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Background: Patients receiving dialysis have unmet palliative care needs. Limited access to palliative care is a key barrier to its integration into routine dialysis care. Objective: To determine the feasibility and acceptability of telepalliative care in rural dialysis units. Methods: This was a single-arm pilot clinical trial. The target population was patients with kidney failure receiving outpatient dialysis in a rural U.S. state. Feasibility was measured by one-month completion rate. Acceptability was measured using an adapted telemedicine questionnaire. Results: We recruited 39 patients with mean age 71.2 years to undergo a telepalliative care consultation while receiving dialysis. Four specialty palliative care clinicians (three physicians and one nurse practitioner) conducted the visits. The recruitment rate was 40% (39/96), scheduling rate was 100% (39/39), and one-month completion rate was 77% (30/39). Thirty-six patient participants (14 women and 22 men) completed the baseline survey. Audiovisual aspects of the visit were rated highly. More than 80% reported the visit being at least as good as an in-person visit and 41% felt the teleconsult was better. Eighty-one percent of patients felt the appointment was relevant to them, 58% felt they learned new things about their condition, and 27% reported the appointment changed the way they think about dialysis. Discussion: Telepalliative care is acceptable to patients receiving dialysis and is a feasible approach to integrating palliative care in rural dialysis units. The study was registered with Clinicaltrials.gov (NCT03744117).

Little information exists on incidence of and risk factors for chronic kidney disease (CKD) in contemporary US cohorts, and whether risk factors differ by race, sex or region in the US.Observational cohort study.4,198 Black and 7,799 White participants age ≥45, recruited 2003-2007 across the continental US with baseline eGFR60 ml/min/1.73mAge, sex, race (Black/White), region (stroke belt/other), education, income, systolic blood pressure, body mass index (BMI), diabetes, coronary heart disease, hyperlipidemia, smoking, albuminuria.1) eGFR change 2) incident CKD, defined as eGFR60 ml/min/1.73mLinear regression and modified Poisson regression were used to determine the association of risk factors with eGFR change and incident CKD, and stratified by race, sex and region.Participants were 63±8 years old, 54% female, and 35% Black. After 9.4±1.0 years follow-up, 9% developed CKD. In an age-, sex- and race-adjusted model, Black race (β -0.13, p0.0001) was associated with higher risk of eGFR change, but this was attenuated in the fully-adjusted model (β 0.02, p=0.54). Stroke belt residence was independently associated with eGFR change (β -0.10, p=0.0007) and incident CKD (RR 1.14 95%CI 1.01,1.30). Albuminuria was more strongly associated with eGFR change (β -0.26 vs β -0.17, pExcluded Hispanics, unknown duration and/or severity of risk factors.Established CKD risk factors accounted for higher risk of incident CKD in Black vs. White individuals. Albuminuria was a stronger risk factor for eGFR decline and incident CKD in Black compared to White individuals. Living in the US stroke belt is a novel risk factor for CKD.

Background: High C-reactive protein (a nonspecific inflammatory biomarker) is a risk factor for incident hypertension. The role of specific inflammation pathways in hypertension’s origins are unresolved. E-selectin, ICAM-1, and VCAM are cell adhesion molecules expressed by endothelial cells that aid leukocyte adhesion during inflammation. Their association with incident hypertension is unclear. Objective: To determine risk of incident hypertension by level of E-selectin, ICAM-1, and VCAM. Methods: REGARDS enrolled 30,239 Black and White US adults aged ≥45 years from across the continental US in 2003-2006, with a second exam in 2013-2016. The Biomarkers as Mediators of Racial Disparities in Risk Factors (BioMedioR) study included 4,400 REGARDS participants who attended both exams. We excluded participants with hypertension or missing biomarkers of interest at baseline. Hypertension was defined using a 140/90 mm Hg threshold or self-reported use of blood pressure (BP) lowering medications. Modified Poisson regression estimated relative risk (RR) of incident hypertension by baseline E-Selectin, ICAM-1, and VCAM. Results: Among 1,923 normotensive participants (mean [SD] age 71 [8] years, 36% Black race, 51% women) with 9 years median follow up, 37% developed hypertension. Baseline E-selectin and ICAM-1 but not VCAM were higher among Black participants and obese participants. In multivariable adjusted models, higher E-selectin was associated with greater risk of incident hypertension among White but not Black adults (P interaction = 0.05) in all but the final model ( Table ). Higher ICAM-1 and VCAM were not associated with risk of hypertension in any model. Conclusion: In a prospective study of Black and White US adults, E-selectin was associated with incident hypertension among White adults except when adjusting for medical comorbidities, including baseline systolic BP. Modification of E-selectin through behavioral interventions or medical therapies might be tested to lower risk of hypertension development.

