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Disordered iron and mineral homeostasis are interrelated complications of chronic kidney disease that may influence cardiovascular and kidney outcomes. In a prospective analysis of 3747 participants in the Chronic Renal Insufficiency Cohort Study, we investigated risks of mortality, heart failure, end-stage kidney disease (ESKD), and atherosclerotic cardiovascular disease according to iron status, and tested for mediation by C-terminal fibroblast growth factor 23 (FGF23), hemoglobin and parathyroid hormone. Study participants were agnostically categorized based on quartiles of transferrin saturation and ferritin as: “Iron Replete” (27.1% of participants; referent group for all outcomes analyses), “Iron Deficiency” (11.1%), “Functional Iron Deficiency” (7.6%), “Mixed Iron Deficiency” (iron indices between the Iron Deficiency and Functional Iron Deficiency groups; 6.3%), “High Iron” (9.2%), or “Non-Classified” (the remaining 38.8% of participants). In multivariable-adjusted Cox models, Iron Deficiency independently associated with mortality (hazard ratio 1.28, 95% confidence interval 1.04–1.58) and heart failure (1.34, 1.05–1.72). Mixed Iron Deficiency associated with mortality (1.61, 1.27–2.04) and ESKD (1.33, 1.02–1.73). High Iron associated with mortality (1.54, 1.24–1.91), heart failure (1.58, 1.21–2.05), and ESKD (1.41, 1.13–1.77). Functional Iron Deficiency did not significantly associate with any outcome, and no iron group significantly associated with atherosclerotic cardiovascular disease. Among the candidate facilitators, FGF23 most significantly mediated the risks of mortality and heart failure conferred by Iron Deficiency. Thus, alterations in iron homeostasis associated with adverse cardiovascular and kidney outcomes in patients with chronic kidney disease.

Rationale and objective Sleep problems affect more than half of patients receiving dialysis and are associated with increased risk of mortality, cardiovascular events, depression and impaired functioning and quality of life. Symptoms such as fatigue and exhaustion may be attributed to sleep problems or sleep disorders, as well as the burden of kidney disease and treatment. This study aims to describe the patient perspectives on the reasons, impact and management of sleep problems in dialysis. Study design Systematic review and thematic synthesis of qualitative studies that report patient experience and perspectives on sleep in dialysis. Setting and population Patients receiving dialysis. Search strategy and sources MEDLINE, Embase, PsycINFO, CINAHL, reference lists and PhD dissertations were searched from inception to August 2019. Data extraction All text from the results/conclusion of the primary studies. Analytical approach Thematic synthesis. Results We included 48 studies involving 1156 participants from 16 countries. We identified six themes: dominating demands of treatment (with subthemes of: demanding and relentless schedule, regret for wasted time); scheduling and control (managing sleep routines, napping and nocturnal sleep disruption, meditative aids); disruptions due to dialysis (unsettled sleep, hypervigilance and worry); symptoms depriving sleep (difficulty falling asleep, constant waking); overwhelmed and without choice (futility of sleep, uncontrollable exhaustion, restlessness is irrepressible); and as a coping mechanism (avoiding anxiety, alleviating symptoms, combating boredom). Limitations Most studies were conducted in high-income, English-speaking countries. Conclusion The treatment and symptom burden of dialysis disrupts and deprives patients of sleep, which leads to overwhelming and uncontrollable exhaustion. Better management of symptoms and effective strategies to manage sleep routines may improve sleep quality for better overall health in patients receiving dialysis.

Patients with CKD and ESRD are vulnerable to increased mortality rates and other poor outcomes. Among those with ESRD, their health-related quality of life (HRQOL) is shown little to no improvement as they undergo treatments such as dialysis and providers concurrently manage other health issues that complicate their already vulnerable state. This review synthesizes evidence demonstrating that a focus on measuring and monitoring patient-reported outcomes (PRO) such as pain and depression can improve HRQOL. Patient-centered care has the potential to create an efficient way for clinicians to address specific challenges facing patients. While there is an emerging literature assessing the use of PROs in kidney research, by examining relevant research in other disciplines it is possible to generate better ways to use PROs in this high-risk population. Electronic health records as well as various other electronic methods of communication between the clinician and patient may serve to accelerate the trajectory toward patient-centered care using PROs.

Background Health information exchange (HIE) capabilities are tied to health care organizations' strategic and business goals. As a technology that connects information from different organizations, HIE may be a source of competitive advantage and a path to improvements in performance. Purpose The aim of the study was to identify the impact of hospitals' use of HIE capabilities on outcomes that may be sensitive to changes in various contracting arrangements and referral patterns arising from improved connectivity. Methodology Using a panel of community hospitals in nine states, we examined the association between the number of different data types the hospital could exchange via HIE and changes in market share, payer mix, and operating margin (2010-2014). Regression models that controlled for the number of different data types shared intraorganizationally and other time-varying factors and included both hospital and time fixed effects were used for adjusted estimates of the relationships between changes in HIE capabilities and outcomes. Results Increasing HIE capability was associated with a 13 percentage point increase in a hospital's discharges that were covered by commercial insurers or Medicare (i.e., payer mix). Conversely, increasing intraorganizational information sharing was associated with a 9.6 percentage point decrease in the percentage of discharges covered by commercial insurers or Medicare. Increasing HIE capability or intraorganizational information sharing was not associated with increased market share nor with operating margin. Conclusions Improving information sharing with external organizations may be an approach to support strategic business goals. Practice implications Organizations may be served by identifying ways to leverage HIE instead of focusing on intraorganizational exchange capabilities.

Objective Event notification systems are an approach to health information exchange (HIE) that notifies end-users of patient interactions with the healthcare system through real-time automated alerts. We examined associations between organizational capabilities and perceptions of event notification system use. Materials and Methods We surveyed representatives (n = 196) from healthcare organizations (n = 96) that subscribed to 1 of 3 Health Information Organizations’ event notification services in New York City (response rate = 27%). The survey was conducted in Fall 2017 and Winter 2018. Surveys measured respondent characteristics, perceived organizational capabilities, event notification use, care coordination, and care quality. Exploratory factor analysis was used to identify relevant independent and dependent variables. We examined the relationship between organizational capabilities, care coordination, and care quality using multilevel linear regression models with random effects. Results Respondents indicated that the majority of their organizations provided follow-up care for emergency department visits (66%) and hospital admissions (73%). Perceptions of care coordination were an estimated 57.5% (β = 0.575; P Discussion and Conclusion Healthcare organizations with specific workflow processes and positive perceptions of fit are more likely to use event notification services to improve care coordination and care quality. In addition, event notification capacity and patient consent procedures influence how end-users perceive event notification services.

We analyzed the relationship between prices paid to 30,549 general internal medicine physicians and the cost and quality of care for 769,281 commercially insured adults. The highest-price physician...

