased hospital days (rate ratio, 1.12; 95% CI, 1.03 to 1.22), and higher Medicare inpatient expenditures ($940; 95% CI, $450 to $1,440) after adjustment for patient age, sex, race, cause of renal failure, number of years on dialysis, and number of comorbid conditions. We estimate that increasing dialysis doses to a Kt/V of 1.2 for all patients nationally may decrease Medicare inpatient expenditures by $150 million annually. In conclusion, inadequate dialysis dose is independently associated with increased hospitalizations, hospital days, and Medicare inpatient expenditures. Improving dialysis adequacy may both improve patient morbidity and lessen health care costs.

A family-based strategy to identify genes for diabetic nephropathy.

Diabetic nephropathy (DN) clusters in families and specific ethnic groups, suggesting a genetic basis of disease transmission. Identification of DN susceptibility loci should reveal new therapeutic targets but requires accurate phenotyping. A powerful family-based strategy, which is novel to the pursuit of nephropathy genes in type 2 diabetes, is being used to collect a sample for candidate gene and genome scan analyses. Sib pairs that include DN index cases plus (1) sibs concordant for type 2 diabetes and DN (affected sib pairs [ASPs]) and (2) sibs concordant for type 2 diabetes but discordant for DN (discordant sib pairs [DSPs]) are targeted specifically for recruitment. Type 2 diabetes and DN phenotype criteria for index cases include diabetes onset after 38 years of age, duration 10 years or longer, no initial insulin treatment, diabetic retinopathy, end-stage renal disease (ESRD), and history of nephrotic proteinuria. ESRD patients were screened by questionnaire and medical record review (n = 2114). Of 666 patients with ESRD secondary to DN, 227 had a family history of ESRD, 150 had a living diabetic sib, and 124 families were enrolled. Sixty-five families, with 86 diabetic relative pairs (69 sibs, 17 children), have been completely phenotyped. If nephropathy in diabetic sibs is defined as albuminuria greater than 0.3 g/24 h, 31 ASPs and 26 DSPs (diabetic sib with albuminuria <0.3 g/24 h) were identified. Applying more stringent criteria, only 12 ASPs (sib with diabetes >10 years, diabetic retinopathy, and nephrotic proteinuria) and 9 DSPs (sib with diabetes >10 years and normal urine albumin excretion) were identified. Extrapolating from the number of subjects recruited using stringent phenotyping criteria, nearly 10,000 ESRD patients are required for screening to achieve adequate statistical power for linkage analysis (80% power to detect locus-specific relative risk of 2.2 at a lod score of 3.0). Careful phenotyping requires a large recruitment effort but is necessary to reduce population heterogeneity, a strategy that increases the likelihood of identifying DN loci.

Why hemodialysis patients fail to complete the transplantation process.

The cadaveric renal transplantation process involves steps related to medical suitability, interest in transplantation, pretransplantation workup, and movement up a waiting list. Failure to complete specific steps may be caused by remaining stationary at that step, moving backward to a previous step, or dying. Knowing the relative importance of these types of movement may enable the development of strategies that improve the efficiency and equity of the transplantation process. We examined 4,597 new dialysis patients to determine the likelihood of remaining stationary, moving backward, or dying at each of the following steps: (A) being medically suitable and possibly interested in transplantation, (B) being definitely interested, (C) completing the pretransplantation workup, and (D) moving up a waiting list and receiving a transplant. Failure to complete a step was generally caused by remaining stationary rather than moving backward or dying. The likelihood of remaining stationary ranged from 78% at step A to 90% at step D. The likelihood of backward movement ranged from 3% to 7%, whereas the likelihood of death ranged from 7% to 22%. Compared with whites, blacks were more likely to remain stationary at steps A (odds ratio [OR], 1.96) and B (OR, 1.52), more likely to move backward at step B (OR, 1.79), and less likely to die at steps A through C (ORs, 0.45 to 0.60). In conclusion, failure to move through the transplantation process is usually caused by remaining stationary at specific steps rather than moving backward or dying. The relative importance of these types of movement differs among blacks and whites.

Can a nutrition intervention improve albumin levels among hemodialysis patients? A pilot study.