Background: Much of chronic kidney disease (CKD) is unexplained by traditional risk factors. Endothelial dysfunction is highly prevalent in CKD and may be a potential target for reducing CKD incidence or progression. We sought to determine the association of plasma biomarkers of endothelial dysfunction with incident CKD in a large prospective cohort. Methods: REGARDS is a prospective population-based cohort of 30,239 Black and White US adults aged ≥45. Baseline biomarkers of endothelial dysfunction (plasma factor VIII, E-selectin, intercellular cellular adhesion molecule 1 (ICAM-1), and vascular cellular adhesion molecule 1 (VCAM-1)) were measured in individuals without CKD who attended a second visit a median of 9.4 years after baseline. Incident CKD was defined as eGFR 2 and a decline of 40%. We used sequential logistic regression models adjusted for confounders to assess associations and tested for interactions by each of age, sex, race, and diabetes. Results: After exclusions, we studied 3,300 participants (median age 62, 49% women, 46% Black, 50% hypertensive, 15% diabetic). 228 (6.9%) developed CKD by the second visit. Substantial interactions were observed for several markers, so stratified analyses were presented (Table). In minimally adjusted models, independent positive associations with CKD were seen with higher levels of each marker: factor VIII in White non-diabetics, E-selectin in women Conclusion: Several plasma markers of endothelial dysfunction were highly relevant to CKD incidence in important subgroups, which may reveal insights into reducing the burden of CKD.

Background: Cardiovascular disease is a major risk for cognitive impairment. The opioid precursor peptide pro-enkephalin A (PENK-A) is a circulating hormone associated with several cardiovascular diseases and possibly vascular dementia. The objective of this study was to test the association of plasma PENK-A with incident cognitive impairment and describe potential differences by age, race, and sex. Methods: REGARDS is a prospective population-based cohort of 30,239 Black and White adults. Baseline plasma PENK-A was measured in 462 participants who developed cognitive impairment over a median 4.7 years and 556 who did not develop this. PENK-A’s association with incident cognitive impairment was assessed by logistic regression models adjusted for confounders. We tested for differences by age, sex, and race with interaction terms. Results: PENK-A concentration was comparable between cases and controls, but higher with White race, female sex, greater age, coronary artery disease, and chronic kidney disease. Categorical and linear models did not reveal an association with cognitive impairment. Spline plots showed a non-linear association with decreased odds at very high PENK-A values (adjusted OR for 95 th vs 50 th percentiles 0.66, 95% CI 0.46-0.95). This association was only apparent after final adjustment for kidney function. Interaction testing showed substantial interactions by each age and sex (all P < 0.06). In subgroup analyses, shapes of association differed but no independent trends were discernable (Figure). Conclusions: Circulating PENK-A was not particularly associated with cognitive impairment odds. High levels may be protective; this finding could be spurious. Differences by sex and age may exist, expanding upon prior findings in REGARDS of differing non-linear associations with stroke by sex and race. Further work is needed to characterize the importance of endogenous opioid pathways to cardiovascular health and differences by demographic factors.

Background Relative to White adults, Black adults have a substantially higher prevalence of hypertension and diabetes, both key risk factors for stroke, cardiovascular disease, cognitive impairment, and dementia. Blood biomarkers have shown promise in identifying contributors to racial disparities in many chronic diseases. Methods We outline the study design and related statistical considerations for a nested cohort study, the Biomarker Mediators of Racial Disparities in Risk Factors (BioMedioR) study, within the 30,239-person biracial REasons for Geographic And Racial Differences in Stroke (REGARDS) study (2003-present). Selected biomarkers will be assessed for contributions to racial disparities in risk factor development over median 9.4 years of follow-up, with initial focus on hypertension and diabetes. Here we outline study design decisions and statistical considerations for the sampling of 4,400 BioMedioR participants. Results The population for biomarker assessment was selected using a random sample study design balanced across race and sex to provide the optimal opportunity to describe association of biomarkers with the development of hypertension and diabetes. Descriptive characteristics of the BioMedioR sample and analytic plans are provided for this nested cohort study. Conclusions This nested biomarker study will examine pathways with the target to help explain racial differences in hypertension and diabetes incidence.