Key Points Question Is private equity acquisition of nursing homes associated with the quality or cost of care for long-stay nursing home residents? Findings In this cohort study with difference-in-differences analysis of 9864 US nursing homes, including 9632 residents in 302 nursing homes acquired by private equity firms and 249 771 residents in 9562 other for-profit nursing homes without private equity ownership, private equity acquisition of nursing homes was associated with higher costs and increases in emergency department visits and hospitalizations for ambulatory sensitive conditions. Meaning This study suggests that more stringent oversight and reporting on private equity ownership of nursing homes may be warranted., Importance Private equity firms have been acquiring US nursing homes; an estimated 5% of US nursing homes are owned by private equity firms. Objective To examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents. Design, Setting, and Participants In this cohort study of 302 private equity nursing homes with 9632 residents and 9562 other for-profit homes with 249 771 residents, a novel national database of private equity nursing home acquisitions was merged with Medicare claims and Minimum Data Set assessments for the period from 2012 to 2018. Changes in outcomes for residents in private equity–acquired nursing homes were compared with changes for residents in other for-profit nursing homes. Analyses were performed from March 25 to June 23, 2021. Exposure Private equity acquisitions of 302 nursing homes between 2013 and 2017. Main Outcomes and Measures This study used difference-in-differences analysis to examine the association of private equity acquisition of nursing homes with outcomes. Primary outcomes were quarterly measures of emergency department visits and hospitalizations for ambulatory care–sensitive (ACS) conditions and total quarterly Medicare costs. Antipsychotic use, pressure ulcers, and severe pain were examined in secondary analyses. Results Of the 259 403 residents in the study (170 687 women [65.8%]; 211 154 White residents [81.4%]; 204 928 residents [79.0%] dually eligible for Medicare and Medicaid; mean [SD] age, 79.3 [5.6] years), 9632 residents were in 302 private equity–acquired nursing homes and 249 771 residents were in 9562 other for-profit homes. The mean quarterly rate of ACS emergency department visits was 14.1% (336 072 of 2 383 491), and the mean quarterly rate of ACS hospitalizations was 17.3% (412 344 of 2 383 491); mean (SD) total quarterly costs were $8050.00 ($9.90). Residents of private equity nursing homes experienced relative increases in ACS emergency department visits of 11.1% (1.7 of 15.3; 1.7 percentage points; 95% CI, 0.3-3.0 percentage points; P = .02) and in ACS hospitalizations of 8.7% (1.0 of 11.5; 1.0 percentage point; 95% CI, 0.2-1.1 percentage points; P = .003) compared with residents in other for-profit homes; quarterly costs increased 3.9% (270.37 of 6972.04; $270.37; 95% CI, $41.53-$499.20; P = .02) or $1081 annually per resident. Private equity acquisition was not significantly associated with antipsychotic use (−0.2 percentage points; 95% CI, −1.7 to 1.4 percentage points; P = .83), severe pain (0.2 percentage points; 95% CI, −1.1 to 1.4 percentage points; P = .79), or pressure ulcers (0.5 percentage points; 95% CI, −0.4 to 1.3 percentage points; P = .30). Conclusions and Relevance This cohort study with difference-in-differences analysis found that private equity acquisition of nursing homes was associated with increases in ACS emergency department visits and hospitalizations and higher Medicare costs., This cohort study uses a national database of private equity nursing home acquisitions as well as Medicare data to examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents.

RATIONALE AND OBJECTIVE: The safety of intensive blood pressure (BP) targets is controversial for persons with chronic kidney disease (CKD). We studied the effects of hypertension treatment on cerebral perfusion and structure in those with and without CKD. STUDY DESIGN: Neuroimaging substudy of a randomized trial. SETTING & PARTICIPANTS: A subset of participants in the Systolic Blood Pressure Intervention Trial who underwent brain MRI studies. Presence of baseline CKD was assessed by estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (UACR). INTERVENTION: Participants were randomly assigned to intensive (systolic BP 30 mg/g (N=151), the effects of intensive versus standard BP treatment on change in global cerebral blood flow, WMLs and total brain volume were 1.91 ml/100g/min (95% CI −3.01, 6.82), 0.003 cm(3) (asinh transformed, 95% CI −0.13, 0.13), and −7.0 cm(3) (95% CI −13.3, −0.3), respectively. The overall treatment effects on cerebral blood flow and total brain volume were not modified by baseline eGFR or UACR; however the effect on WMLs was attenuated in participants with albuminuria (interaction p-value 0.04). LIMITATIONS: Measurement variability due to multi-site design. CONCLUSIONS: Among hypertensive adults with primarily early kidney disease, intensive versus standard blood pressure treatment did not appear to have a detrimental effect on brain perfusion or structure. The findings support the safety of intensive blood pressure treatment targets on brain health in persons with early kidney disease. FUNDING: The Systolic Blood Pressure Intervention Trial was funded by the National Institutes of Health (including the National Heart, Lung, and Blood Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute on Aging, and the National Institute of Neurological Disorders and Stroke), and this substudy was funded by the National Institutes of Diabetes and Digestive and Kidney Diseases. TRIAL REGISTRATION: SPRINT was registered at ClinicalTrials.gov with the study number NCT01206062.

Background: On average Black patients have longer LOS than comparable White patients. Longer hospital length of stay (LOS) may be associated with higher readmission risk. However, evidence suggests that the Hospital Readmission Reduction Program (HRRP) reduced overall racial differences in 30-day adjusted readmission risk. Yet, it is unclear whether the HRRP narrowed these LOS racial differences. Objective: We examined the relationship between Medicare-insured Black-White differences in average, adjusted LOS (ALOS) and the HRRP’s implementation and evaluation periods. Methods: Using 2009-2017 data from State Inpatient Dataset from New York, New Jersey, and Florida, we employed an interrupted time series analysis with multivariate generalized regression models controlling for patient, disease, and hospital characteristics. Results are reported per 100 admissions. Results: We found that for those discharged home, Black-White ALOS differences significantly widened by 4.15 days per 100 admissions (95% CI: 1.19 to 7.11, P < 0.001) for targeted conditions from before to after the HRRP implementation period, but narrowed in the HRRP evaluation period by 1.84 days per 100 admissions for every year-quarter (95% CI: −2.86 to −0.82, P < 0.001); for those discharged to non-home destinations, there was no significant change between HRRP periods, but ALOS differences widened over the study period. Black-White ALOS differences for non-targeted conditions remained unchanged regardless of HRRP phase and discharge destination. Conclusion: Increased LOS for Black patients may have played a role in reducing Black-White disparities in 30-day readmission risks for targeted conditions among patients discharged to home.

This cohort study uses Medicare data to assess trends and characteristics among hospitalists who shift practice to settings outside of the hospital.

Background: Presence of chronic kidney disease (CKD Stages 3-5) prior to breast cancer diagnosis may increase the risk of mortality among women with invasive breast cancer. However, the evidence base is limited, and the magnitude of this mortality risk is unknown. Breast cancer therapy may also be altered by presence of CKD. We sought to understand the role of CKD in breast cancer survival, with particular attention to receipt of recommended treatment. Methods: All women diagnosed with invasive breast cancer from 1992-2016 in 18 SEER-Medicare sites (age 66 or older; n= 168701) were evaluated for breast cancer-specific mortality (BCSM) using multivariate Cox models, with estimation of hazard ratios (HR) and 95% confidence intervals (CI). All analyses were adjusted for age, race/ethnicity, diagnosis year, tumor characteristics, and socioeconomic factors, and also for diabetes, myocardial infarction, and congestive heart failure prior to diagnosis. Separate analyses were run according to receipt vs non-receipt of standard of care for breast cancer treatment (defined according to National Comprehensive Cancer Network (NCCN) guidelines. Results: Median follow-up was 63 months (26 months with CKD). Women with CKD were at increased risk of BCSM (CKD Stage 3: HR 1.2; 95% CI 1.0-1.5; CKD Stage 4 HR 1.7; 95% CI 1.3-2.2; CKD Stage 5/End Stage Renal Disease HR 1.5; 95% CI 1.1-2.1), compared to women without CKD. In analyses of any CKD, restricted to women who met NCCN guideline therapy recommendations, women had an elevated risk of BCSM regardless of whether they did (HR 1.6; 95% CI 1.1-2.1) or did not (HR 1.4; 95% CI 1.0-1.8) receive recommended chemotherapy, and whether they did (HR 1.6; 95% CI 1.1-2.3) or did not (HR 1.3; 95% CI 0.9-2.0) receive recommended radiotherapy. Discussion: Women with CKD have an increased risk of breast cancer mortality regardless of receipt of guideline-based treatment. CKD is underascertained in Medicare claims data, thus the reported results (likely underestimates) will be presented with sensitivity analyses. CKD may influence breast cancer outcomes due to associated systemic inflammation and comorbid conditions, as well as release of soluble mediators such as cytokines, chemokines, growth factors, and factors involved in remodeling of the extracellular matrix and epithelial-mesenchymal transition. As such factors involved in CKD progression also influence cancer, increased understanding may provide clues to ameliorate adverse outcomes in both disease entities. Citation Format: Deirdre A Hill, Christos Argyropoulos, Maria-Eleni Roumelioti, Mark Unruh. Chronic kidney disease in breast cancer treatment and survival [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-07-14.

