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PURPOSE: Recent observational studies reporting a lack of benefit from 24-hour urine testing for urinary stone disease (USD) prevention assumed testing included all components recommended from clinical guidelines. We sought to assess the completeness of 24-hour urine testing in the VA population. MATERIALS AND METHODS: From the VHA Corporate Data Warehouse (2012–2019), we identified patients with USD (n=198,621) and determined those who saw a urologist and/or nephrologist, and received 24-hour urine testing within 12 months of their index USD encounter. Through Logical Observation Identifiers Names and Codes, we evaluated each collection’s completeness, defined as including all of urine volume, calcium, oxalate, citrate, uric acid, and creatinine. We then fit a multilevel logistic regression model with random effects for VHA facility to evaluate factors associated with specialist follow-up, testing, and testing completeness. RESULTS: Specialist follow-up occurred in 54.3% and was stable over time. Testing occurred in 8.4%, declining from 9.3% in 2012 to 7.2% in 2019. Of tests performed, 54.6% were complete (43.7% increasing to 62.7% from 2012–2019). In adjusted analysis, there was high between-facility variation in specialist follow-up (median OR 2.0; 95% CI 1.7–2.0), testing (median OR 2.2, 95% CI 1.9–2.4), and testing completeness (median OR, 6.0, 95% CI 4.5–7.3). Individual facilities contributed 52% (intraclass correlation coefficient, 0.52; 95% CI, 0.44–0.57) towards the observed variation in testing completeness. CONCLUSIONS: Approximately 1 in 12 U.S. Veterans with USD receive metabolic testing and half of these tests are complete. Addressing facility level variation in testing completeness may improve USD care.

To compare the frequency of stone-related events among patients receiving thiazides, alkali citrate, and allopurinol without prior 24 h urine testing. It is unknown whether 1 preventative pharmacological therapy (PPT) medication class is more beneficial for reducing kidney stone recurrence when prescribed empirically.Using medical claims data from working-age adults with kidney stone disease diagnoses (2008-2018), we identified those prescribed thiazides, alkali citrate, or allopurinol. We excluded those who received 24 h urine testing prior to initiating PPT and those with less than 3 years of follow-up. We fit multivariable regression models to estimate the association between the occurrence of a stone-related event (emergency department visit, hospitalization, or surgery for stones) and PPT medication class.Our cohort consisted of 1834 (60%), 654 (21%), and 558 (18%) patients empirically prescribed thiazides, alkali citrate, or allopurinol, respectively. After controlling for patient factors including medication adherence and concomitant conditions that increase recurrence risk, the adjusted rate of any stone event was lowest for the thiazide group (14.8%) compared to alkali citrate (20.4%) or allopurinol (20.4%) (each P.001). Thiazides, compared to allopurinol, were associated with 32% lower odds of a subsequent stone event by 3 years (OR 0.68, 95% CI 0.53-0.88). No such association was observed when comparing alkali citrate to allopurinol (OR 1.00, 95% CI 0.75-1.34).Empiric PPT with thiazides is associated with significantly lower odds of subsequent stone-related events. When 24 h urine testing is unavailable, thiazides may be preferred over alkali citrate or allopurinol for empiric PPT.

Rationale & Objective Persons with chronic kidney disease (CKD) are often unaware of their disease status. Efforts to improve CKD awareness may be most effective if focused on persons at highest risk for progression to kidney failure. Study Design Serial cross-sectional surveys. Setting & Participants Nonpregnant adults (aged ≥20 years) with CKD glomerular filtration rate categories 3-4 (G3-G4) who participated in the National Health and Nutrition Examination Survey from 1999 to 2016 (n = 3,713). Predictor 5-year kidney failure risk, estimated using the Kidney Failure Risk Equation. Predicted risk was categorized as minimal ( Outcome CKD awareness, defined by answering “yes” to the question “Have you ever been told by a doctor or other health professional that you had weak or failing kidneys?” Analytical Approach Prevalence of CKD awareness was estimated within each risk group using complex sample survey methods. Associations between Kidney Failure Risk Equation risk and CKD awareness were assessed using multivariable logistic regression. CKD awareness was compared with awareness of hypertension and diabetes during the same period. Results In 2011 to 2016, unadjusted CKD awareness was 9.6%, 22.6%, 44.7%, and 49.0% in the minimal-, low-, intermediate-, and high-risk groups, respectively. In adjusted analyses, these proportions did not change over time. Awareness of CKD, including among the highest risk group, remains consistently below that of hypertension and diabetes and awareness of these conditions increased over time. Limitations Imperfect sensitivity of the “weak or failing kidneys” question for ascertaining CKD awareness. Conclusions Among adults with CKD G3-G4 who have 5-year estimated risks for kidney failure of 5%