Palliative care initiatives are needed in nephrology, yet implementation is lacking. We created a 6-hour workshop to teach the skills of active listening, responding to emotion, and exploring goals and values to nurses and social workers working in dialysis units. The workshop consisted of interactive didactics and structured role play with trained simulated patients. We assessed preparedness using a Likert scale and utilized paired t tests to measure the impact using a self-assessment survey following the training. Ten nurses and two social workers from six dialysis units completed the training. Mean scores improved in all domains: demonstrating empathic behaviors, responding to emotion and end-of-life concerns, eliciting family's concerns at end-of-life and patient's goals, and discussing spiritual concerns. Further testing in larger samples may help to confirm these results.

Background: Oxidative stress and inflammation are proposed mechanisms of nonspecific kidney injury and progressive kidney failure. Higher dietary oxidative balance scores (OBS) are associated with lower prevalence of chronic kidney disease (CKD). Methods: We investigated the association between OBS and biomarkers of inflammation using data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Nutrient estimates from the Block Food Frequency Questionnaires were used to define tertiles of 11 pro- and antioxidant factors. Points for each OBS component were summed, with a higher score indicating predominance of antioxidant exposures. Multivariable linear regression models were used to estimate the association between OBS and biomarkers of inflammation (interleukin-6 [IL-6], interleukin-8 [IL-8], interleukin-10 [IL-10], fibrinogen, C-reactive protein [CRP], white blood cell count, and cystatin C). An interaction term was included to determine if associations between OBS and inflammatory markers differed between individuals with and without CKD. Results: Of 682 participants, 22.4% had CKD. In adjusted models, OBS was associated with CRP and IL-6. For every 5-unit increase in OBS, the CRP concentration was –15.3% lower (95% CI: –25.6, –3.6). The association of OBS with IL-6 differed by CKD status; for every 5-unit increase in OBS, IL-6 was –10.7% lower (95% CI: –16.3, –4.7) among those without CKD, but there was no association among those with CKD (p = 0.03). Conclusion: This study suggests that a higher OBS is associated with more favorable levels of IL-6 and CRP, and that the association of OBS and IL-6 may be modified by CKD status.

Background Kidney disease has been associated with venous thromboembolism (VTE) risk, but results conflict and there is little information regarding blacks. Study Design Prospective cohort study. Setting & Participants 30,239 black and white adults 45 years or older enrolled in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study 2003 to 2007. Predictors Estimated glomerular filtration rate (eGFR) using the combined creatinine–cystatin C (eGFR cr-cys ) equation and urinary albumin-creatinine ratio (ACR). Outcomes The primary outcome was adjudicated VTE, and secondary outcomes were provoked and unprovoked VTE, separately. Mortality was a competing-risk event. Results During 4.6 years of follow-up, 239 incident VTE events occurred over 124,624 person-years. Cause-specific HRs of VTE were calculated using proportional hazards regression adjusted for age, sex, race, region of residence, and body mass index. Adjusted VTE HRs for eGFR cr-cys of 60 to 2 were 1.28 (95% CI, 0.94-1.76), 1.30 (95% CI, 0.77-2.18), and 2.13 (95% CI, 1.21-3.76). Adjusted VTE HRs for ACR of 10 to Limitations Single measurement of eGFR and ACR may have led to misclassification. Smaller numbers of events may have limited power. Conclusions There was an independent association of low eGFR ( 2 ) with VTE risk, but no association of ACR and VTE.

