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Evidence-informed decision making in clinical care and policy in nephrology is undermined by trials that selectively report a large number of heterogeneous outcomes, many of which are not patient centered. The Standardized Outcomes in Nephrology−Hemodialysis (SONG-HD) Initiative convened an international consensus workshop on November 7, 2015, to discuss the identification and implementation of a potential core outcome set for all trials in hemodialysis. The purpose of this article is to report qualitative analyses of the workshop discussions, describing the key aspects to consider when establishing core outcomes in trials involving patients on hemodialysis therapy. Key stakeholders including 8 patients/caregivers and 47 health professionals (nephrologists, policymakers, industry, and researchers) attended the workshop. Attendees suggested that identifying core outcomes required equitable stakeholder engagement to ensure relevance across patient populations, flexibility to consider evolving priorities over time, deconstruction of language and meaning for conceptual consistency and clarity, understanding of potential overlap and associations between outcomes, and an assessment of applicability to the range of interventions in hemodialysis. For implementation, they proposed that core outcomes must have simple, inexpensive, and validated outcome measures that could be used in clinical care (quality indicators) and trials (including pragmatic trials) and endorsement by regulatory agencies. Integrating these recommendations may foster acceptance and optimize the uptake and translation of core outcomes in hemodialysis, leading to more informative research, for better treatment and improved patient outcomes.

We present PerformanceVis, a visual analytics tool for analyzing student admission and course performance data and investigating homework and exam question design. Targeting a university-wide introductory chemistry course with nearly 1000 student enrollment, we consider the requirements and needs of students, instructors, and administrators in the design of PerformanceVis. We study the correlation between question items from assignments and exams, employ machine learning techniques for student grade prediction, and develop an interface for interactive exploration of student course performance data. PerformanceVis includes four main views (overall exam grade pathway, detailed exam grade pathway, detailed exam item analysis, and overall exam & homework analysis) which are dynamically linked together for user interaction and exploration. We demonstrate the effectiveness of PerformanceVis through case studies along with an ad-hoc expert evaluation. Finally, we conclude this work by pointing out future work in this direction of learning analytics research.

Seizures have been associated with uremia, but there are few data regarding the prevalence, treatment, and outcomes of patients with end-stage renal disease (ESRD) with epilepsy compared to those with ESRD without epilepsy. Here we conducted a retrospective cohort study using the United States Renal Data System to assess mortality and antiseizure medication prescriptions among patients with ESRD with and without a diagnosis of epilepsy. A modified Poisson regression with a robust variance was used to estimate the association between epilepsy status and mortality, and evaluate effect modification by neurology consultation. Additionally antiseizure medications were assessed in relation to mortality among those with epilepsy. Of 148,294 patients with ESRD in the cohort, 13,094 (8.8%) met a claims-based definition for epilepsy. Among those with epilepsy, 80.9% filled an anticonvulsant or hydantoin prescription in 2013-2014, compared to 33.3% without epilepsy. After adjustment for confounders, the mortality risk among those with epilepsy was 1.11 (95% confidence interval: 1.07, 1.14) times higher than those without. An epilepsy diagnosis was associated with a 15% increase in mortality risk among patients who did not have a neurology consultation (relative risk: 1.15 [95% confidence interval: 1.10, 1.20]), but this risk was attenuated among patients with a neurology consultation (1.07 [1.03, 1.11]). Prescription of gabapentin to patients with an epilepsy diagnosis compared to other antiseizure medications was associated with increased mortality (1.08 [1.01, 1.15]). Thus, patients with ESRD treated with dialysis have a high prevalence of epilepsy, which was associated with increased mortality risk compared to those without epilepsy. Hence, appropriate multidisciplinary care, treatment, and medication selection may reduce mortality among dialysis patients with epilepsy.