OBJECTIVE: To determine the effect of a tailored intervention on albumin levels among hemodialysis patients. DESIGN: Randomized controlled trial. SETTING: Eight freestanding chronic hemodialysis units in northeast Ohio. SUBJECTS: Eighty-three randomly selected adult patients who had been on dialysis for at least 6 months and had a mean albumin <3.7 g/dL (bromcresol green method) or <3.4 g/dL (bromcresol purple method) for the last 3 months. To better elucidate the feasibility and outcomes of the intervention, we selected more intervention than control patients. INTERVENTION: Dietitians of the 52 intervention patients determined whether any of the following potential barriers to adequate protein nutrition were present for each patient: (1) poor knowledge of protein-containing foods, (2) poor appetite, (3) needing help shopping or cooking, (4) low fluid intake, and (5) inadequate dialysis. Depending on the specific barriers present, the dietitians (1) educated patients on protein-containing foods, (2) recommended snacks for which patients had preserved appetite, (3) helped set up social supports, (4) provided recommendations on fluid intake, and/or (5) arranged for improved dialysis. Dietitians of the 31 control patients continued to provide usual care. MAIN OUTCOME MEASURES: Change in albumin after 6 months, stratified as minimal change (less than.25 g/dL increase or decrease), moderate improvement (.25 to.49 g/dL increase), and large improvement (increase of .50 g/dL or more). To examine the role of inflammatory states, we also determined serum C-reactive protein levels at the beginning and end of the trial. RESULTS: Among intervention patients, 29% had a minimal change in albumin, 44% had a moderate improvement, and 27% had a large improvement. Among control patients, 74% had a minimal change in albumin, 19% had a moderate improvement, and 6% had a large improvement (P <.001 for comparison of intervention and control subjects). About 60% of subjects had high baseline C-reactive protein levels (> 10 mg/L). However, there was little relationship between change in albumin and either baseline C-reactive protein levels or changes in C-reactive protein levels (P = .83). CONCLUSION: A nutrition intervention tailored to patient-specific barriers resulted in improved albumin levels even among patients with high C-reactive protein levels. Further work is needed to refine and test this intervention on a larger sample.

Inaccuracy of clinical phenotyping parameters for hypertensive nephrosclerosis.

BACKGROUND: Multiple studies suggest that hypertension-induced end-stage renal disease (ESRD) is heritable. Identification of nephropathy susceptibility genes absolutely requires accurate phenotyping, but the clinical hypertensive nephrosclerosis (HN) phenotype is poorly characterized. We hypothesized that many patients with HN as the indicated cause of ESRD on the Health Care Financing Administration (HCFA) 2728 form, fail to satisfy stringent HN phenotyping criteria. METHODS: Since renal biopsy documentation of HN is uncommon, clinical parameters for HN phenotype were applied: family history of hypertension, left ventricular hypertrophy, proteinuria <0.5 g/day, and hypertension preceding renal dysfunction (Schlessinger et al., 1994) or urine protein:creatinine (prot:creat) ratio <2.0 and no evidence of other renal diseases (AASK Trial Group, 1997). RESULTS: ESRD patients (n=607, 73% African American, 25% Caucasian) were enrolled in a study to identify HN susceptibility genes. HN was the most common cause of ESRD according to HCFA 2728 forms (37% prevalence). Phenotyping of randomly selected patients with HN from the total cohort revealed that 4/100 subjects satisfied the Schlessinger criteria, and 28/91 African Americans met AASK criteria for HN. From these figures, the adjusted prevalence of HN was only 1.5-13.5%. Of patients that could not be phenotyped for HN, 14 were misdiagnosed, 14 had urine prot:creat >2.0, and insufficient data were available in the remainder. Four patients underwent renal biopsy, but histology from only one was consistent with HN. If the HN phenotype definitions are revised to exclude 'hypertension preceding renal dysfunction', or proteinuria limits, then 44/100 and 39/91 patients respectively satisfy clinical phenotyping parameters for HN. CONCLUSIONS: (i) We provide the strongest evidence to date that HN is less frequent in an ESRD population than commonly assumed if strict clinical criteria are used; many patients clinically diagnosed with HN may have undetected, treatable renal disease from other causes; (ii) relaxing HN phenotype criteria may erroneously include patients with glomerular diseases and secondary hypertension; (iii) reliance on HCFA 2728 diagnoses will confound identification of HN susceptibility genes; (iv) to attain adequate statistical power for genotype analysis, rigorous HN phenotyping will require screening an extremely large number of patients, which can be reasonably accomplished only in a multi-centre trial design.

How do physicians lobby their members of Congress?

BACKGROUND: Physicians are uniquely qualified to educate legislators about health care issues, but little is known about how physicians lobby members of Congress. METHODS: From the staff of 84 randomly selected members of Congress (49 senators and 35 representatives), we interviewed the legislative assistants who work on health care legislation and meet with constituents and lobbyists on behalf of their senator or representative. We asked about (1) the frequency of meetings between legislative assistants and physicians, (2) the issues discussed, and (3) the perceived effectiveness of lobbying. RESULTS: Senate and house legislative assistants met with an average of 10.0 and 4.0 physicians per month, respectively. This suggests that approximately 29,000 such meetings occur annually. The most common issues discussed were Medicare reimbursement (mentioned by 67 [81%] of 83 subjects), managed care reform (62 subjects [75%]), and funding for medical research (21 subjects [25%]). Other issues, such as access to care for the uninsured, tobacco control, abortion rights, and violence prevention, were rarely discussed. Most legislative assistants rated physicians as effective (37 [44%]) or somewhat effective (39 [46%]) as lobbyists. The most common suggestion for improving physician lobbying was to focus less on reimbursement and to address a broader range of health care issues. CONCLUSIONS: Physicians are frequent and effective lobbyists on reimbursement, managed care, and research issues. Policy makers appear receptive to increased physician input on a broader range of health care issues. Including these issues in lobbying efforts has the potential to shape health policy in a way that improves patient care and public health. Arch Intern Med. 2000;160:3248-3251.