We hypothesized that high incidence rates of end-stage renal disease (ESRD) in certain counties of the U.S. are partly due to patients with a type of ESRD resembling chronic kidney disease of uncertain etiology (CKDu), which has been observed in Central America and other countries. Using data on 338,126 incident ESRD patients from the United States Renal Data System (USRDS) (2011 - 2013) and the Behavior Risk Factor Surveillance System (BRFSS) Supplement on county-level variables (2006), we describe both patient-level and county-level characteristics in counties with the highest quartile of ESRD incidence rate standardized for age, sex, and race (> 420 cases/million population/year) compared to the rest of the U.S. and two specific "hotspots" of ESRD: the San Joaquin Valley and the Rio Grande Valley. Logistic regression was used to examine characteristics associated with patients who had either missing cause of ESRD or "unknown" listed as the primary cause of ESRD. High incidence rates of ESRD were observed in southern Texas, the Southeast and parts of California (including the San Joaquin valley area), while low rates were seen in the Northwest and the Mountain Regions. The median crude incidence rate of ESRD was 335 (range 0 - 2,341) new cases per million population per year among counties. Significant predictors of missing/unknown primary cause of ESRD included: older age, white or unknown race, non-Hispanic ethnicity, lack of comorbidities at ESRD onset, lower estimated glomerular filtration rate (eGFR) at initiation, and lack of pre-dialysis care. Large areas of the U.S. have very high rates of ESRD incidence. We cannot confirm that CKDu is present in the U.S. based on this preliminary work. This topic therefore requires further investigation, as many of these patients may well be undocumented aliens working as farm laborers and therefore not registered in the USRDS. .

To compare the frequency of stone-related events among subgroups of high-risk patients with and without 24-hour urine testing before preventive pharmacological therapy (PPT) prescription. While recent studies show, on average, no benefit to a selective approach to PPT for urinary stone disease (USD), there could be heterogeneity in treatment effect across patient subgroups.Using medical claims data from working-age adults and their dependents with USD (2008-2019), we identified those with a prescription fill for a PPT agent (thiazide diuretic, alkali therapy, or allopurinol). We then stratified patients into subgroups based on the presence of a concomitant condition or other factors that raised their stone recurrence risk. Finally, we fit multivariable regression models to measure the association between stone-related events (emergency department visit, hospitalization, and surgery) and 24-hour urine testing before PPT prescription by high-risk subgroup.Overall, 8369 adults with USD had a concomitant condition that raised their recurrence risk. Thirty-three percent (n = 2722) of these patients were prescribed PPT after 24-hour urine testing (median follow-up, 590 days), and 67% (n = 5647) received PPT empirically (median follow-up, 533 days). Compared to patients treated empirically, those with a history of recurrent USD had a significantly lower hazard of a subsequent stone-related event if they received selective PPT (hazard ratio, 0.83; 95% confidence interval, 0.71-0.96). No significant associations were noted for selective PPT in the other high-risk subgroups.Patients with a history of recurrent USD benefit from PPT when guided by findings from 24-hour urine testing.

e17055 Background: Many men with prostate cancer will be exposed to ADT at some point during cancer survivorship. Unfortunately, ADT overuse in low-value scenarios is not uncommon (e.g., monotherapy in localized prostate cancer, biochemically-recurrent non-metastatic disease) resulting in more harms than benefits. We conducted an innovative survey study to unpack ADT overuse to inform behavior change and de-implementation strategies. Methods: Our survey used the Theoretical Domains Framework (TDF), and the Capability, Opportunity, Motivation – Behavior (COM-B) Model. The survey was fielded to the Society of Government Service Urologists listserv in December 2020. We stratified respondents based on their likelihood of stopping ADT monotherapy in the case of a localized prostate cancer patient presenting to their office (yes/probably yes, probably no/no), and characterized Likert scale responses to 7 COM-B statements. We used multivariable logistic regression to identify associations between stopping ADT and COM-B responses across a dichotomized Likert scale of “strongly disagree/disagree/neutral” and “agree/strongly agree.”. Results: Our survey was completed by 84 respondents (13% response rate), with 27% indicating ‘probably no’/‘no’ to stopping low-value ADT monotherapy in the case of a localized prostate cancer patient presenting to their office. Our multivariable model identified 2 COM-B statements significantly associated with lower likelihood of stopping low-value ADT. Conclusions: Using an innovative, behavioral theory-informed survey, we identified that providers less likely to stop low-value ADT had greater concern about patient worry and were more interested in providing ADT recommendations consistent with peers, informing de-implementation strategy selection. Clinical trial information: MCT03579680. [Table: see text]

