Clinical and Sociodemographic Predictors of Mortality in End-Stage Renal Disease Inpatients in Rural Areas of the USA: Evidence From the Nationwide Inpatient Sample.

BACKGROUND: End-stage renal disease (ESRD) has been associated with an increase in all-cause mortality among patients. The accumulation of comorbidities appears to be a contributing factor. This study set out to identify the effect of comorbidity severity and other predictors of mortality among ESRD inpatients in rural America. METHODS: This is a cross-sectional study that used the 2016-2018 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). The study included patients aged 18 years or older with ESRD hospitalized in rural hospitals in America. Independent variables used in the survey include age, gender, race, type of admission (elective versus nonelective), type of hospital control, expected primary payer, and severity of comorbidities. The dependent variable was death during hospitalization. All analyses were weighted. Univariate (frequencies), bivariate (Chi-square), and logistic regression analyses were done using the SAS Studio (SAS Institute Inc., Cary, NC, USA). RESULTS: There were 144,575 weighted ESRD hospitalizations, and 5% of the hospitalized patients died. In the bivariate analysis, significant variables include age group, race, type of hospital admission, expected primary payer, type of hospital control, and severity of comorbidities, and all had a significant P-value of <0.0001. On multivariable logistic regression analysis, middle-aged and elderly patients had 40% (adjusted odds ratio (AOR): 1.40, 95% confidence interval (CI): 1.20-1.62) and 201% (AOR: 3.01, 95% CI: 2.61-3.48) more odds of mortality while hospitalized, respectively, compared to the young. Compared to whites, blacks had 19% (AOR: 0.81, 95% CI: 0.77-0.86) reduced odds of mortality, Hispanics had 47% (AOR: 0.53, 95% CI: 0.46-0.61) reduced odds of mortality, Native Americans had 27% (AOR: 0.73, 95% CI: 0.63-0.84) reduced odds of mortality, and Asian or Pacific Islanders had 30% (AOR: 0.70, 95% CI: 0.54-0.90) reduced odds of mortality. ESRD patients on nonelective hospitalizations had 16% (AOR: 0.84, 95% CI: 0.79-0.90) reduced odds of mortality while hospitalized versus those on elective hospitalization. ESRD patients with severe comorbidities had 40% (AOR: 1.40, 95% CI: 1.26-1.54) more odds of mortality compared to those with mild comorbidities, and those with moderate comorbidities had 22% (AOR: 1.22, 95% CI: 1.10-1.36) compared to those with mild comorbidities. Compared to patients on Medicare, ESRD hospitalizations on Medicaid had 19% (AOR: 1.19, 95% CI: 1.06-1.32) higher odds of mortality, hospitalizations on private insurance had 26% (AOR: 1.26, 96% CI: 1.15-1.37) higher odds of mortality, self-pay patients had 99% (AOR: 1.99, 95% CI: 1.61-2.45) higher odds of mortality, and no charge patients had over 1400% (AOR: 15.61, 95% CI: 7.09-34.35) higher odds of mortality. The area under the curve (AUC) for the model was 62%. CONCLUSION: The severity of comorbidities and expected primary payer are the modifiable predictors identified to predict ESRD inpatient mortality. From this study, the findings suggest that strategies aimed at preventing the severity of comorbidities and ensuring universal health coverage might help reduce ESRD inpatient mortality in rural America.

In Every Man, There Is a Child: Henoch-Schönlein Purpura in an Adult With Liver Cirrhosis.

Henoch-Schönlein purpura (HSP), also known as immunoglobulin A (IgA) vasculitis, is a small-vessel vasculitis characterized by IgA deposits in various organs in the body producing a unique constellation of symptoms. This disease predominantly affects the skin (palpable purpura), joints (arthritis/arthralgia), gut (abdominal pain), and kidneys (nephritic syndrome-IgA nephropathy [IgAN]). The pathogenesis of HSP in children is usually secondary to an immune reaction after viral infections. In adults, few cases of HSP/IgA vasculitis have been reported secondary to altered metabolism of IgA in patients with alcoholic liver cirrhosis. Here, we report an unusual case of HSP/IgA vasculitis. The patient presented with signs of alcoholic liver cirrhosis with abdominal pain and ascites along with a lower extremity purpuric rash. The patient had significant findings of liver cirrhosis with radiographic evidence of cirrhotic liver with esophageal varices and splenorenal shunt and elevated serum ascites albumin gradient. Urinalysis revealed proteinuria with microscopic hematuria, further evaluated with a kidney biopsy. Microscopic analysis revealed focal segmental endocapillary and extracapillary proliferative glomerulonephritis with focal necrotizing features, consistent with IgAN/HSP nephritis. Treatment was initiated with high-dose steroids and cyclophosphamide infusions. Alcohol-induced endotoxin release and inflammation lead to high amounts of circulating IgA due to increased intestinal permeability and reduced hepatic clearance. Further disease development is caused by IgA deposits in affected organs (skin and kidney in our case). We hypothesize that the development of disease for the patient was secondary to altered IgA processing in decompensated alcoholic cirrhosis.