IMPORTANCE: Cardiovascular disease (CVD) is a leading cause of death among patients with end-stage renal disease (ESRD). Young adult (ages 22-29 years) have risks for ESRD-associated CVD that may vary from other ages. OBJECTIVE: To test the hypothesis that young adult–onset ESRD is associated with higher cardiovascular (CV) hospitalizations and mortality with different characteristics than childhood-onset disease. DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study used the US Renal Data System to categorize patients who initiated ESRD care between 2003 and 2013 by age at ESRD onset (1-11, 12-21, and 22-29 years). Cardiovascular hospitalizations were identified via International Classification of Diseases, Ninth Revision discharge codes and CV mortality from the Centers for Medicare & Medicaid ESRD Death Notification Form. Patients were censored at death from non-CVD events, loss to follow-up, recovery, or survival to December 31, 2014. Adjusted proportional hazard models (95% CI) were fit to determine risk of CV hospitalization and mortality by age group. Data analysis occurred from May 2016 and December 2017. EXPOSURES: Onset of ESRD. MAIN OUTCOMES AND MEASURES: Cardiovascular mortality and hospitalization. RESULTS: A total of 33 156 patients aged 1 to 29 years were included in the study population. Young adults (aged 22-29 years) had a 1-year CV hospitalization rate of 138 (95% CI, 121-159) per 1000 patient-years. Young adults had a higher risk for CV hospitalization than children (aged 1-11 years; hazard ratio [HR], 0.41 [95% CI, 0.26-0.64]) and adolescents (aged 12-21 years; HR, 0.86 [95% CI, 0.77-0.97]). Of 4038 deaths in young adults, 1577 (39.1%) were owing to CVD. Five-year cumulative incidence of mortality in this group (7.3%) was higher than in younger patients (adolescents, 4.0%; children, 1.7%). Adjusted HRs for CV mortality were higher for young adults with all causes of ESRD than children (cystic, hereditary, and congenital conditions: HR, 0.22 [95% CI, 0.11-0.46]; P < .001; glomerulonephritis: HR, 0.21 [95% CI, 0.10-0.44]; P < .001; other conditions: HR, 0.33 [95% CI, 0.23-0.49]; P < .001). Adolescents had a lower risk for CV mortality than young adults for all causes of ESRD except glomerulonephritis (cystic, hereditary, and congenital conditions: HR, 0.45 [95% CI, 0.27-0.74]; glomerulonephritis: HR, 0.99 [95% CI, 0.76-1.11]; other: HR, 0.47 [95% CI, 0.40-0.57]). Higher risks for CV hospitalization and mortality were associated with lack of preemptive transplant compared with hemodialysis (hospital: HR, 14.24 [95% CI, 5.92-34.28]; mortality: HR, 13.64 [95% CI, 8.79-21.14]) and peritoneal dialysis [hospital: HR, 8.47 [95% CI, 3.50-20.53]; mortality: HR, 7.86 [95% CI, 4.96-12.45]). Nephrology care before ESRD was associated with lower risk for CV mortality (HR, 0.77 [95% CI, 0.70-0.85]). CONCLUSIONS AND RELEVANCE: Cardiovascular disease accounted for nearly 40% of deaths in young adults with incident ESRD in this cohort. Identified risk factors may inform development of age-appropriate ESRD strategies to improve the CV health of this population.

Diabetic patients with declining kidney function are at heightened risk for hypoglycemia. We sought to determine whether hypoglycemia-related hospitalizations in the interval before dialysis therapy initiation are associated with post–end-stage renal disease (ESRD) mortality among incident patients with ESRD with diabetes.

To develop and validate a risk prediction model that would help individualize treatment and improve the shared decision-making process between clinicians and patients.

Chronic, and especially chronic high dose opioid use, is associated with increased risk of death and graft loss in kidney transplant recipients compared to no or short-term use. Supplemental digital content is available in the text.

Vascular access outcomes in hemodialysis are critically important for patients and clinicians, but frequently are neither patient relevant nor measured consistently in randomized trials. A Standardized Outcomes in Nephrology–Hemodialysis (SONG-HD) consensus workshop was convened to discuss the development of a core outcome measure for vascular access. 13 patients/caregivers and 46 professionals (clinicians, policy makers, industry representatives, and researchers) attended. Participants advocated for vascular access function to be a core outcome based on the broad applicability of function regardless of access type, involvement of a multidisciplinary team in achieving a functioning access, and the impact of access function on quality of life, survival, and other access-related outcomes. A core outcome measure for vascular access required demonstrable feasibility for implementation across different clinical and trial settings. Participants advocated for a practical and flexible outcome measure with a simple actionable definition. Integrating patients’ values and preferences was warranted to enhance the relevance of the measure. Proposed outcome measures for function included “uninterrupted use of the access without the need for interventions” and “ability to receive prescribed dialysis,” but not “access blood flow,” which was deemed too expensive and unreliable. These recommendations will inform the definition and implementation of a core outcome measure for vascular access function in hemodialysis trials.