Background: Uremic pruritus (UP) and restless legs syndrome (RLS) are highly prevalent complaints among patients with end-stage renal disease (ESRD) undergoing chronic dialysis. These chronic troublesome symptoms lead to a significant decrease in quality of life (QOL) and increase in mortality rate. Despite their distressing characteristics, these symptoms usually remain under-recognized by healthcare providers. Therefore, careful history intake, and stepwise treatment are essential. Numerous pharmacological and non-pharmacological treatments have been demonstrated to help in controlling these 2 conditions. Summary: In this review, we discuss the latest findings regarding UP and RLS among ESRD patients on maintenance dialysis. We also examine different treatment options in this group of patients. The majority of these patients do not have the opportunity to receive a kidney transplant and need other treatments for these burdensome symptoms in order to improve their QOL and prognosis. Key Messages: UP and RLS are common but underdiagnosed conditions in ESRD patients on maintenance dialysis that are related to a decline in patients’ QOL and poor prognosis. The pathophysiology of these conditions remains not well understood. Therefore, controversies still exist on treatment options. Treating these conditions provides an opportunity to improve the health-related QOL and outcomes of dialysis patients.

Rationale & Objective Fatigue is a highly prevalent and debilitating symptom in patients on hemodialysis therapy due to the uremic milieu, the hemodialysis treatment itself, and other comorbid conditions. However, fatigue remains underrecognized and the consequences are underappreciated because it may not be visible in clinical settings. This study aims to describe the experience that patients undergoing maintenance hemodialysis have with fatigue. Study Design Systematic review and thematic synthesis of qualitative studies. Setting & Study Populations Patients undergoing hemodialysis. Search Strategy & Sources MEDLINE, Embase, PsycINFO, CINAHL, reference lists, and PhD dissertations were searched from inception to October 2018. Data Extraction All text from the results/conclusion of the primary studies. Analytical Approach Thematic synthesis. Results 65 studies involving 1,713 participants undergoing hemodialysis were included. We identified 4 themes related to fatigue: debilitating and exhausting burden of dialysis (bodily depletion, trapped in a vicious cycle of postdialysis exhaustion, vigilance and worry inhibiting rest, tiresome and agonizing regimen, and without remedy and relief), restricted life participation (deprived of time, managing energy reserves, frustrating need to rest, and joys foregone), diminishing capacities to fulfil relationship roles (losing ability to work and provide for family, failing as a parent, lacking stamina for sexual intimacy, and relying on others), and vulnerable to misunderstanding (being criticized for the need to rest and failing to meet expectations). Limitations Non-English articles were excluded and most studies were conducted in high-income countries. Conclusions For patients undergoing hemodialysis who experience fatigue, fatigue is a profound and relentless exhaustion that pervades the entire body and encompasses weakness. The fatigue drains vitality in patients and constrains their ability to do usual activities and fulfill their roles and meet personal aspirations. Explicit recognition of the impact of fatigue and establishing additional effective interventions to improve fatigue are needed.

Objective Enterprise health information exchange (HIE) and a single electronic health record (EHR) vendor solution are 2 information exchange approaches to improve performance and increase the quality of care. This study sought to determine the association between adoption of enterprise HIE vs a single vendor environment and changes in unplanned readmissions. Materials and Methods The association between unplanned 30-day readmissions among adult patients and adoption of enterprise HIE or a single vendor environment was measured in a panel of 211 system-member hospitals from 2010 through 2014 using fixed-effects regression models. Sample hospitals were members of health systems in 7 states. Enterprise HIE was defined as self-reported ability to exchange information with other members of the same health system who used different EHR vendors. A single EHR vendor environment reported exchanging information with other health system members, but all using the same EHR vendor. Results Enterprise HIE adoption was more common among the study sample than EHR (75% vs 24%). However, adoption of a single EHR vendor environment was associated with a 0.8% reduction in the probability of a readmission within 30 days of discharge. The estimated impact of adopting an enterprise HIE strategy on readmissions was smaller and not statically significant. Conclusion Reductions in the probability of an unplanned readmission after a hospital adopts a single vendor environment suggests that HIE technologies can better support the aim of higher quality care. Additionally, health systems may benefit more from a single vendor environment approach than attempting to foster exchange across multiple EHR vendors.

OBJECTIVE: To evaluate the effect of the 2013–2014 Affordable Care Act (ACA) Medicaid Primary Care Rate Increase on Medicaid-insured women’s prenatal care utilization, overall and by race and ethnicity. METHODS: We employed a difference-in-differences design, using births data from the 2010–2014 National Vital Statistics System. Our study population included approximately 6.2 million births to Medicaid insured mothers conceived between April 2009 and March 2014. Our treatment group was births in states with a large (relative to small) fee bump, defined as having a Medicaid-to-Medicare fee ratio below the median of all states (0.7) in 2012. Our control group was births in states with a small fee bump. Prenatal care utilization measures included initiation of prenatal care in the first trimester and number of prenatal care visits. RESULTS: Non-Hispanic Black women giving births in large fee bump states had 9% higher odds (95% CI 1.02, 1.17) of initiating prenatal care in the first trimester during the fee bump period, compared to small fee bump states. Prenatal care visits in this group also increased by 0.24 (95% CI 0.10, 0.39), 2.4% of the mean. A smaller increase in prenatal care visits of 0.17 (95% CI 0.00, 0.33) was found among non-Hispanic Whites. The fee bump had no impact among Hispanics or non-Hispanic women of other races. CONCLUSIONS FOR PRACTICE: The Medicaid “fee bump” improved prenatal care utilization for non-Hispanic Black and White women. Policymakers may consider reinstating higher Medicaid reimbursements to improve access to care for disadvantaged populations.

Objective To quantify the impact of two approaches (directed and query-based) to health information exchange (HIE) on potentially avoidable use of health care services. Data sources/study setting Data on ambulatory care providers' adoption of HIE were merged with Medicare fee-for-service claims from 2008 to 2014. Providers were from 13 counties in New York served by the Rochester Regional Health Information Organization (RHIO). Study design Linear regression models with provider and year fixed effects were used to estimate changes in the probability of utilization outcomes for Medicare beneficiaries attributed to providers adopting directed and/or query-based HIE compared with beneficiaries attributed to providers who had not adopted HIE. Data collection Providers' HIE adoption status was determined through Rochester RHIO registration records. RHIO and claims data were linked via National Provider Identifiers. Principal findings Query-based HIE adoption was associated with a 0.2 percentage point reduction in the probability of an ambulatory care sensitive hospitalization and a 1.1 percentage point decrease in the likelihood of an unplanned readmission. Directed HIE adoption was not associated with any outcome. Conclusions The Centers for Medicare & Medicaid Services' (CMS) EHR certification criteria includes requirements for directed HIE, but not query-based HIE. Pending further research, certification criteria should place equal weight on facilitating query-based and directed exchange.