AKI, a frequent complication among hospitalized patients, confers excess short- and long-term mortality. We sought to determine trends in in-hospital and 1-year mortality associated with AKI as defined by Kidney Disease Improving Global Outcomes consensus criteria.This retrospective cohort study used data from the national Veterans Health Administration on all patients hospitalized from October 1, 2008 to September 31, 2017. AKI was defined by Kidney Disease Improving Global Outcomes serum creatinine criteria. In-hospital and 1-year mortality trends were analyzed in patients with and without AKI using Cox regression with year as a continuous variable.We identified 1,688,457 patients and 2,689,093 hospitalizations across the study period. Among patients with AKI, 6% died in hospital, and 28% died within 1 year. In contrast, in-hospital and 1-year mortality rates were 0.8% and 14%, respectively, among non-AKI hospitalizations. During the study period, there was a slight decline in crude in-hospital AKI-associated mortality (hazard ratio, 0.98 per year; 95% confidence interval, 0.98 to 0.99) that was attenuated after accounting for patient demographics, comorbid conditions, and acute hospitalization characteristics (adjusted hazard ratio, 0.99 per year; 95% confidence interval, 0.99 to 1.00). This stable temporal trend in mortality persisted at 1 year (adjusted hazard ratio, 1.00 per year; 95% confidence interval, 0.99 to 1.00).AKI associated mortality remains high, as greater than one in four patients with AKI died within 1 year of hospitalization. Over the past decade, there seems to have been no significant progress toward improving in-hospital or long-term AKI survivorship.

Kidney disease is a common, complex, costly, and life-limiting condition. Most kidney disease registries or information systems have been limited to single institutions or regions. A national US Department of Veterans Affairs (VA) Renal Information System (VA-REINS) was recently developed. We describe its creation and present key initial findings related to chronic kidney disease (CKD) without kidney replacement therapy (KRT). Data from the VA's Corporate Data Warehouse were processed and linked with national Medicare data for patients with CKD receiving KRT. Operational definitions for VA user, CKD, acute kidney injury, and kidney failure were developed. Among 7 million VA users in fiscal year 2014, CKD was identified using either a strict or liberal operational definition in 1.1 million (16.4%) and 2.5 million (36.3%) veterans, respectively. Most were identified using an estimated glomerular filtration rate laboratory phenotype, some through proteinuria assessment, and very few through International Classification of Diseases, Ninth Revision coding. The VA spent ∼$18 billion for the care of patients with CKD without KRT, most of which was for CKD stage 3, with higher per-patient costs by CKD stage. VA-REINS can be leveraged for disease surveillance, population health management, and improving the quality and value of care, thereby enhancing VA's capacity as a patient-centered learning health system for US veterans.

Author(s): Saran, Rajiv; Robinson, Bruce; Abbott, Kevin C; Agodoa, Lawrence YC; Bragg-Gresham, Jennifer; Balkrishnan, Rajesh; Bhave, Nicole; Dietrich, Xue; Ding, Zhechen; Eggers, Paul W; Gaipov, Abduzhappar; Gillen, Daniel; Gipson, Debbie; Gu, Haoyu; Guro, Paula; Haggerty, Diana; Han, Yun; He, Kevin; Herman, William; Heung, Michael; Hirth, Richard A; Hsiung, Jui-Ting; Hutton, David; Inoue, Aya; Jacobsen, Steven J; Jin, Yan; Kalantar-Zadeh, Kamyar; Kapke, Alissa; Kleine, Carola-Ellen; Kovesdy, Csaba P; Krueter, William; Kurtz, Vivian; Li, Yiting; Liu, Sai; Marroquin, Maria V; McCullough, Keith; Molnar, Miklos Z; Modi, Zubin; Montez-Rath, Maria; Moradi, Hamid; Morgenstern, Hal; Mukhopadhyay, Purna; Nallamothu, Brahmajee; Nguyen, Danh V; Norris, Keith C; O'Hare, Ann M; Obi, Yoshitsugu; Park, Christina; Pearson, Jeffrey; Pisoni, Ronald; Potukuchi, Praveen K; Repeck, Kaitlyn; Rhee, Connie M; Schaubel, Douglas E; Schrager, Jillian; Selewski, David T; Shamraj, Ruth; Shaw, Sally F; Shi, Jiaxiao M; Shieu, Monica; Sim, John J; Soohoo, Melissa; Steffick, Diane; Streja, Elani; Sumida, Keiichi; Kurella Tamura, Manjula; Tilea, Anca; Turf, Megan; Wang, Dongyu; Weng, Wenjing; Woodside, Kenneth J; Wyncott, April; Xiang, Jie; Xin, Xin; Yin, Maggie; You, Amy S; Zhang, Xiaosong; Zhou, Hui; Shahinian, Vahakn