Higher mortality in Blacks than Whites has been consistently reported in the US, but previous investigations have not accounted for poverty at the individual level. The health of its population is an important part of the capital of a nation. We examined the association between individual level poverty and disability and racial mortality differences in a 5% Medicare beneficiary random sample from 2004 to 2010. Cox regression models examined associations of race with all-cause mortality, adjusted for demographics, comorbidities, disability, neighborhood income, and Medicare “Buy-in” status (a proxy for individual level poverty) in 1,190,510 Black and White beneficiaries between 65 and 99 years old as of January 1, 2014, who had full and primary Medicare Part A and B coverage in 2004, and lived in one of the 50 states or Washington, DC.

ABSTRACTBackground From 2010 to 2011, more than 70 of the clinical rotation competency evaluations for nephrology fellows in our program were rated “superior” using a 9-point Likert scale, suggesting some degree of “grade inflation.”Objective We sought to assess the efficacy of a 5-point centered rotation evaluation in reducing grade inflation.Methods This retrospective cohort study of the impact of faculty education and a 5-point rotation evaluation on grade inflation was measured by superior item rating frequency and proportion of evaluations without superior ratings. The 5-point evaluation centered performance at the level expected for stage of training. Faculty education began in 2011–2012. The 5-point centered evaluation was introduced in 2012–2013 and used exclusively thereafter. A total of 68 evaluations, using the 9-point Likert scale, and 63 evaluations, using the 5-point centered scale, were performed after first-year fellow clinical rotations. Nine to 12 faculty members participated yearly.Results Faculty education alone was associated with fewer superior ratings from 2010–2011 to 2011–2012 (70.5 versus 48.3, P  .001), declining further with 5-point centered scale introduction (2012–2013; 48.3 versus 35.6; P  .012). Superior ratings declined with 5-point centered versus 9-point Likert scales (37.3 versus 59.3, P  .001), specifically for medical knowledge, patient care, practice-based learning and improvement, and professionalism. On logistic regression, evaluations without superior scores were more likely for 5-point centered versus 9-point Likert scales (adjusted odds ratio aOR  8.26; 95 CI 1.53–44.64; P  .014) and associated with faculty identifier (aOR 1.18; 95 CI 1.03–1.35; P  .013), but not fellow identifier or training year quarter.Conclusions Grade inflation was reduced with faculty education and the 5-point centered evaluation scale.

A recent study showed an increased risk of death in African Americans compared with whites with end-stage renal disease (ESRD) due to lupus nephritis (LN). We assessed the impact of age stratification, socioeconomic factors, and kidney transplantation on the disparity in patient survival among African American versus non–African American patients with LN-caused ESRD, compared with other causes.

Beginning in the 2014-2015 training year, the US Accreditation Council for Graduate Medical Education (ACGME) required that nephrology Clinical Competency Committees assess fellows’ progress toward 23 subcompetency “context nonspecific” internal medicine subspecialty milestones. Fellows’ advancement toward the “ready for unsupervised practice” target milestone now is tracked in each of the 6 competencies: Patient Care, Medical Knowledge, Professionalism, Interpersonal Communication Skills, Practice-Based Learning and Improvement, and Systems-Based Practice. Nephrology program directors and subspecialty societies must define nephrology-specific “curricular milestones,” mapped to the nonspecific ACGME milestones. Although the ACGME goal is to produce data that can discriminate between successful and underperforming training programs, the approach is at risk to produce biased, inaccurate, and unhelpful information. We map the ACGME internal medicine subspecialty milestones to our previously published nephrology-specific milestone schema and describe entrustable professional activities and other objective assessment tools that inform milestone decisions. Mapping our schema onto the ACGME subspecialty milestone reporting form allows comparison with the ACGME subspecialty milestones and the curricular milestones developed by the American Society of Nephrology Program Directors. Clinical Competency Committees may easily adapt and directly translate milestone decisions reached using our schema onto the ACGME internal medicine subspecialty competency milestone-reporting format.

Entrustable professional activities (EPAs) are complex tasks representing vital physician functions in multiple competencies, used to demonstrate trainee development along milestones. Managing a nephrology outpatient clinic has been proposed as an EPA for nephrology fellowship training.