The delivery of medical care services in U.S. nursing homes (NHs) is dependent on a workforce that comprises physicians, nurse practitioners, and physician assistants. Each of these disciplines operates under a unique regulatory framework while adhering to common standards of care. NH provider characteristics and their roles in NH care can illuminate potential links to clinical outcomes and overall quality of care with important policy and cost implications. This perspective provides an overview of what is currently known about medical provider practice in NH and organizational models of practice. Links to quality, both conceptual and established, are presented as is a research and policy agenda that addresses the gaps in the evidence base within the context of our ever-changing health care landscape.

This study examines whether skilled nursing facilities (SNFs) that consistently provided more rehabilitation therapy than other SNFs had lower 30-day rehospitalization rates. A cross-sectional analysis of 11 866 SNFs in the United States compared 30-day rehospitalization rates of SNFs that consistently provided more rehabilitation therapy to other SNFs using linear regression models. High-billing SNFs were defined as the 10% of SNFs with the highest proportions of Medicare fee-for-service claims that just surpassed the therapy minute threshold for the highest payment category. After controlling for patient and facility characteristics, high-billing SNFs had higher 30-day rehospitalization rates as well as longer median length of stay and greater mean cost per stay. Small reductions in the amount of therapy provided are unlikely to increase 30-day rehospitalization rates in SNFs. This has important consequences for the recently implemented patient-driven payment model, which incentivizes SNFs to provide less rehabilitation therapy.

Background:Length of stay (LOS), a metric of hospital efficiency, differs by race/ethnicity and socioeconomic status (SES) and longer LOS is associated with adverse health outcomes. Historically, projects to improve LOS efficiency have yielded LOS reductions by 0.3 to 0.7 days per admission.Objective:To assess differences in average adjusted length of stay (aALOS) over time by race/ethnicity, and SES stratified by discharge destination (home or non-home).Method:Data were obtained from 2009-2014 Healthcare Cost and Utilization Project State Inpatient Datasets for New York, New Jersey, and Florida. Multivariate generalized linear models were used to examine trends in aALOS differences by race/ethnicity, and by high vs low SES patients (defined first vs fourth quartile of median income by zip code) controlling for patient, disease and hospital characteristics.Results:For those discharged home, racial/ethnic and SES aALOS differences remained stable from 2009 to 2014. However, among those discharged to non-home destinations, Black vs White aALOS differences increased from 0.21 days in Q1 2009, (95% confidence interval (CI): 0.13 to 0.30) to 0.32 days in Q3 2013, (95% CI: 0.23 to 0.40), and for low vs high SES patients from 0.03 days in Q1 2009 (95% CI: -0.04 to 0.1) to 0.26 days, (95% CI: 0.19 to 0.34). Notably, for patients not discharged home, racial/ethnic and SES aALOS differences increased and persisted after Q3 2011, coinciding with the introduction of the Affordable Care Act (ACA).Conclusion:Further research to understand the ACA’s policy impact on hospital efficiencies, and relationship to racial/ethnic and SES differences in LOS is warranted.

This case series examines the increase in acquisitions of hospice agencies by private equity firms and publicly traded corporations from 2011 to 2019.

Measuring and monitoring quality of life (QOL) in ESRD may contribute to more patient-centered care and higher-quality care. This chapter reviews unique issues impacting the QOL of patients with ESRD. It reviews the literature comparing QOL of patients receiving renal replacement therapies through different dialysis modalities. There is a detailed discussion of strategies to assess QOL and issues related to its measurement. The chapter also reviews the literature on interventions designed to improve QOL and concludes with recommendations and future directions of the field.

Rationale & Objectives Adiposity and physical fitness levels are major drivers of cardiometabolic risk, but these relationships have not been well-characterized in chronic kidney disease (CKD). We examined the associations of visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), intrahepatic fat, and physical function with inflammation, insulin resistance, and adipokine levels in patients with CKD. Study Design Prospective cohort study. Setting & Participants Participants with stages 3-5 CKD not receiving maintenance dialysis, followed up at one of 8 clinical sites in the Chronic Renal Insufficiency Cohort (CRIC) Study, and who underwent magnetic resonance imaging of the abdomen at an annual CRIC Study visit (n = 419). Predictors VAT volume, SAT volume, intrahepatic fat, body mass index, waist circumference, and time taken to complete the 400-m walk test (physical function). Outcomes Markers of inflammation (interleukin 1β [IL-1β], IL-6, tumor necrosis factor receptor 1 [TNFR1], and TNFR2), insulin resistance (homeostasis model assessment of insulin resistance), and adipokine levels (adiponectin, total and high molecular weight, resistin, and leptin). Analytical Approach Multivariable linear regression of VAT and SAT volume, intrahepatic fat, and physical function with individual markers (log-transformed values), adjusting for relevant covariates. Results Mean age of the study population was 64.3 years; 41% were women, and mean estimated glomerular filtration rate was 53.2 ± 14.6 (SD) mL/min/1.73 m2. More than 85% were overweight or obese, and 40% had diabetes. Higher VAT volume, SAT volume, and liver proton density fat fraction were associated with lower levels of total and high-molecular-weight adiponectin, higher levels of leptin and insulin resistance, and lower high-density lipoprotein cholesterol and higher serum triglyceride levels. A slower 400-m walk time was associated only with higher levels of leptin, total adiponectin, plasma IL-6, and TNFR1 and did not modify the associations between fat measures and cardiometabolic risk factors. Limitations Lack of longitudinal data and dietary details. Conclusions Various measures of adiposity are associated with cardiometabolic risk factors. Physical function was also associated with the cardiometabolic risk factors studied and does not modify associations between fat measures and cardiometabolic risk factors. Longitudinal studies of the relationship between body fat and aerobic fitness with cardiovascular and kidney disease progression are warranted.

Sleep is critical for physical, emotional, and mental health. Health providers should be aware of sleep disorders to address patient-centered concerns. Patients with chronic kidney disease (CKD) or dialysis-dependent end-stage renal disease (ESRD) frequently report poor sleep quality and other sleep-related symptoms. Adult and pediatric patients with CKD often complain of snoring, difficulty falling asleep and maintaining sleep, excessive daytime sleepiness, unintentional daytime napping, and restless legs. Polysomnography studies often reveal a high frequency of obstructive sleep apnea in these patients. The high frequency of sleep disorders among those with CKD and ESRD is multifactorial, has an atypical presentation, and results in poor health, impaired daily functioning, poor quality of life, and reduced well-being. This chapter focuses on the most common sleep disorders and symptoms in CKD/ESRD and characterizes the extent to which these are reported. Finally, this chapter explores the diagnostic challenges and available management options.