The Dietary Approaches to Stop Hypertension (DASH) diet lowers blood pressure, an important risk factor for chronic kidney disease (CKD) and end-stage renal disease (ESRD). However, it is unclear whether adherence to a DASH diet confers protection against future ESRD, especially among those with pre-existing CKD and hypertension. We examined whether a DASH diet is associated with lower risk of ESRD among 1,110 adults aged ≥ 20 years with hypertension and CKD (estimated glomerular filtration rate, eGFR 30-59 ml/min/1.73 m2) enrolled in the National Health and Nutrition Examination Survey (1988-1994). Baseline DASH diet accordance score was assessed using a 24-hour dietary recall questionnaire. ESRD was ascertained by linkage to the U.S. Renal Data System registry. We used the Fine-Gray competing risks method to estimate the relative hazard (RH) for ESRD after adjusting for sociodemographics, clinical and nutritional factors, eGFR, and albuminuria. Over a median follow-up of 7.8 years, 18.4% of subjects developed ESRD. Compared to the highest quintile of DASH diet accordance, there was a greater risk of ESRD among subjects in quintiles 1 (RH=1.7; 95% CI 1.1-2.7) and 2 (RH 2.2; 95% CI 1.1-4.1). Significant interactions were observed with diabetes status and race/ethnicity, with the strongest association between DASH diet adherence and ESRD risk observed in individuals with diabetes and in non-Hispanic blacks. Low accordance to a DASH diet is associated with greater risk of ESRD in adults with moderate CKD and hypertension, particularly in non-Hispanic blacks and persons with diabetes.

Author(s): Saran, Rajiv; Robinson, Bruce; Abbott, Kevin C; Agodoa, Lawrence YC; Bhave, Nicole; Bragg-Gresham, Jennifer; Balkrishnan, Rajesh; Dietrich, Xue; Eckard, Ashley; Eggers, Paul W; Gaipov, Abduzhappar; Gillen, Daniel; Gipson, Debbie; Hailpern, Susan M; Hall, Yoshio N; Han, Yun; He, Kevin; Herman, William; Heung, Michael; Hirth, Richard A; Hutton, David; Jacobsen, Steven J; Jin, Yan; Kalantar-Zadeh, Kamyar; Kapke, Alissa; Kovesdy, Csaba P; Lavallee, Danielle; Leslie, Janet; McCullough, Keith; Modi, Zubin; Molnar, Miklos Z; Montez-Rath, Maria; Moradi, Hamid; Morgenstern, Hal; Mukhopadhyay, Purna; Nallamothu, Brahmajee; Nguyen, Danh V; Norris, Keith C; O'Hare, Ann M; Obi, Yoshitsugu; Park, Christina; Pearson, Jeffrey; Pisoni, Ronald; Potukuchi, Praveen K; Rao, Panduranga; Repeck, Kaitlyn; Rhee, Connie M; Schrager, Jillian; Schaubel, Douglas E; Selewski, David T; Shaw, Sally F; Shi, Jiaxiao M; Shieu, Monica; Sim, John J; Soohoo, Melissa; Steffick, Diane; Streja, Elani; Sumida, Keiichi; Tamura, Manjula K; Tilea, Anca; Tong, Lan; Wang, Dongyu; Wang, Mia; Woodside, Kenneth J; Xin, Xin; Yin, Maggie; You, Amy S; Zhou, Hui; Shahinian, Vahakn