Objectively structured clinical examinations (OSCEs) are widely used in medical education, but we know of none described that are specifically for nephrology fellowship training. OSCEs use simulation to educate and evaluate. We describe a technically simple, multidisciplinary, low-cost OSCE developed by our program that contains both examination and training features and focuses on management and clinical knowledge of rare hemodialysis emergencies. The emergencies tested are venous air embolism, blood leak, dialysis membrane reaction, and hemolysis. Fifteen fellows have participated in the OSCE as examinees and/or preceptors since June 2010. All have passed the exercise. Thirteen responded to an anonymous survey in July 2013 that inquired about their confidence in managing each of the 4 tested emergencies pre- and post-OSCE. Fellows were significantly more confident in their ability to respond to the emergencies after the OSCE. Those who subsequently saw such an emergency reported that the OSCE experience was somewhat or very helpful in managing the event. The OSCE tested and trained fellows in the recognition and management of rare hemodialysis emergencies. OSCEs and simulation generally deserve greater use in nephrology subspecialty training; however, collaboration between training programs would be necessary to validate such exercises.

To describe the development of the Combat Casualty Critical Care Database, a comprehensive database of critically injured combat casualties to identify potentially modifiable risk factors for morbidity and mortality in this population.

An analysis of income and racialethnic disparities on renal transplant outcomes in recipients with lupus nephritis (LN) has not been reported. We analyzed the United States Renal Data System database to assess the impact of these disparities on graft loss and death in the LN and non-LN cohorts.

Purpose Incident arteriovenous fistula (AVF) rates remain low. AVF placement is often not attempted because of small cephalic vein (CV) diameter. We postulated that isometric handgrip exercises would increase forearm CV diameter and allow successful AVF creation in non-AVF candidates.Methods Adult subjects without prior vascular access (eGFR<25mL/min/1.73m2; CV<2.5mm) were prospectively enrolled. They performed daily handgrip exercises in the preferred access arm (EA), with the nonexercised arm (NEA) as control. Adherence was assessed by exercise logs and grip strength. CV diameter was measured at baseline, four and eight weeks by ultrasound. The primary endpoint was the mean increase in CV diameter. Secondary endpoints were mean CV diameter increase from baseline, increased proportion of potential AVF sites and successful AVF placement.Results A total of 17 subjects were enrolled and 15 completed the study. EA grip strength increased significantly. Mean CV diameter increased in both the EA and NEA by 0.48-0.59 and 0.71-0.81 mm (P=NS), respectively. Compared to baseline, all CV diameters increased significantly (P<.05) after four weeks. In the EA, mean distal and proximal CV increased from 1.66 to 2.13 mm and from 2.22 to 2.81 mm, respectively. Similar changes were noted in the NEA. There were also significant increases in the number of sites and subjects eligible for AVF creation. Five subjects had successful AVF placement.Conclusions Isometric handgrip exercises resulted in significant CV diameter increases after four weeks, in both the EA and the NEA and potentially allows for AVF creation in those not previously deemed candidates.

Colonic necrosis has been reported after sodium polystyrene sulfonate (SPS)/sorbitol use, but the incidence and relative risk (RR) are not established.

Mortality records identify cancer as the leading cause of death among living kidney donors, but information on the burden of cancer outside death records is limited in this population.

We investigated the effect of smoking on postkidney transplant outcomes in the United States Renal Data System.

Posttransplant neutropenia (PTN) is relatively common after kidney transplantation, and may result in a reduction of immunosuppression, which may precipitate acute rejection. Granulocyte colony-stimulating factors (GCSF) have been used to treat PTN, although outcomes associated with use of this medication in this population are unknown.

We previously reported that posttransplant lymphoproliferative disorders (PTLD) occurred more frequently in non-African American (AF) kidney transplant recipients. An in-depth analysis of racial differences in the development of PTLD has not been reported.

Little is known about associations of family health history with outcomes after kidney donation.

Limited data are available on the use of potentially cardioprotective medications among U.S. kidney transplant recipients.

We examined the United States Renal Data System registry to analyze trends in renal transplantation in patients with human immunodeficiency virus (HIV) infection.

We carried out an analysis of the United States Renal Data System to determine the incidence, risk factors, prognosis, and costs associated with the diagnosis of renal cell carcinoma (RCC) after kidney transplantation.

Strategy of transplanting kidneys from A2 donors into patients with blood group B and O recipients has been used to alleviate the long waiting times.

Acute phosphate nephropathy (APN) has been identified in renal biopsy specimens of patients exposed to oral sodium phosphate (OSP) bowel purgatives. Biopsy confirmed cases presented with bland urinary sediment, low-grade proteinuria, and varying degrees of creatinine elevation. Prospective identification of APN is difficult in that definitive diagnosis requires renal biopsy, and biopsy is rarely performed for patients with this clinical presentation.

To investigate the effect of modern immunosuppression on the incidence, risk factors, morbidity, and mortality of Pneumocystispneumonia (PCP) in recipients of kidney transplants.