Use of transplant status codes to monitor access to kidney transplantation.

The kidney transplantation process involves a series of steps related to interest in transplantation, medical suitability, pretransplant workup, and eventual transplantation. We developed transplant status codes to monitor the progress of dialysis patients in Ohio, Kentucky, Indiana, and Illinois as they move through these steps. Of the first 2,137 dialysis patients monitored with these new codes, 29% were interested in receiving a transplant, 31% were medically suitable to receive a kidney transplant, 15% had completed a pretransplant workup, 13% were on a cadaveric transplant waiting list, and 2% were awaiting a living-related transplant. Examination of these steps by gender showed differences in interest (men 32% v women 26%, P =.01) and medical suitability (men 33% v women 28%, P =.01). The proportion of patients successfully completing each step differed across facilities. In conclusion, transplant status codes are a useful method to monitor access to transplantation. As part of a facility-specific quality improvement program, such codes may be used to develop targeted interventions to help patients move through the transplant process as expeditiously as possible.

Patient-nephrologist discussions about kidney transplantation as a treatment option.

Little is known about how nephrologists discuss transplantation as a treatment option with end-stage renal disease patients. The authors sought to describe the content and manner of patient-nephrologist discussions about transplantation. Using a cross-sectional study design, we interviewed 79 chronic hemodialysis patients and 12 nephrologists using a semistructured questionnaire that focused on nephrologist and patient reports of discussions about transplantation. The authors found that nephrologists provided information on treatment options gradually over several weeks to months. They generally presented the option of dialysis first, then transplantation, but avoided discussing mortality data. Nephrologists said they encouraged most patients, but especially young patients, to seek transplantation. Of all patients, 68% reported being encouraged to seek transplantation by nephrologists. Low socioeconomic status patients were less likely to report being encouraged to seek transplantation even after adjustment for transplant suitability. Both nephrologists and patients avoided discussing life expectancy data. In conclusion, patient age and socioeconomic status appear to influence discussions of transplantation as a treatment option. Further work is needed to determine how the content and manner of such discussions affect treatment decisions.

Outcomes of renal replacement therapy among blacks and women.

The outcomes of renal replacement therapy differ dramatically by race and gender. Compared with white patients, black patients have poorer outcomes in five clinical parameters (anemia, hypertension, vascular access, adequacy of dialysis, compliance), employment, and access to transplantation. Compared with males, females have poorer outcomes in hospitalization, three clinical parameters (anemia, vascular access, nutrition), quality of life, and access to transplantation. Despite several poorer intermediate outcomes, blacks and women do better than whites and men in survival. Eliminating racial and gender differences in outcomes of renal replacement therapy requires that we (1) become aware of such differences, (2) determine barriers to optimal outcomes, and (3) develop interventions to overcome these barriers. This approach can lead to improved outcomes not just among blacks and women but among all renal patients. Examining racial and gender differences can also lead to an increased understanding of renal disease.

Interdialytic weight gain, compliance with dialysis regimen, and age are independent predictors of blood pressure in hemodialysis patients.

Hypertension is a common problem in patients undergoing chronic hemodialysis. The purpose of this study is to identify the clinical and demographic factors independently associated with blood pressure in this population. Data collected for the Dialysis Morbidity and Mortality Study Wave 1 by the US Renal Data System were analyzed. The mean predialysis blood pressure for this cohort of 5,369 patients was 149/79 mm Hg. Sixty-three percent of the patients were hypertensive; 27%, 25%, and 11% had stages 1, 2, and 3 hypertension, respectively. Young age, black race, male sex, diabetes as cause of end-stage renal disease, erythropoietin therapy, and smoking were associated with higher blood pressure in the univariate analysis. Patients skipping or shortening one or more dialysis treatments had higher blood pressure. The presence of congestive heart failure and coronary heart disease was associated with lower blood pressure. On multivariate analysis, high interdialytic weight gain, noncompliance with dialysis regimen, and younger age were independent predictors of higher blood pressure. In summary, hypertension is common and poorly controlled in patients undergoing chronic hemodialysis. Greater interdialytic weight gain and noncompliance with dialysis regimen are independently associated with higher blood pressure, and advancing age is associated with lower blood pressure levels in this population. Therapeutic regimens emphasizing reduction of interdialytic weight gain and improved compliance with the dialysis regimen need to be evaluated for improving the management of hypertension. The effect of age and other comorbid conditions, particularly cardiovascular disease, must be considered while studying the relationship between blood pressure and mortality in patients undergoing chronic hemodialysis.