Author(s): Saran, Rajiv; Robinson, Bruce; Abbott, Kevin C; Agodoa, Lawrence YC; Albertus, Patrick; Ayanian, John; Balkrishnan, Rajesh; Bragg-Gresham, Jennifer; Cao, Jie; Chen, Joline LT; Cope, Elizabeth; Dharmarajan, Sai; Dietrich, Xue; Eckard, Ashley; Eggers, Paul W; Gaber, Charles; Gillen, Daniel; Gipson, Debbie; Gu, Haoyu; Hailpern, Susan M; Hall, Yoshio N; Han, Yun; He, Kevin; Hebert, Paul; Helmuth, Margaret; Herman, William; Heung, Michael; Hutton, David; Jacobsen, Steven J; Ji, Nan; Jin, Yan; Kalantar-Zadeh, Kamyar; Kapke, Alissa; Katz, Ronit; Kovesdy, Csaba P; Kurtz, Vivian; Lavalee, Danielle; Li, Yi; Lu, Yee; McCullough, Keith; Molnar, Miklos Z; Montez-Rath, Maria; Morgenstern, Hal; Mu, Qiao; Mukhopadhyay, Purna; Nallamothu, Brahmajee; Nguyen, Danh V; Norris, Keith C; O'Hare, Ann M; Obi, Yoshitsugu; Pearson, Jeffrey; Pisoni, Ronald; Plattner, Brett; Port, Friedrich K; Potukuchi, Praveen; Rao, Panduranga; Ratkowiak, Kaitlyn; Ravel, Vanessa; Ray, Debabrata; Rhee, Connie M; Schaubel, Douglas E; Selewski, David T; Shaw, Sally; Shi, Jiaxiao; Shieu, Monica; Sim, John J; Song, Peter; Soohoo, Melissa; Steffick, Diane; Streja, Elani; Tamura, Manjula Kurella; Tentori, Francesca; Tilea, Anca; Tong, Lan; Turf, Megan; Wang, Dongyu; Wang, Mia; Woodside, Kenneth; Wyncott, April; Xin, Xin; Zang, Wei; Zepel, Lindsay; Zhang, Sai; Zho, Hui; Hirth, Richard A

Background Poor access to food among low-income adults has been recognized as a risk factor for chronic kidney disease (CKD), but there are no data for the impact of food insecurity on progression to end-stage renal disease (ESRD). We hypothesized that food insecurity would be independently associated with risk for ESRD among persons with and without earlier stages of CKD. Study Design Longitudinal cohort study. Setting & Participants 2,320 adults (aged ≥ 20 years) with CKD and 10,448 adults with no CKD enrolled in NHANES III (1988-1994) with household income ≤ 400% of the federal poverty level linked to the Medicare ESRD Registry for a median follow-up of 12 years. Predictor Food insecurity, defined as an affirmative response to the food-insecurity screening question. Outcome Development of ESRD. Measurements Demographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. Dietary acid load was estimated from 24-hour dietary recall. We used a Fine-Gray competing-risk model to estimate the relative hazard (RH) for ESRD associated with food insecurity after adjusting for covariates. Results 4.5% of adults with CKD were food insecure. Food-insecure individuals were more likely to be younger and have diabetes (29.9%), hypertension (73.9%), or albuminuria (90.4%) as compared with their counterparts ( P P =0.05). Food-insecure adults were more likely to develop ESRD (RH, 1.38; 95% CI, 1.08-3.10) compared with food-secure adults after adjustment for demographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. In the non-CKD group, 5.7% were food insecure. We did not find a significant association between food insecurity and ESRD (RH, 0.77; 95% CI, 0.40-1.49). Limitations Use of single 24-hour diet recall; lack of laboratory follow-up data and measure of changes in food insecurity over time; follow-up of cohort ended 10 years ago. Conclusions Among adults with CKD, food insecurity was independently associated with a higher likelihood of developing ESRD. Innovative approaches to address food insecurity should be tested for their impact on CKD outcomes.

OBJECTIVES: To compare survival and cause of death in men aged 65 and older diagnosed with prostate cancer and with survival and cause of death in a noncancer control population. DESIGN: Retrospective cohort from a population-based tumor registry linked to Medicare claims data. SETTING: Eleven regions of the Surveillance, Epidemiology and End Results (SEER) Tumor Registry. PARTICIPANTS: Men aged 65 to 84 (N=208,601) diagnosed with prostate cancer from 1988 through 2002 formed the basis for different analytical cohorts. MEASUREMENTS: Survival as a function of stage and tumor grade (low, Gleason grade