Background Kidney disease disproportionately affects minority populations, including African Americans and Hispanics; therefore, understanding the relationship of kidney function to cardiovascular (CV) outcomes within different racial/ethnic groups is of considerable interest. We investigated the relationship between kidney function and CV events and assessed effect modification by race/ethnicity in the Women's Health Initiative. Study Design Prospective cohort study. Setting & Participants Baseline serum creatinine concentrations (assay traceable to isotope-dilution mass spectrometry standard) of 19,411 postmenopausal women aged 50 to 79 years who self-identified as either non-Hispanic white (n=8,921), African American (n=7,436), or Hispanic (n=3,054) were used to calculate estimated glomerular filtration rates (eGFRs). Predictors Categories of eGFR (exposure); race/ethnicity (effect modifier). Outcomes The primary outcome was the composite of 3 physician-adjudicated CV events: myocardial infarction, stroke, or CV-related death. Measurements We evaluated the multivariable-adjusted associations between categories of eGFR and CV events using proportional hazards regression and formally tested for effect modification by race/ethnicity. Results During a mean follow-up of 7.6 years, 1,424 CV events (653 myocardial infarctions, 627 strokes, and 297 CV-related deaths) were observed. The association between eGFR and CV events was curvilinear; however, the association of eGFR with CV outcomes differed by race ( P =0.006). In stratified analyses, we observed that the U-shaped association was present in non-Hispanic whites, whereas African American participants had a rather curvilinear relationship, with lower eGFR being associated with higher CV risk, and higher eGFR, with reduced CV risk. Analyses among Hispanic women were inconclusive owing to few Hispanic women having very low or high eGFRs and very few events occurring in these categories. Limitations Lack of urinary albumin measurements; residual confounding by unmeasured or imprecisely measured characteristics. Conclusions In postmenopausal women, the patterns of association between eGFR and CV risk differed between non-Hispanic whites and African American women.

Prognosis communication is one hypothesized mechanism by which effective palliative care (PC) promotes preference-concordant treatment near end of life (EOL), but little is known about this relationship.This is a multisite cohort study of 231 hospitalized patients with advanced cancer who consulted with PC. We audio-recorded the initial consultation with the PC team and coded conversations for all statements regarding expectations for how long the patient will live. We refer to these statements as length-of-life talk. We followed patients for up to six months to determine EOL treatment utilization, including hospice enrollment. Patients completed a brief interviewer-facilitated questionnaire at study enrollment.Forty-four percent (101/231) of observed conversations contained at least one statement about expectations for length of life, and 60% of patients (139/231) enrolled in hospice during the six months following these conversations. The association between length-of-life talk and hospice enrollment was strong among those (155/231) who endorsed treatment preferences favoring comfort over longevity in the last weeks to months of life (odds ratio [OR]Talking about expectations for remaining length of life during PC consultations is associated with six-month hospice enrollment among people with advanced cancer who endorse preferences for EOL treatment that favor comfort over longevity.

Essentials Chronic kidney disease (CKD) is associated with procoagulant and inflammatory biomarkers. We studied the association of CKD and venous thromboembolism (VTE) in a case-cohort study. Factor VIII, D-dimer and C-reactive protein appeared to explain the association of CKD and VTE. Statin use was protective against VTE in those with and without CKD. Summary Background Chronic kidney disease (CKD) is associated with venous thromboembolism (VTE) risk via unknown mechanisms. Whether factors associated with reduced VTE risk in the general population might also be associated with reduced VTE risk in CKD patients is unknown. Objectives To determine whether thrombosis biomarkers attenuate VTE risk, and whether factors associated with reduced VTE risk are similarly effective in CKD patients. Methods Baseline biomarkers were measured in a cohort (294 VTE cases; 939 non-cases) from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a nationwide prospective cohort study of 30 239 persons aged ≥45 years with 4.3 years of follow-up. The hazard ratio (HR) of VTE per 10 mL min-1 1.73 m-2 decrease in estimated glomerular filtration rate (eGFR), and the percentage attenuation of this HR by each biomarker, were calculated. Associations of protective factors (physical activity, lower body mass index [BMI], and aspirin, warfarin and statin use) with VTE were estimated in those with and without CKD. Results The HR for VTE with lower eGFR was 1.13 (95% confidence interval [CI] 1.02-1.25), and VTE risk was attenuated by 23% (95% CI 5-100) by D-dimer, by 100% (95% CI 50-100) by factor VIII, and by 15% (95% CI 2-84) by C-reactive protein. Normal BMI was associated with lower VTE risk in those without CKD (HR 0.47, 95% CI 0.32-0.70), but not in those with CKD (HR 1.07, 95% CI 0.51-2.22). Statin use, physical activity and warfarin use were associated with lower VTE risk in both groups. Conclusions Procoagulant and inflammatory biomarkers mediated the association of eGFR with VTE. Higher physical activity, statin use and warfarin use mitigated VTE risk in those with CKD and those without CKD, but normal BMI did not mitigate VTE risk in CKD patients.