Key Points Question Compared with other nursing homes, are private equity (PE)–owned nursing homes associated with better or worse coronavirus disease 2019 (COVID-19) outcomes? Findings In this cross-sectional study of 11 470 US nursing homes, there were no statistically significant differences in staffing levels, COVID-19 cases or deaths, or deaths from any cause between PE nursing homes and facilities with other ownership types. Compared with PE, all other ownership types were more likely to have at least a 1-week supply of N95 masks and medical gowns. Meaning In this study, PE-owned nursing homes performed comparably with for-profit and nonprofit nursing homes based on COVID-19 cases and deaths and deaths by any cause but had less personal protective equipment than other nursing homes., This cross-sectional study evaluates the comparative performance of private equity–owned nursing homes on coronavirus disease 2019 (COVID-19) outcomes., Importance It is not known whether nursing homes with private equity (PE) ownership have performed better or worse than other nursing homes during the coronavirus disease 2019 (COVID-19) pandemic. Objective To evaluate the comparative performance of PE-owned nursing homes on COVID-19 outcomes. Design, Setting, and Participants This cross-sectional study of 11 470 US nursing homes used the Nursing Home COVID-19 Public File from May 17, 2020, to July 2, 2020, to compare outcomes of PE-owned nursing homes with for-profit, nonprofit, and government-owned homes, adjusting for facility characteristics. Exposure Nursing home ownership status. Main Outcomes and Measures Self-reported number of COVID-19 cases and deaths and deaths by any cause per 1000 residents; possessing 1-week supplies of personal protective equipment (PPE); staffing shortages. Results Of 11 470 nursing homes, 7793 (67.9%) were for-profit; 2523 (22.0%), nonprofit; 511 (5.3%), government-owned; and 543 (4.7%), PE-owned; with mean (SD) COVID-19 cases per 1000 residents of 88.3 [2.1], 67.0 [3.8], 39.8 [7.6] and 110.8 [8.1], respectively. Mean (SD) COVID-19 deaths per 1000 residents were 61.9 [1.6], 66.4 [3.0], 56.2 [7.3], and 78.9 [5.9], respectively; mean deaths by any cause per 1000 residents were 78.1 [1.3], 91.5 [2.2], 67.6 [4.5], and 87.9 [4.8], respectively. In adjusted analyses, government-owned homes had 35.5 (95% CI, −69.2 to −1.8; P = .03) fewer COVID-19 cases per 1000 residents than PE-owned nursing homes. Cases in PE-owned nursing homes were not statistically different compared with for-profit and nonprofit facilities; nor were there statistically significant differences in COVID-19 deaths or deaths by any cause between PE-owned nursing homes and for-profit, nonprofit, and government-owned facilities. For-profit, nonprofit, and government-owned nursing homes were 10.5% (9.1 percentage points; 95% CI, 1.8 to 16.3 percentage points; P = .006), 15.0% (13.0 percentage points; 95% CI, 5.5 to 20.6 percentage points; P

Background and objectives Fatigue is a very common and debilitating symptom and identified by patients as a critically important core outcome to be included in all trials involving patients receiving hemodialysis. A valid, standardized measure for fatigue is needed to yield meaningful and relevant evidence about this outcome. This study validated a core patient-reported outcome measure for fatigue in hemodialysis. Design, setting, participants, & measurements A longitudinal cohort study was conducted to assess the validity and reliability of a new fatigue measure (Standardized Outcomes in Nephrology-Hemodialysis Fatigue [SONG-HD Fatigue]). Eligible and consenting patients completed the measure at three time points: baseline, a week later, and 12 days following the second time point. Cronbach α and intraclass correlation coefficient were calculated to assess internal consistency, and Spearman rho was used to assess convergent validity. Confirmatory factor analysis was also conducted. Hemodialysis units in the United Kingdom, Australia, and Romania participated in this study. Adult patients aged 18 years and over who were English speaking and receiving maintenance hemodialysis were eligible to participate. Standardized Outcomes in Nephrology-Hemodialysis, the Visual Analog Scale for fatigue, the 12-Item Short Form Survey, and Functional Assessment of Chronic Illness Therapy–Fatigue were used. Results In total, 485 participants completed the study across the United Kingdom, Australia, and Romania. Psychometric assessment demonstrated that Standardized Outcomes in Nephrology-Hemodialysis is internally consistent (Cronbach α =0.81–0.86) and stable over a 1-week period (intraclass correlation coefficient =0.68–0.74). The measure demonstrated convergence with Functional Assessment of Chronic Illness Therapy–Fatigue and had moderate correlations with other measures that assessed related but not the same concept (the 12-Item Short Form Survey and the Visual Analog Scale). Confirmatory factor analysis supported the one-factor model. Conclusions SONG-HD Fatigue seems to be a reliable and valid measure to be used in trials involving patients receiving hemodialysis.

BackgroundPatients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) experience many distressing symptoms. One frequently reported symptom is insomnia. There are unique issues about HD treatments and schedules that disrupt regular sleep/wake routines and possibly contribute to the high severity of insomnia. Despite evidence for broad-ranging health effects of insomnia, very few clinical trials have tested the efficacy of treatments for HD patients. Cognitive-behavioral therapy for insomnia (CBT-I) is a recommended first-line therapy but largely inaccessible to HD patients in the United States, partly because they commit considerable amounts of time to thrice-weekly dialysis treatments. Another important reason could be the logistical and reimbursement challenges associated with providing behavioral health care at the dialysis center. CBT-I delivered by telehealth can overcome barriers to access, but its efficacy has never been rigorously tested for these patients. Pharmacotherapy is the most widely used treatment for insomnia; however, some drugs presently used are unsafe as they are associated with a higher risk for death for HD patients (benzodiazepines and zolpidem-like drugs). The efficacy and safety of other medications (trazodone) for the treatment of insomnia has never been tested for patients treated with HD.MethodsThis trial tests the short- and long-term comparative effectiveness of 6-week treatment with telehealth CBT-I, trazodone, or medication placebo. This will be accomplished with a randomized controlled trial (RCT) in which 126 participants treated with HD in community-based dialysis facilities with chronic insomnia will be assigned 1:1:1 to telehealth CBT-I, trazodone, or medication placebo, respectively; short-term effectiveness of each treatment arm will be determined at the end of 6-weeks of treatment and long-term effectiveness at 25-weeks. The primary and secondary patient-reported outcomes will be assessed with computer-based telephone interviewing by research scientists blinded to treatment assignment; additional secondary outcomes will be assessed by participant interview and actigraphy.DiscussionThis clinical RCT will provide the first evidence for the comparative effectiveness of two distinct approaches for treating chronic insomnia and other patient-reported outcomes for patients receiving maintenance HD.Trial registrationNCT03534284May 23, 2018.SLEEP-HD Protocol Version:1.3.4 (7/22/2020).

Introduction Patients receiving in-center maintenance hemodialysis (HD) spend a significant amount of time together. To date, little or no research has examined how these patients perceive and process other patients' medical events in and absences from their centers. We therefore undertook this qualitative study using semi-structured interviews to explore these phenomena from the patient perspective. Methods Patients at a suburban Pittsburgh HD center participated in semi-structured interviews in April to May 2011, reporting on their impressions of their relationships with other patients in the center; their experiences of witnessing clinical decompensations in the center; and their reactions to absences of fellow patients from the center. Trained coders developed a codebook and applied it to interview transcripts. Findings There were 17 participants, 47% women, 29% black, with median age 63 years. Almost every participant had witnessed other patients' medical events during HD. Three main themes emerged in analysis of interviews: (1) incomplete knowledge of many aspects of witnessed events and patient absences in the HD center; (2) a process of "filling in the blanks": Participants used their own past events and absences to help process other patients' events and absences and used other patients' events and absences to help process their own future events and absences; and (3) participants' broad support for HD center staff being able to share with other patients basic information about their whereabouts if they themselves are absent from the center. Discussion Witnessed medical events in and patients' absences from the HD center are not only common but are also important to patients, who struggle to process these events and absences due to limited information about what actually happened. Interventions, such as providing patients with more information, could improve patients' experience of witnessed events and fellow patients' absences and potentially impact other patient-centered outcomes.