Risk of malignancy with long-term immunosuppression in renal transplant recipients.BackgroundImprovements in immunosuppressive regimens have significantly enhanced patient and graft survival in renal transplant recipients. However, susceptibility to neoplastic disorders is increased as a consequence of prolonged immunosuppression. Available data pertaining to cancer risks in renal transplant recipients have been inconsistent, and much of it is derived from international studies, which may not be truly representative of the United States population.MethodsWe studied a total of 1979 transplants performed in 1739 patients from a single center in the United States with a mean follow-up of 6.1 years, and a total of 9852 person-years' follow-up.ResultsThe mean age at the time of diagnosis of cancer was 50 years, and the mean interval between transplant and diagnosis of cancer was 95 months. Older patients receiving a transplant had a significantly higher risk for developing cancer as opposed to younger patients (RR 6.2 for >60 years compared with 10 years had an SIR of 2.4 (P < 0.001).ConclusionWe believe that this study is representative of the United States' renal transplant population, and highlights the need for reduced immunosuppression in the long-term and increased vigilance for cancers in younger patients receiving renal transplantation.

Author(s): Saran, Rajiv; Li, Yi; Robinson, Bruce; Abbott, Kevin C; Agodoa, Lawrence YC; Ayanian, John; Bragg-Gresham, Jennifer; Balkrishnan, Rajesh; Chen, Joline LT; Cope, Elizabeth; Eggers, Paul W; Gillen, Daniel; Gipson, Debbie; Hailpern, Susan M; Hall, Yoshio N; He, Kevin; Herman, William; Heung, Michael; Hirth, Richard A; Hutton, David; Jacobsen, Steven J; Kalantar-Zadeh, Kamyar; Kovesdy, Csaba P; Lu, Yee; Molnar, Miklos Z; Morgenstern, Hal; Nallamothu, Brahmajee; Nguyen, Danh V; O'Hare, Ann M; Plattner, Brett; Pisoni, Ronald; Port, Friedrich K; Rao, Panduranga; Rhee, Connie M; Sakhuja, Ankit; Schaubel, Douglas E; Selewski, David T; Shahinian, Vahakn; Sim, John J; Song, Peter; Streja, Elani; Kurella Tamura, Manjula; Tentori, Francesca; White, Sarah; Woodside, Kenneth; Hirth, Richard A

Initial reports have suggested that approximately 10% of patients with HIV-infection develop HIV-associated nephropathy (HIVAN). It has also been predicted that by the end of the decade, HIVAN is likely to become a third leading cause of end-stage renal disease (ESRD) in African-Americans between the ages of 20–64 years. As the morbidity and mortality from HIV-infection has decreased in the last few years, it is possible that prevalence of HIVAN is also changing. We therefore screened HIV-1-infected patients followed in our hospital for HIVAN. A screening urinalysis was performed in 557 HIV-1-infected adult patients between March and May 1998. Of these, 252 were outpatients and 305 were Texas Department of Criminal Justice inmates (TDCJI). Demographic and laboratory data of these patients was obtained from the HIV patients’ database. Fifty percent of the patients were African-American, 36.6% were Caucasian and 12.7% were Hispanic. The mean age of patients was 37 ± 8 years. Seventy-nine percent of the patients were males and a history of intravenous drug abuse (IVDA) was present in 28%. Twenty-three percent of the patients were concomitantly infected with hepatitis C virus, 4.1% were positive for hepatitis B surface antigen, and rapid plasma reagin test for syphilis was positive in 9.1%. In 38 patients who had more than 100 mg/dl (2+) proteins on screening urinalysis, total urinary proteins were quantitated by collecting 24 h urine specimens. Fifteen of these patients had urinary proteins more than 1.5 g/day (12 patients >3.5 g/24 h and 3 patients >1.5 g/24 h). A renal biopsy was done in 14 of these patients and clinical diagnosis of HIVAN was made in one patient who refused biopsy. Renal biopsies revealed HIVAN [9], diabetic nephropathy [2], membranoproliferative glomerulonephritis [2], Fibrillary glomerulonephritis [1]. All 10 patients (5 TDCJI and 5 outpatients) with HIVAN were African-American. Two of these 10 patients had a history of IVDA and another two were concomitantly infected with hepatitis C virus. The plasma viral load (Pvl) and total CD4 count was not different in patients with or without HIVAN [(Pvl log 10.05 ± 1.39 vs. 9.9 ± 2.18 copies/ml, p = 0.78) (CD4: 187 ± 192 vs. 288 ± 249 cells/μl, p = 1.17) mean ± SD]. We conclude that in our HIV-infected population HIVAN exclusively affected African-Americans and the prevalence in them was 3.5%.

