RESUMO
BACKGROUND: Acute kidney injury (AKI) has been extensively studied in hospital settings. Limited data exist regarding outcomes for patients with outpatient AKI who are not subsequently admitted. We investigated whether outpatient AKI, defined by a 50% increase in creatinine (Cr), is associated with increased mortality and renal events. METHODS: In this retrospective study, outpatient serum Cr values from adults receiving primary care at a health system during an 18-month exposure period were used to categorize patients into one of five groups (no outpatient AKI, outpatient AKI with recovery, outpatient AKI without recovery, outpatient AKI without repeat Cr and no Cr). Principal outcomes of all-cause mortality and renal events (50% decline in estimated glomerular filtration rate to <30 mL/min/1.73 m2) were examined using Cox proportional hazards models. RESULTS: Among 384 869 eligible patients, 51% had at least one Cr measured during the exposure period. Outpatient AKI occurred in 1.4% of patients while hospital AKI occurred in only 0.3% of patients. The average follow-up was 5.3 years. Outpatient AKI was associated with an increased risk of all-cause mortality {adjusted hazard ratio [aHR] 1.90 [95% confidence interval (CI) 1.76-2.06]} and results were consistent across all AKI groups. Outpatient AKI was also associated with an increased risk of renal events [aHR 1.33 (95% CI 1.11-1.59)], even among those who recovered. CONCLUSIONS: Outpatient AKI is more prevalent than inpatient AKI and is a risk factor for all-cause mortality and renal events, even among those who recover kidney function. Further research is necessary to determine risk factors and identify strategies for preventing outpatient AKI.
Assuntos
Injúria Renal Aguda/complicações , Hospitalização/estatística & dados numéricos , Pacientes Ambulatoriais/estatística & dados numéricos , Insuficiência Renal Crônica/etiologia , Insuficiência Renal Crônica/mortalidade , Adulto , Creatinina/sangue , Feminino , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de SobrevidaRESUMO
PURPOSE OF REVIEW: To review the current understanding of hemodialysis-mediated clearance of commonly used cardiovascular medications. RECENT FINDINGS: Although cardiovascular drug dialyzability is poorly understood, many drug classes appear to include agents with substantially different degrees of dialyzability. Recent data suggest that more readily dialyzable beta-blockers associate with higher short-term mortality in patients initiating these drugs when on hemodialysis. Although this relationship was not observed in a later study with angiotensin-converting enzyme inhibitors of varying dialyzability, studies of this kind are currently limited by pharmacokinetic data that are either incomplete or no longer applicable to modern hemodialysis procedures. SUMMARY: There are substantial deficits in our understanding of cardiovascular medication dialyzability, which relates in large part to advances in the process of hemodialysis that have rendered older studies of dialyzability irrelevant. The importance of cardiovascular disease in patients receiving hemodialysis demands a better understanding of the effect hemodialysis exerts on cardiovascular drug pharmacokinetics.
Assuntos
Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Fármacos Cardiovasculares/uso terapêutico , Doenças Cardiovasculares/terapia , Falência Renal Crônica/terapia , Diálise Renal , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/mortalidade , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/mortalidade , Diálise Renal/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Bacterial endocarditis in dialysis patients is associated with high mortality rates. The literature is limited on the long-term outcomes of valvular replacement surgery and the choice of prosthesis in dialysis patients with bacterial endocarditis. METHODS AND RESULTS: Dialysis patients hospitalized for bacterial endocarditis from 2004 to 2007 were studied retrospectively using data from the United States Renal Data System. Long-term survival of patients undergoing valve replacement surgery with tissue or nontissue valves was compared by use of the Kaplan-Meier method. A Cox proportional hazards model was used to identify independent predictors of mortality in patients undergoing valvular replacement surgery. During the study period, 11 156 dialysis patients were hospitalized for bacterial endocarditis and 1267 (11.4%) underwent valvular replacement surgery (tissue valve, 44.3%; nontissue valve, 55.7%). In the valve replacement cohort, 60% were men, 50% were white, 54% were 45 to 64 years of age, and 36% were diabetic. Estimated survival with tissue and nontissue valves at 0.5, 1, 2, and 3 years was 59% and 60%, 48% and 50%, 35% and 37%, and 25% and 30%, respectively (log-rank P=0.42). Staphylococcus was the predominant organism (66% of identified organisms). Independent predictors of mortality in patients undergoing valve replacement surgery included older age, diabetes mellitus as the cause of end-stage renal disease, surgery during index hospitalization, staphylococcus as the causative organism, and dysrhythmias as a comorbid condition. CONCLUSIONS: Valve replacement surgery is appropriate for well-selected dialysis patients with bacterial endocarditis but is associated with high mortality rates. Survival does not differ with tissue or nontissue prosthesis.
Assuntos
Endocardite Bacteriana/mortalidade , Doenças das Valvas Cardíacas/mortalidade , Implante de Prótese de Valva Cardíaca/mortalidade , Falência Renal Crônica/mortalidade , Diálise Renal/mortalidade , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Feminino , Doenças das Valvas Cardíacas/cirurgia , Humanos , Lactente , Recém-Nascido , Estimativa de Kaplan-Meier , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estados Unidos/epidemiologia , Adulto JovemRESUMO
Previous studies have shown that the uninsured receive a lower level of care and that their uninsured status is a risk factor for poorly controlled diabetes mellitus (DM). The Access To Care (ATC) program in Cook County, Illinois provides care to uninsured individuals who do not qualify for other public aid. The aim of our study was to evaluate DM management at Loyola University Health System's ATC clinic. We compared ATC patients and insured patients at Loyola using processes of care and outcome measures outlined by the National Diabetes Quality Improvement Alliance. We found that the ATC group was equivalent in all processes of care. There were no differences in hemoglobin A1C or blood pressure while ATC patients had lower cholesterol. To our knowledge, this is the first study describing a clinic for the uninsured with a level of DM care and outcomes equivalent to those of insured individuals.