Retrospective comparison of treatment-related kidney transplant outcomes may be facilitated by multivariable statistical adjustments and case-matching.

Published data for BK virus allograft nephropathy, a recently emerged graft-threatening complication of kidney transplantation, are from limited-center series. Since June 30, 2004, the Organ Procurement Transplant Network national registry in the United States started collecting data on treatment of BK virus (TBKV) on the kidney follow-up forms. This study determined the rates of TBKV within 24 months posttransplant time and elucidated the risk factors for TBKV from this multicenter database.

Limited data exist on the safety and efficacy of bariatric surgery (BS) in patients with kidney failure.

Experience with delivery of renal replacement therapy (RRT) in support of combat operations by the U.S. military has not been reported since the 1970s. We describe the tri-service military medical experience with RRT in support of Operation Iraqi Freedom. Through December 31, 2006, RRT was provided to 12 individuals inside the theater of operations. Navy medical personnel provided RRT to three patients (two U.S. active duty service members and one host nation individual) aboard the USNS Comfort, a mobile level 4 hospital. Dialysis was performed using conventional single-pass hemodialysis machines equipped with portable reverse osmosis systems. Army and Air Force medical personnel provided RRT to nine patients in theater (eight host nation patients and one U.S. active duty service member), using peritoneal dialysis and continuous renal replacement therapy (CRRT), not requiring trained renal nurses or technicians. Originally, U.S. military personnel with acute kidney injury (AKI) who were evacuated from theater to Landstuhl Regional Medical Center (LRMC), or those who developed AKI at LRMC were transferred to the German civilian medical system, if RRT was required. After creation of a rapid-response dialysis team and, later, positioning of a full-time active duty reserve nephrologist at LRMC, 16 patients received RRT at LRMC. None had required RRT in theater. Renal failure requiring RRT during combat operations remains an unusual but serious event, calling for flexibility in the provision of care. Notably, the Operation Iraqi Freedom experience has highlighted the needs of injured host nation patients with AKI and future military medical planning will need to account for their intratheater renal care.

Mycophenolate mofetil (MMF) use may be associated with progressive multifocal leukoencephalopathy (PML). We conducted a retrospective cohort study of 32,757 renal transplant recipients using the United States Renal Data System kidney transplant files for the incidence, prognosis, and clinical features associated with PML occurring after kidney transplant. Subjects were transplanted from January 1, 2000 to July 31, 2004 and followed through December 31, 2004. The incidence density of PML in MMF users was 14.4 cases/100,000 person-years at risk versus 0 for non-MMF users (P0.11) by log rank test. Factors significantly associated with PML were BK virus infection (22.2% vs. 1.1%), pretransplant transfusion (75% vs. 34%), panel reactive antibody more than 20% (56% vs. 14%), and use of antirejection medications in the first year (33% vs. 9.2%), all Pless than 0.05. PML is rare in the renal transplant population. There was no significant association between PML and MMF, but MMF use in this cohort is too high to accurately assess an association.

The cardiac implications of obesity in kidney transplant recipients are not well-described.

Background. End-stage renal disease is known to disrupt the cell-mediated immune response that is responsible for the killing of intracellular organisms such as Mycobacterium tuberculosis. Risk factors that contribute to the development of tuberculosis (TB) disease in the US dialysis population have not been studied on a large scale.Methods. A retrospective cohort study of TB disease in 272 024 patients in the US Renal Data System initiated on dialysis therapy between 1 April 1995 and 31 December 1999 with Medicare or Medicaid as primary payer were analysed. A total of 21 risk factors were analysed.Results. Among the US population studied, there is a 1.2 and 1.6% cumulative incidence of TB in patients undergoing either peritoneal or haemodialysis, respectively. Ten risk factors for TB that proved to be statistically significant included advanced age (P < 0.001), unemployment (P < 0.001), Medicaid insurance (P < 0.001), reduced body mass index (P < 0.001), decreased serum albumin (P < 0.001), haemodialysis (P = 0.019), both Asian (P = 0.010) and Native American (P = 0.020) race, ischaemic heart disease (P = 0.032), smoking (P = 0.010), illicit drug use (P = 0.018) and anaemia (P = 0.028). TB was independently associated with increased mortality, adjusted hazard ratio (AHR) 1.42 (95% CI 1.18–1.70, P < 0.001).Conclusions. The prevalence of TB disease in the US dialysis population is low compared with worldwide rates; however, the disease is associated with increased mortality. Of the 10 significant risk factors identified, five are potentially modifiable.