Fractures are a recognized consequence of androgen deprivation therapy (ADT); however, less is known about the incidence of fracture in relation to the timing of ADT use or the impact of fracture on mortality in men with prostate cancer.Using data from the Surveillance, Epidemiology, and End Results-Medicare linked database, we estimated adjusted hazard ratios (aHRs) using time-dependent Cox regression for fracture incidence related to the recency of exposure and dose among prostate cancer patients on gonadotropin-releasing hormone (GnRH) agonists, as well as mortality associated with fractures.In our cohort of 80 844 patients, ADT was associated with an increased rate of fracture in both non-metastatic patients (aHR = 1.34; 95% confidence interval [CI] = 1.29-1.39) and metastatic patients (aHR = 1.51; 95%CI = 1.36-1.67). Fracture rates increased with increasing cumulative GnRH dose but decreased with increasing number of months since last use in each dose category. The mortality rate doubled for men experiencing a fracture after their diagnosis compared with that for men who did not experience a fracture (aHR = 2.05; 95%CI = 1.98-2.12).ADT in elderly men with prostate cancer increased the incidence of fractures, and the effect appears to diminish with increasing time since the last dose of a GnRH agonist. Experiencing a fracture after the diagnosis of prostate cancer was associated with decreased survival.

Androgen deprivation therapy, particularly in the form of gonadotropin-releasing hormone agonists, is a common therapy for prostate cancer that is used in almost half of all patients over the course of their disease (1,2). This therapy is indicated for the palliation of metastases of prostate cancer and in locally advanced cancer when combined with radiation (3,4). Although the use of androgen deprivation therapy in other settings remains controversial (5), recent studies have shown a dramatic increase in use of androgen deprivation therapy for prostate cancer during the 1990s, even in contexts in which its benefit is unproven or highly improbable (2,6). Because androgen deprivation therapy is a costly and potentially toxic therapy (7,8), it is important to understand the factors responsible for its use. Growth in the use of androgen deprivation therapy, even when there is weak or no evidence of benefit, indicates that factors other than typical patient and tumor characteristics may be driving its use. One possibility is as stated in Wennberg’s practice style hypothesis (9,10)—that is, when there is uncertainty about the optimal treatment course, use of medical interventions is determined by characteristics of the physician. In other words, the treatment provided depends more on the physician who is treating the patient than on specific characteristics of the patient’s disease. However, previous studies (11–14) that have used multilevel analyses to examine the contribution of the physician to variance in the use of various treatments (i.e., for diabetes or angina) or resources (i.e., hospitalizations or pharmacy expenditures) have found the physician’s contribution to be quite small, generally less than 10%. To assess the importance of the physician as a determinant of the use of androgen deprivation therapy in prostate cancer, we conducted a multilevel analysis in a large population-based retrospective cohort by use of the Surveillance, Epidemiology and End-Results (SEER)-Medicare linked database (15,16). In particular, we compared the percentage of variance in the use of androgen deprivation therapy that was attributable to patient characteristics with the percentage that was attributable to the physician. Although we acknowledge the difficulties in defining appropriate care, we divided the prostate cancer patients into those for whom androgen deprivation therapy was evidence based (i.e., clinical trials showing survival benefit or improvements in palliation) and those for whom the benefit of androgen deprivation therapy was uncertain (i.e., no clinical trials showing survival benefit, or presence of conflicting data regarding benefits in the literature). We tested the hypothesis that most of the variance in the use of androgen deprivation therapy was attributable to the physician. We also tested the hypothesis that the variance attributable to the physician would be greater for situations in which the benefits of androgen deprivation therapy were uncertain.