Background The coronavirus disease 2019 (COVID-19) may have a negative effect on the mental and social health of patients with ESKD on chronic in-center hemodialysis (HD), who have a high burden of psychologic symptoms at baseline and unavoidable treatment-related COVID exposures. The goal of our study was to assess the effect of the COVID-19 pandemic on the psychosocial health of patients on chronic in-center HD. Methods Participants enrolled in the ongoing Technology Assisted Collaborative Care (TĀCcare) trial in Western Pennsylvania and New Mexico were approached for participation in a phone survey in May 2020. Data on the pandemic’s effects on participants’ physical and mental health, symptoms (such as anxiety, mood, loneliness, sleep, and stress), and food and housing security were collected. Results Surveys were completed by 49 participants (mean age 56 years; 53% men, 18% Black, 20% American Indian, and 22% Hispanic). Almost 80% of participants reported being moderately to extremely worried about the pandemic’s effects on their mental/emotional health and interpersonal relationships. More than 85% of the participants were worried about obtaining their dialysis treatments due to infection risk from close contact in the dialysis facility or during transportation. Despite this, 82% of participants reported being not at all/slightly interested in trying home dialysis as an alternative option. Overall, 27% of the participants had clinical levels of depressive symptoms but only 12% had anxiety meeting clinical criteria. About 33% of participants reported poor sleep quality over the last month. Perceived stress was high in about 30% of participants and 85% felt overwhelmed by difficulties with COVID-19, although 41% felt that things were fairly/very often going their way. Conclusions Our study provides preliminary insights into the psychosocial distress caused by the COVID-19 pandemic among a diverse cohort of patients receiving chronic HD who are participating in an ongoing clinical trial.

BACKGROUND: African Americans have lower rates of kidney transplantation (KT) compared to Whites, even after adjusting for demographic and medical factors. In this study, we examined whether racial disparity in KT wait-listing persists after adjusting for social determinants of health (e.g. cultural, psychosocial, knowledge). METHODS: We prospectively followed a cohort of 1055 patients who were evaluated for KT between 3/10–10/12 and followed through 8/18. Participants completed a semi-structured telephone interview shortly after their first KT evaluation appointment. We used Wilcoxon rank-sum and Pearson chi-square tests to examine race differences in the baseline characteristics. We then assessed racial differences in the probability of wait-listing while accounting for all predictors using cumulative incidence curves and Fine & Gray proportional subdistribution hazards models. RESULTS: There were significant differences in the baseline characteristics between non-Hispanic African Americans (AA) and non-Hispanic Whites (WH). AA were 25% less likely (95% confidence interval, 0.60–0.96) to be wait-listed than WH even after adjusting for medical factors and social determinants of health. In addition, being older, having lower income, public insurance, more comorbidities, and being on dialysis decreased the probability of wait-listing while having more social support and transplant knowledge increased the probability of wait-listing. CONCLUSION: Racial disparity in kidney transplant wait-listing persisted even after adjusting for medical factors and social determinants of health, suggesting the need to identify novel factors that impact racial disparity in transplant wait-listing. Developing interventions targeting cultural and psychosocial factors may enhance equity in access to transplantation.

Individuals with dialysis-dependent kidney failure experience considerable disease- and treatment-related decline in functional status and overall well-being. Despite these experiences, there have been few substantive technological advances in KRT in decades. As such, new federal initiatives seek to accelerate innovation. Historically, integration of patient perspectives into KRT product development has been limited. However, the US Food and Drug Administration recognizes the importance of incorporating patient perspectives into the total product life cycle (i.e., from product conception to postmarket surveillance) and encourages the consideration of patient-reported outcomes in regulatory-focused clinical trials when appropriate. Recognizing the significance of identifying patient-reported outcome measures (PROMs) that capture contemporary patient priorities, the Kidney Health Initiative, a public–private partnership between the American Society of Nephrology and US Food and Drug Administration, convened a workgroup to (1) develop a conceptual framework for a health-related quality of life PROM; (2) identify and map existing PROMs to the conceptual framework, prioritizing them on the basis of their supporting evidence for use in the regulatory environment; and (3) describe next steps for identifying PROMs for use in regulatory clinical trials of transformative KRT devices. This paper summarizes the proposed health-related quality-of-life PROM conceptual framework, maps and prioritizes PROMs, and identifies gaps and future needs to advance the development of rigorous, meaningful PROMS for use in clinical trials of transformative KRT devices.

Background and objectives Black patients have a higher incidence of kidney failure but lower rate of deceased- and living-donor kidney transplantation compared with White patients, even after taking differences in comorbidities into account. We assessed whether social determinants of health (e.g., demographics, cultural, psychosocial, knowledge factors) could account for race differences in receiving deceased- and living-donor kidney transplantation. Design, setting, participants, & measurements Via medical record review, we prospectively followed 1056 patients referred for kidney transplant (2010-2012), who completed an interview soon after kidney transplant evaluation, until their kidney transplant. We used multivariable competing risk models to estimate the cumulative incidence of receipt of any kidney transplant, deceased-donor transplant, or living-donor transplant, and the factors associated with each outcome. Results Even after accounting for social determinants of health, Black patients had a lower likelihood of kidney transplant (subdistribution hazard ratio, 0.74; 95% confidence interval, 0.55 to 0.99) and living-donor transplant (subdistribution hazard ratio, 0.49; 95% confidence interval, 0.26 to 0.95), but not deceased-donor transplant (subdistribution hazard ratio, 0.92; 95% confidence interval, 0.67 to 1.26). Black race, older age, lower income, public insurance, more comorbidities, being transplanted before changes to the Kidney Allocation System, greater religiosity, less social support, less transplant knowledge, and fewer learning activities were each associated with a lower probability of any kidney transplant. Older age, more comorbidities, being transplanted before changes to the Kidney Allocation System, greater religiosity, less social support, and fewer learning activities were each associated with a lower probability of deceased-donor transplant. Black race, older age, lower income, public insurance, higher body mass index, dialysis before kidney transplant, not presenting with a potential living donor, religious objection to living-donor transplant, and less transplant knowledge were each associated with a lower probability of living-donor transplant. Conclusions Race and social determinants of health are associated with the likelihood of undergoing kidney transplant.

In the chronic kidney disease (CKD) population, problems with sleep have been linked to disability days, healthcare utilization, and quality of life (QOL) for dialysis patients. The health burden associated with sleep disturbances is significant. Studies in the general population have linked these problems to greater use of health services, increased use of hypnotics, and reduced functional capabilities. The need to address sleep quality in the CKD population is highlighted by the 15% to 31% prevalence of hypnotic use. Among incident dialysis patients, patients with poor sleep quality were more likely to report poor physical and mental well being, decreased vitality and more bodily pain. While there are many causes for poor sleep in patients with kidney disease, such as depression, insomnia, restless legs, and periodic limb movements, sleep apnea may be the most common. A significant percentage of end-stage renal disease patients report hypersomnolence, snoring, and even witnessed apneas. Those undergoing thrice-weekly hemodialysis have been shown to have a high rate of sleep apnea, insomnia, restless legs syndrome, and excessive daytime sleepiness. In the general population, sleep disorders such as sleep apnea have been associated with premature death, cardiovascular disease, depression, and poor QOL. Emerging evidence suggests that sleep disorders may contribute to the high rates of medical and psychological comorbidity in CKD patients. The diagnosis and treatment of sleep disorders among this high-risk population remains understudied. The recommendations for therapy have been largely based on findings in the general population since studies of the CKD population have been limited in scope.

International audience; Cardiovascular disease (CVD) affects more than two-thirds of patients receiving hemodialysis and is the leading cause of death in this population, yet CVD outcomes are infrequently and inconsistently reported in trials in patients receiving hemodialysis. As part of the Standardised Outcomes in Nephrology-Haemodialysis (SONG-HD) initiative, we convened a consensus workshop to discuss the potential use of myocardial infarction and sudden cardiac death as core outcome measures for CVD for use in all trials in people receiving hemodialysis. Eight patients or caregivers and 46 health professionals from 15 countries discussed selection and implementation of the proposed core outcome measures. Five main themes were identified: capturing specific relevance to the hemodialysis population (acknowledging prevalence, risk, severity, unique symptomology, and pathophysiology), the dilemmas in using composite outcomes, addressing challenges in outcome definitions (establishing a common definition and addressing uncertainty in the utility of biomarkers in hemodialysis), selecting a meaningful metric for decision making (to facilitate comparison across trials), and enabling and incentivizing implementation (by ensuring that cardiologists are involved in the development and integration of the outcome measure into registries, trial design, and reporting guidelines). Based on these themes, participants supported the use of myocardial infarction and sudden cardiac death as core outcome measures of CVD to be reported in all hemodialysis trials.