Chronic kidney disease (CKD) affects 30 million Americans and is associated with approximately a two-fold increased risk of venous thromboembolism (VTE). There is a graded increased risk of VTE across declining kidney function, as measured by estimated glomerular filtration rate (eGFR) and albuminuria. When patients with end-stage kidney disease (ESKD) experience VTE they are more likely than the general population to be hospitalized and they have a higher mortality. The incidence and consequences of VTE may also differ depending on the cause of kidney disease. In addition, kidney transplant patients with VTE are at a greater risk for death and graft loss than transplant patients without VTE. The reasons that patients with CKD are at increased risk of VTE are not well understood, but recent data suggest that factor VIII is a mediator. Factor VIII is an essential cofactor in the coagulation cascade and a strong risk factor for VTE in general. It is inversely correlated with eGFR and prospective studies demonstrate that factor VIII activity predicts incident CKD and rapid eGFR decline. The etiology of CKD may also influence factor VIII levels. This review summarizes the epidemiology VTE in CKD and reviews the biochemistry of factor VIII and determinants of its levels, including von Willebrand factor and ABO blood group. We explore mechanisms by which the complications of CKD might give rise to higher factor VIII and suggests future research directions to understand how factor VIII and CKD are linked.

Background Although dialysis prolongs life for patients with end-stage kidney disease, 20% of deaths in this population are preceded by dialysis therapy withdrawal. Recently, there has been more focus on conservative (nondialytic) care as a legitimate option, particularly for elderly patients. This study aims to describe patients' and caregivers' perspectives on conservative treatment and end-of-life care in chronic kidney disease (CKD). Study Design Systematic review and thematic synthesis of qualitative studies. Setting & Population Patients with CKD and caregivers. Search Strategy & Sources MEDLINE, Embase, PsycINFO, CINAHL, and reference lists were searched to May 2013. Analytical Approach Thematic synthesis was used to analyze the findings. Results 26 studies involving more than 711 patients (non–dialysis dependent [n=41], hemodialysis [n=544], peritoneal dialysis [n=9]; unspecified dialysis modality [n=31], conservative management [n=86]) and 178 caregivers were included. We identified 5 themes: invasive suffering (bodily deterioration, loss of freedom and independence, unyielding fatigue and pain, resignation, treatment burden and harm, financial strain), personal vulnerability (imminence of death, misunderstanding and judgment, autonomy and dignity, medical abandonment, trust and safety), relational responsibility (being a burden, demonstrating loyalty, protecting others from grief), negotiating existential tensions (accepting natural course of life, disrupted aging, worthlessness, living on borrowed time, respecting sanctity of life, life satisfaction, preserving self-identity), and preparedness (decisional clarity, informational power, spirituality and hope). Limitations Non-English articles were excluded; therefore, the transferability of findings to other populations is unclear. Conclusions Some patients with CKD experience physical and psychosocial frailty and feel ambivalent about prolonging life. Some caregivers believe in providing relief from suffering, but are uncertain about making decisions regarding dialysis therapy initiation and discontinuation. We suggest that CKD management should encompass palliative care strategies that promote emotional resilience, sense of well-being, and self-value. Also, respectful and attentive communication may empower patients to convey their values and preferences about their own care.

Pregnancy involves remarkable orchestration of physiologic changes. The kidneys are central players in the evolving hormonal milieu of pregnancy, responding and contributing to the changes in the environment for the pregnant woman and fetus. The functional impact of pregnancy on kidney physiology is widespread, involving practically all aspects of kidney function. The glomerular filtration rate increases 50% with subsequent decrease in serum creatinine, urea, and uric acid values. The threshold for thirst and antidiuretic hormone secretion are depressed, resulting in lower osmolality and serum sodium levels. Blood pressure drops approximately 10 mmHg by the second trimester despite a gain in intravascular volume of 30% to 50%. The drop in systemic vascular resistance is multifactorial, attributed in part to insensitivity to vasoactive hormones, and leads to activation of the renin-aldosterone-angiostensin system. A rise in serum aldosterone results in a net gain of approximately 1000 mg of sodium. A parallel rise in progesterone protects the pregnant woman from hypokalemia. The kidneys increase in length and volume, and physiologic hydronephrosis occurs in up to 80% of women. This review will provide an understanding of these important changes in kidney physiology during pregnancy, which is fundamental in caring for the pregnant patient.