Acute Transient Stress Induced Adrenal Hypertrophy and Adrenal Medullary Hyperactivity.

OBJECTIVES: Adrenal gland hypertrophy can be related to acute stress with abnormal adrenal function tests. It may not always need treatment. MATERIAL AND METHODS: An acute presentation of adrenal gland hypertrophy following an abdominal emergency, with subsequent hypoadrenalism was investigated. RESULTS: Adrenal medullary and cortical function fully recovered without treatment. CONCLUSIONS: We postulate that the adrenal glands became enlarged and hypertrophied during an acute stress event, possibly caused by acute adrenal medullary hypersecretion and subsequent cortical hyposecretion. A wait and watch policy should be followed if no other clinical symptoms and signs of adrenal disease are present. CT scan remains an important diagnostic tool. LEARNING POINTS: Abnormal adrenocortical function tests and hypertrophy can occur in an acutely ill patient as a stress response.It is possible to have both hypersecretion and hyposecretion of adrenal hormones.A wait and watch policy should be followed if no other clinical symptoms and signs of adrenal disease are present in an acutely ill patient.

Hypoglyceamia in a Patient with a Solitary Fibrous Tumour.

OBJECTIVE: To illustrate an unusual mechanism causing hypoglycaemia. MATERIAL AND METHODS: A 76-year-old man presented with episodes of agitation and confusion and was resuscitated with oral glucose gel when found to be hypoglycaemic. RESULTS: A CT scan for an abdominal mass confirmed a solitary fibrous tumour (SFT). The sarcoma multidisciplinary team suggested conservative management. The patient's episodic hypoglycaemia was managed with diet modification including corn-based starch, scheduled snacks and dexamethasone. Glucose levels were within normal range at discharge from hospital. The patient was referred to the palliative care team for follow-up. CONCLUSION: SFTs causing non-islet cell tumour hypoglycaemia are difficult to treat. LEARNING POINTS: To be aware of rarer causes of hypoglycaemia and to consider unusual causes in acute presentations of hypoglycaemia, especially in patients who do not have diabetes.This case illustrates the importance of a thorough general physical and systemic examination, as identifying the abdominal mass is essential to the early diagnosis of this rare condition.Solitary fibrous tumours causing non-islet cell tumour hypoglycaemia are difficult to treat, and even when surgical resections are applicable, recurrence rates are high.

Hepatitis B and C virus co-infection in Nigerian patients with HIV infection.

INTRODUCTION: We set out to determine the seroprevalence of hepatitis B and hepatitis C viruses among human immunodeficiency virus infected individuals and its impact on pattern of presentation. METHODOLOGY: A serological study for hepatitis B and hepatitis C viruses was performed on 260 HIV-positive individuals. These patients were tested for the presence of hepatitis B surface antigen and anti-hepatitis C virus (HCV) antibody. RESULTS: Thirty (11.5%) patients tested positive for hepatitis B surface antigen, six (2.3%) tested positive for anti-hepatitis C virus antibody, four (1.5%) were positive for both hepatitis B surface antigen and anti-hepatitis C virus and the overall prevalence was 15.4% . Individuals younger than 40 years of age were more affected, and the odds ratio of a female being co-infected was 1.2, 25% versus 75% p value = 0.03. The prevalence of HIV and hepatitis co-infection rises with age except for hepatitis C. There was no significant difference in the mean levels of liver enzymes (AST, ALT) among the various groups. The groups differ significantly in their mean CD4 count: it was lowest for those co-infected with hepatitis B and hepatitis C; 106 cells/mm(3), 171 cells/mm(3) for those with HIV alone; and the highest value of 260 cells/mm(3) was obtained in those who tested positive for anti-HCV. Scarification marks and multiple blood transfusions were more common among those infected. There was no case of intravenous drug abuse identified. CONCLUSION: This low frequency of HIV/HCV co-infection is probably due to the uncommon intravenous drug abuse in this population. Co-infection with hepatitis B virus is common among our HIV-infected patients and should be a major consideration in the initiation and choice of therapy.