BackgroundCity-wide lockdowns and school closures have demonstrably impacted COVID-19 transmission. However, simulation studies have suggested an increased risk of COVID-19 related morbidity for older individuals inoculated by house-bound children. This study examines whether the March 2020 lockdown in New York City (NYC) was associated with higher COVID-19 hospitalization rates in neighborhoods with larger proportions of multigenerational households.MethodsWe obtained daily age-segmented COVID-19 hospitalization counts in each of 166 ZIP code tabulation areas (ZCTAs) in NYC. Using Bayesian Poisson regression models that account for spatiotemporal dependencies between ZCTAs, as well as socioeconomic risk factors, we conducted a difference-in-differences study amongst ZCTA-level hospitalization rates from February 23 to May 2, 2020. We compared ZCTAs in the lowest quartile of multigenerational housing to other quartiles before and after the lockdown.FindingsAmong individuals over 55 years, the lockdown was associated with higher COVID-19 hospitalization rates in ZCTAs with more multigenerational households. The greatest difference occurred three weeks after lockdown: Q2 vs. Q1: 54% increase (95% Bayesian credible intervals: 22 – 96%); Q3 vs. Q1: 48%, (17 – 89%); Q4 vs. Q1: 66%, (30 – 211%). After accounting for pandemic-related population shifts, a significant difference was observed only in Q4 ZCTAs: 37% (7 –76%).InterpretationBy increasing house-bound mixing across older and younger age groups, city-wide lockdown mandates imposed during the growth of COVID-19 cases may have inadvertently, but transiently, contributed to increased transmission in multigenerational households.FundingNational Center for Advancing Translational Sciences; Clinical and Translational Science Center at Weill Cornell Medical College.

IntroductionPlasmin and its precursor, plasminogen, are detectable in urine from patients with glomerular disease. Urinary plasmin(ogen) levels correlate with blood pressure (BP) and may contribute to renal Na+ retention by activating the epithelial Na+ channel (ENaC). In a longitudinal nested-cohort study, we asked whether urinary plasmin(ogen) levels predict subsequent increase in BP, incident hypertension, or mortality in subjects with type I diabetes, who often develop proteinuria.MethodsThe Pittsburgh Epidemiology of Diabetes Complications (EDC) study followed up type I diabetic subjects for 25 years. Urine specimens from 70 subjects with a spectrum of baseline urinary albumin levels were examined. Outcomes included increased BP after 2 years (≥1 SD over baseline systolic or diastolic BP, examined via logistic regression), 25-year incident hypertension (≥140/90 mmHg or initiating BP-lowering medications), and all-cause or cardiovascular mortality, examined using Cox regression.ResultsSubjects experiencing a 2-year increase in BP had higher baseline urinary plasmin(ogen)/creatinine levels (uPl/Cr) than other subjects (P= 0.04); the difference in baseline urinary albumin/creatinine levels (uAlb/Cr) was similar (P= 0.07). Baseline uPl/Cr was associated with increased 25-year hypertension incidence (hazard ratio= 2.05, P= 0.001), all-cause mortality (HR= 2.05, P= 0.01) and cardiovascular mortality (HR= 3.30, P= 0.005), although not independent of uAlb/Cr.ConclusionThis is the first long-term prospective study addressing clinical outcomes associated with increased urinary plasmin(ogen). Findings are consistent with a role for plasmin(ogen) in promoting increased BP, but also demonstrate the difficulty in distinguishing effects due to plasmin(ogen) from those of albuminuria.

Background Fatigue is a prevalent and debilitating symptom in patients receiving hemodialysis. We aimed to identify and evaluate the characteristics and psychometric properties of patient-reported outcome measures for fatigue in patients receiving hemodialysis, to inform the selection of a robust and feasible measure for use in randomized trials in hemodialysis. Study Design Systematic review of outcome measures for fatigue. Setting & Population Patients receiving hemodialysis. Search Strategy & Sources MEDLINE, Embase, PsycINFO, and CINAHL from inception to April 2017 were searched for all studies that reported fatigue in patients receiving hemodialysis. Analytical Approach With a focus on addressing methods, items (individual questions) from all measures were categorized into content and measurement dimensions of fatigue. We assessed the general characteristics (eg, number of items and cost) and psychometric properties of all measures. Results From 123 studies, we identified 43 different measures: 24 (55%) were developed specifically for the hemodialysis population (of which 18 were nonvalidated author-developed measures for use in their study only), 17 (40%) for other populations, and 2 (5%) for chronic kidney disease (all stages). The measures assessed 11 content dimensions of fatigue, the 3 most frequent being level of energy (19 [44%]), tiredness (15 [35%]), and life participation (14 [33%]); and 4 measurement dimensions: severity (34 [79%]), frequency (10 [23%]), duration (4 [9%]), and change (1 [2%]). The vitality subscale of the 36-Item Short Form Health Survey (SF-36) was the most frequently used (19 [15%] studies), but has only been tested for reliability in hemodialysis. Of the fatigue-specific measures, the Chalder Fatigue Scale was the only one evaluated in hemodialysis, but the full psychometric robustness remains uncertain. Limitations For feasibility, we searched for validation studies in the hemodialysis population using the names of measures identified in the primary search strategy. Conclusions A very wide range of measures have been used to assess fatigue in patients receiving hemodialysis, each varying in content and length. Many have limited validation data available in this population. A standardized and psychometrically robust measure that captures dimensions of fatigue that are important to patients is needed to estimate and improve this disabling complication of hemodialysis.

Background Rural areas in the state of New Mexico have been the “ground-zero” for the epidemic of diabetic Chronic Kidney Disease (CKD) in the United States. However, there is limited research about risk factors of diabetic CKD in this area and scarce data regarding the performance of emerging markers of renal filtration and epigenetic biomarkers of renal function and diabetes in this area with its unique ethnic/racial population. We designed the COMPASS study as a community-based program in rural New Mexico aiming to screen for CKD and to discover CKD-related translational biomarkers. Methods/design The study involves a prospective, longitudinal cohort design involving individuals living in rural New Mexico. Participants undergo a screening for kidney disease using markers of abnormal renal filtration (impaired glomerular filtration rate) or damage (albuminuria). Those found to have CKD on the basis of these tests or those at risk for CKD are enrolled in a prospective longitudinal cohort. We measure markers of renal function, insulin resistance and epigenetics (microRNAs) on patients. Individuals are invited to participate in interviews and focus groups in order to characterize their attitudes towards research and barriers or facilitators to participation in future research studies about kidney disease. Discussion This study will provide important data about the local epidemiology of kidney disease in a high-risk rural setting and the utility of emerging renal filtration markers (Beta 2 Microglobulin and Cystatin C), while generating data and methods for the analyses of microRNA biomarkers. The qualitative research subproject will identify factors associated with increased willingness to participate in future translational research projects. With its geographical focus, this study will address a critical disparity in kidney disease research, while generating novel epigenetic data that are relevant for future studies in the general population.