OBJECTIVE This study aims to determine whether menopausal symptoms differed between women with chronic kidney disease (CKD) and women without CKD, and whether CKD modified associations of late vasomotor symptoms (VMS) with mortality and/or cardiovascular events. METHODS CKD, defined as estimated glomerular filtration rate lower than 60 mL/minute/1.73 m (using the Chronic Kidney Disease Epidemiology Collaboration equation), was determined in 17,891 postmenopausal women, aged 50 to 79 years at baseline, in the multiethnic Women's Health Initiative cohort. Primary outcomes were presence, severity, and timing/duration of VMS (self-reported hot flashes and night sweats) at baseline. We used polytomous logistic regression to test for associations among CKD and four VMS categories (no VMS; early VMS-present before menopause but not at study baseline; late VMS-present only at study baseline; persistent VMS-present before menopause and study baseline) and Cox regression to determine whether CKD modified associations between late VMS and mortality or cardiovascular events. RESULTS Women with CKD (1,017 of 17,891; mean estimated glomerular filtration rate, 50.7 mL/min/1.73 m) were more likely to have had menopause before age 45 years (26% vs 23%, P = 0.02) but were less likely to experience VMS (38% vs 46%, P

The care of elderly persons with CKD may be complicated by several factors, including uncertainty about the accuracy and significance of low GFR estimates, age-associated pharmacokinetic changes and the high prevalence of polypharmacy, and co-morbid conditions. All of these factors make weighing the risks and benefits of CKD treatment strategies more challenging. When managing elderly patients, it is important to keep in mind that CKD clinical practice guidelines, such as those for blood pressure control, were largely developed in non-elderly populations with CKD. Thus, CKD treatment guidelines must be tailored to suit the individual patient and his or her treatment goals and preferences. Ultimately, achieving patient-centered care for the growing elderly population with CKD will require a more collaborative approach with pharmacists and geriatricians and individualized care plans that go beyond the guidelines.

Introduction: Vasomotor symptoms (VMS) are common menopausal symptoms and the timing of these symptoms, specifically onset of late VMS, has recently been linked with cardiovascular risk factors. Chronic kidney disease (CKD) affects 13% of all women in the US and carries high risk for cardiovascular disease (CVD). The association between CKD and VMS has not been studied. Hypothesis: We hypothesized that the timing of VMS would differ between women with CKD compared to women without CKD. We also hypothesized that CKD would modify the effect of VMS on all-cause mortality, coronary heart disease and stroke. Methods: We studied the Women’s Health Initiative (WHI) biomarker cohort, which is comprised of all black and Hispanic participants in the WHI observation study and clinical trials plus a subset of white WHI participants such that the biomarker cohort reflects the age distribution of the HT population. CKD was defined as estimated glomerular filtration rate 2 and VMS was defined as self-report of hot flushes and night sweats. We used polytomous logistic regression to determine the cross-sectional associations (unadjusted, demographics-adjusted and multivariable-adjusted between CKD and reported VMS categories (none, early, late, persistent). We used Cox proportional hazards models with an interaction term to determine whether the association between late VMS and all-cause mortality or incident CVD was modified by CKD. Results: Among the 18,024 WHI participants, 1281 women (5.86%) had CKD. VMS were less common in women with CKD versus without CKD (37.6% vs 45.8%, p Conclusions: In this multiethnic cohort, VMS were less common in women with CKD and CKD did not appear to modify the association between VMS and either incident CVD or total mortality.

Accurate prognostic models could inform treatment decisions for older adults with end-stage renal disease who are considering dialysis and might identify patients more appropriate for conservative care or hospice.In a cohort of patients aged ≥ 67 years commencing dialysis in the United States between January 1, 2008 and June 30, 2009, we compared the discrimination of three existing instruments (the Liu index; the French Renal Epidemiology and Information Network score; and hospice eligibility criteria) for the prediction of 6-month mortality. We estimated the odds of death associated with each prognostic index using logistic regression with and without adjustment for age. Predictive indices were compared using the concordance ("c")-statistic.Of 44,109 eligible patients, 10,289 (23.3%) died within 6 months of dialysis initiation. The c-statistic for the Liu, Renal Epidemiology and Information Network, hospice eligibility criteria, and combined Liu/hospice eligibility criteria scores without and with age were 0.62/0.65, 0.63/0.66, 0.65/0.68, and 0.68/0.70, respectively. Discrimination was poorer at older ages, especially for the Liu and Renal Epidemiology and Information Network scores. Although sensitivity was poor, a Renal Epidemiology and Information Network score ≥ 9 or an hospice eligibility criteria ≥ 3 had relatively high specificity.Existing prognostic indices based on administrative data perform poorly with respect to prediction of 6-month mortality in older patients with end-stage renal disease commencing dialysis.