Insomnia is common among patients on maintenance haemodialysis and may be exacerbated by the challenges of the COVID pandemic. However, data on the efficacy of insomnia interventions in this population are limited. Efforts are needed to address this important problem and increase access to insomnia interventions for patients on haemodialysis.

h3Background and objectives/h3 pThe use of palliative care in AKI is not well described. We sought to better understand palliative care practice patterns for hospitalized patients with AKI requiring dialysis in the United States./ph3Design, setting, participants, amp; measurements/h3 pUsing the 2012 National Inpatient Sample, we identified patients with AKI and palliative care encounters using validated International Classification of Diseases, Ninth Revision, Clinical Modification codes. We compared palliative care encounters in patients with AKI requiring dialysis, patients with AKI not requiring dialysis, and patients without AKI. We described the provision of palliative care in patients with AKI requiring dialysis and compared the frequency of palliative care encounters for patients with AKI requiring dialysis with that for patients with other illnesses with similarly poor prognoses. We used logistic regression to determine factors associated with the provision of palliative care, adjusting for demographics, hospital-level variables, and patient comorbidities./ph3Results/h3 pWe identified 3,031,036 patients with AKI, of whom 91,850 (3%) received dialysis. We observed significant patient- and hospital-level differences in the provision of palliative care for patients with AKI requiring dialysis; adjusted odds were 26% (95% confidence interval, 12% to 38%) lower in blacks and 23% (95% confidence interval, 3% to 39%) lower in Hispanics relative to whites. Lower provision of palliative care was observed for rural and urban nonteaching hospitals relative to urban teaching hospitals, small and medium hospitals relative to large hospitals, and hospitals in the Northeast compared with the South. After adjusting for age and sex, there was low utilization of palliative care services for patients with AKI requiring dialysis (8%)?comparable with rates of utilization by patients with other illnesses with poor prognosis, including cardiogenic shock (9%), intracranial hemorrhage (10%), and acute respiratory distress syndrome (10%)./ph3Conclusions/h3 pThe provision of palliative care varied widely by patient and facility characteristics. Palliative care was infrequently used in hospitalized patients with AKI requiring dialysis, despite its poor prognosis and the regular application of life-sustaining therapy./p

Introduction Renal sodium (Na+) retention and extracellular fluid volume expansion are hallmarks of nephrotic syndrome, which occurs even in the absence of activation of hormones that stimulate renal Na+ transporters. Plasmin-dependent activation of the epithelial Na+ channel has been proposed to have a role in renal Na+ retention in the setting of nephrotic syndrome. We hypothesized that the epithelial Na+ channel inhibitor amiloride would be an effective therapeutic agent in inducing a natriuresis and lowering blood pressure in individuals with macroscopic proteinuria. Methods We conducted a pilot double-blind randomized cross-over study comparing the effects of daily administration of either oral amiloride or hydrochlorothiazide to patients with type 2 diabetes and macroscopic proteinuria. Safety and efficacy were assessed by monitoring systolic blood pressure, kidney function, adherence, weight, urinary Na+ excretion, and serum electrolytes. Nine subjects were enrolled in the trial. Results No significant difference in systolic blood pressure or weight was seen between subjects receiving hydrochlorothiazide and those receiving amiloride (P ≥ 0.15). Amiloride induced differences in serum potassium (P < 0.001), with a 0.88 ± 0.30 mmol/l greater acute increase observed. Two subjects developed acute kidney injury and hyperkalemia when treated with amiloride. Four subjects had readily detectable levels of urinary plasminogen plus plasmin, and 5 did not. Changes in systolic blood pressure in response to amiloride did not differ between individuals with versus those without detectable urinary plasminogen plus plasmin. Discussion In summary, among patients with type 2 diabetes, normal renal function, and proteinuria, there were reductions in systolic blood pressure in groups treated with hydrochlorothiazide or amiloride. Acute kidney injury and severe hyperkalemia were safety concerns with amiloride.

Objective Sleep and mood disorders are common in hemodialysis (HD) patients and the pathophysiology is still unclear. Tryptophan (TRP) and its metabolites may play a prominent role in neural pathways related to sleep, fatigue, and depression. Here, we sought to compare the levels of TRP and its metabolites between HD patients and healthy subjects and examine their association with sleep, fatigue, and depression in HD patients. The design was cross-sectional analysis. Subjects Ninety-nine adult patients on stable thrice weekly HD schedule between September 2011 and March 2014 and 10 healthy controls. Intervention Venous blood samples were drawn in healthy subjects and immediately before dialysis in chronic HD patients. TRP and kynurenine (KYN) metabolites were measured by high-performance liquid chromatography. The Medical Outcomes Study Sleep Scale, the PROMIS Short form Fatigue, and the Patient Health Questionnaire were administered concurrently. Main Outcome Measure Sleep, fatigue, and depression as assessed by subjective questionnaire. Results TRP levels were significantly lower (52.4 ± 15.2 vs. 67.9 ± 3.1 μmol/L; P P r 2 = 0.23 and 0.21; P ≤ .05, respectively). We found no association between TRP and KYN/TRP ratio with sleep disturbances, fatigue, and depression in HD patients. Conclusions Our study indicates disturbed TRP metabolism in HD patients, but low TRP levels were not related with sleep disturbances, depression, and fatigue. In contrast, KYN levels, a metabolite of TRP, were much higher in HD patients compared with controls, and higher KYN associated with depression and fatigue. Further studies exploring the biological and functional consequences of increased TRP catabolism in HD patients are warranted.

Nearly one-fifth of hospitalized Medicare fee-for-service beneficiaries are readmitted within 30 days. Participation in the Meaningful Use initiative among outpatient physicians may reduce readmissions.To evaluate the impact of outpatient physicians' participation in Meaningful Use on readmissions.The study population included 90,774 Medicare fee-for-service beneficiaries from New York State (2010-2012). We compared changes in the adjusted odds of readmission for patients of physicians who participated in Meaningful Use-stage 1, before and after attestation as meaningful users, with concurrent patients of matched control physicians who used paper records or electronic health records without Meaningful Use participation. Three secondary analyses were conducted: (1) limited to patients with 3+ Elixhauser comorbidities; (2) limited to patients with conditions used by Medicare to penalize hospitals with high readmission rates (acute myocardial infarction, congestive heart failure, and pneumonia); and (3) using only patients of physicians with electronic health records who were not meaningful users as the controls.Thirty-day readmission.Patients of Meaningful Use physicians had 6% lower odds of readmission compared with patients of physicians who were not meaningful users, but the estimate was not statistically significant (odds ratio: 0.94, 95% confidence interval, 0.88-1.01). Estimated odds ratios from secondary analyses were broadly consistent with our primary analysis.Physician participation in Meaningful Use was not associated with reduced readmissions. Additional studies are warranted to see if readmissions decline in future stages of Meaningful Use where more emphasis is placed on health information exchange and outcomes.

Each year approximately 13,000 Veterans transition to maintenance dialysis, mostly in the traditional form of thrice-weekly hemodialysis from the start. Among >6000 dialysis units nationwide, there are currently approximately 70 Veterans Affairs (VA) dialysis centers. Given this number of VA dialysis centers and their limited capacity, only 10% of all incident dialysis Veterans initiate treatment in a VA center. Evidence suggests that, among Veterans, the receipt of care within the VA system is associated with favorable outcomes, potentially because of the enhanced access to healthcare resources. Data from the United States Renal Data System Special Study Center "Transition-of-Care-in-CKD" suggest that Veterans who receive dialysis in a VA unit exhibit greater survival compared with the non-VA centers. Substantial financial expenditures arise from the high volume of outsourced care and higher dialysis reimbursement paid by the VA than by Medicare to outsourced providers. Given the exceedingly high mortality and abrupt decline in residual kidney function (RKF) in the first dialysis year, it is possible that incremental transition to dialysis through an initial twice-weekly hemodialysis regimen might preserve RKF, prolong vascular access longevity, improve patients' quality of life, and be a more patient-centered approach, more consistent with "personalized" dialysis. Broad implementation of incremental dialysis might also result in more Veterans receiving care within a VA dialysis unit. Controlled trials are needed to examine the safety and efficacy of incremental hemodialysis in Veterans and other populations; the administrative and health care as well as provider structure within the VA system would facilitate the performance of such trials.