Background The objective of this analysis was to systematically review the evidence for virtual reality (VR) therapy in an adult post-stroke population in both custom built virtual environments (VE) and commercially available gaming systems (CG). Methods MEDLINE, CINAHL, EMBASE, ERIC, PSYCInfo, DARE, PEDro, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were systematically searched from the earliest available date until April 4, 2013. Controlled trials that compared VR to conventional therapy were included. Population criteria included adults (>18) post-stroke, excluding children, cerebral palsy, and other neurological disorders. Included studies were reported in English. Quality of studies was assessed with the Physiotherapy Evidence Database Scale (PEDro). Results Twenty-six studies met the inclusion criteria. For body function outcomes, there was a significant benefit of VR therapy compared to conventional therapy controls, G = 0.48, 95% CI = [0.27, 0.70], and no significant difference between VE and CG interventions (P = 0.38). For activity outcomes, there was a significant benefit of VR therapy, G = 0.58, 95% CI = [0.32, 0.85], and no significant difference between VE and CG interventions (P = 0.66). For participation outcomes, the overall effect size was G = 0.56, 95% CI = [0.02, 1.10]. All participation outcomes came from VE studies. Discussion VR rehabilitation moderately improves outcomes compared to conventional therapy in adults post-stroke. Current CG interventions have been too few and too small to assess potential benefits of CG. Future research in this area should aim to clearly define conventional therapy, report on participation measures, consider motivational components of therapy, and investigate commercially available systems in larger RCTs. Trial Registration Prospero CRD42013004338

The nature of neuroplasticity and the physiological mechanisms involved in the induction of both short- and long-term changes in the brain that enable us to store and retrieve motor memories for later use is discussed. The ways in which neuroplastic changes can be classified using the biological principles related to neuroplasticity and the underlying tenets of learning are reviewed. The fundamental elements of experience-dependent neuroplasticity and clinical interventions, including VR technology, which have the potential to induce and affect neuroplasticity are considered. The empirical evidence of the effects of VR on neuroplastic changes in the brain is summarised.

Current understanding of the term "concussion" is fraught with misconceptions regarding the extent and nature of brain injury. Despite increasing attention in popular media and within the context of sports, considerable gaps exist in our knowledge of the diagnosis, underlying brain pathology, recovery of function, and optimal interventions for concussion. In this special interest article, we discuss the definition and risk factors associated with concussion, summarize and highlight some of the most widely used assessment tools, and critique the evidence for current principles of concussion management. Our evaluation has identified opportunities for novel neuroimaging techniques to improve the understanding of the pathophysiology of concussion and to evaluate the changes in the recovering brain in response to rehabilitation. In summary, a clear definition of the underlying brain pathology, the potential long-term consequences, and the risk factors of injury and recovery will help guide future research aiming to minimize the impact of injury and develop innovative and successful therapeutic approaches aimed at ameliorating the functional impairments associated with concussion.

Background: End Stage Renal Disease (ESRD) accounts for 9% of Medicare spending, with the beneficiaries suffering from ESRD costing 7-9 times more than the average. This population is expected to continue to grow as a portion of Medicare beneficiaries. To provide clinicians and administrators with a greater understanding of the combined costs associated with the multiple critical care pathways for End Stage Renal Disease we have developed a model to predict ESRD populations through 2020. Methods: A system dynamics model was designed to project the prevalence and total costs of ESRD treatment for the United States through 2020. Incidence, transplant and mortality rates were modeled for 35 age and primary diagnosis subgroups coursing through different ESRD critical care pathways. Using a web interface that allows users to alter certain combinations of parameters, several demonstration analysis were run to predict the impact of three policy interventions on the future of ESRD care. Results: The model was successfully calibrated against the output of United States Renal Data System’s (USRDS) prior predictions and tested by comparing the output to historical data. Our model predicts that the ESRD patient population will continue to rise, with total prevalence increasing to 829,000 by 2020. This would be a 30% increase from the reported 2010 prevalence. Conclusions: Findings suggest that clinical care and policy changes can be leveraged to more effectively and efficiently manage the inevitable growth of ESRD patient populations. Patients can be shifted to more effective treatments, while planning integrating systems thinking can save Medicare’s ESRD program billions over the next decade.