Background: Androgen deprivation therapy for prostate cancer has been associated with a spectrum of adverseeffects,suchasdepression,memorydifficulties,and fatigue, termed the androgen deprivation syndrome. Primary care physicians providing follow-up care for men with prostate cancer will be faced with managing these effects. We therefore sought to estimate the incidence of these effects and, by using a control group, ascertain whether these effects were related to androgen deprivation itself. Methods: We assessed the risk of physician diagnoses of depression, cognitive impairment, or constitutional symptoms in Medicare data following androgen deprivation using a sample of 50613 men with incident prostate cancer and 50476 men without cancer, from 1992 through 1997, in the linked Surveillance, Epidemiology, and End Results–Medicare database. Cox proportional hazards regression was used to adjust for confounding variables. Results: Of men surviving at least 5 years after diagnosis, 31.3% of those receiving androgen deprivation developed at least 1 depressive, cognitive, or constitutional diagnosis compared with 23.7% in those who did not (P.001). After adjustment for variables such as comorbidity, tumor characteristics, and age, the risks associatedwithandrogendeprivationweresubstantiallyreduced or abolished: relative risk (RR) for depression diagnosis, 1.08 (95% confidence interval [CI], 1.021.15); RR for cognitive impairment, 0.99 (95% CI, 0.941.04); and RR for constitutional symptoms, 1.17 (95% CI, 1.13-1.22). Conclusion:Depressive,cognitive,andconstitutionaldisordersoccurmorecommonlyinpatientsreceivingandrogen deprivation, but this appears to be primarily because patientsreceivingandrogendeprivationareolderandhave more comorbid conditions and more advanced cancers. Arch Intern Med. 2006;166:465-471

The use of androgen-deprivation therapy for prostate cancer has increased substantially over the past 15 years. This treatment is associated with a loss of bone-mineral density, but the risk of fracture after androgen-deprivation therapy has not been well studied.We studied the records of 50,613 men who were listed in the linked database of the Surveillance, Epidemiology, and End Results program and Medicare as having received a diagnosis of prostate cancer in the period from 1992 through 1997. The primary outcomes were the occurrence of any fracture and the occurrence of a fracture resulting in hospitalization. Cox proportional-hazards analyses were adjusted for characteristics of the patients and the cancer, other cancer treatment received, and the occurrence of a fracture or the diagnosis of osteoporosis during the 12 months preceding the diagnosis of cancer.Of men surviving at least five years after diagnosis, 19.4 percent of those who received androgen-deprivation therapy had a fracture, as compared with 12.6 percent of those not receiving androgen-deprivation therapy (P0.001). In the Cox proportional-hazards analyses, adjusted for characteristics of the patient and the tumor, there was a statistically significant relation between the number of doses of gonadotropin-releasing hormone received during the 12 months after diagnosis and the subsequent risk of fracture.Androgen-deprivation therapy for prostate cancer increases the risk of fracture.

Previous studies have reported that approximately 10% of the patients with human immunodeficiency virus (HIV) infection develop HIV-associated nephropathy (HIVAN). However, over the last decade, morbidity and mortality as a result of HIV-1 infection has remarkably decreased with the availability of potent new antiretroviral drugs. We therefore determined the prevalence of HIVAN from autopsy data of HIV-infected patients in more recent years (1992 to 1997). Autopsy reports of 389 patients were reviewed. In reports suggestive of possible HIVAN, slides of renal tissue were retrieved and reviewed again to ensure appropriate classification. The criteria for the diagnosis of HIVAN were focal segmental glomerulosclerosis with collapse of the glomerular tuft in some glomeruli, extensive tubular ectasia, and significant tubulointerstitial disease. Of 389 autopsy reports, 54% of the patients were black, 35% were white, and 11% were Hispanic. Thirty-three percent of the patients had a history of intravenous drug abuse. The mean CD4 count of the patients was 54 +/- 91/microL (mean +/- SD). In 27 cases, typical features of HIVAN were found based on the criteria used, accounting for an overall HIVAN prevalence of 6.9% (27 of 389 autopsies). Because the overwhelming majority of these patients were black (93%), the prevalence in blacks was 12% (25 of 209 autopsies). We conclude that although mortality and morbidity from HIV infection is decreasing, HIVAN remains an important complication of HIV infection in blacks, even in recent years.

Figure S1. Flow diagram showing selection of state for data analysis. Figure S2. Dialysis-requiring acute kidney injury (AKI-D) incidence vs. rate of renal recovery among incident end-stage renal disease (ESRD) patients per million population across states by sex. A) male, B) female. Figure S3. Dialysis-requiring acute kidney injury (AKI-D) incidence vs. rate of renal recovery among incident end-stage renal disease (ESRD) patients per million population across states by age group. A) age 45-64 years, B) age 65-74 years, C) age 75 years or older. Table S1. The number of dialysis-requiring acute kidney injury (AKI-D) hospitalization, AKI-D incidence, the number of renal recovery cases among incident end stage renal disease (ESRD) patients, and renal recovery rate among incident ESRD patients in 18 states. (DOCX 499 kb)

Figure S1. Flow diagram showing selection of state for data analysis. Figure S2. Dialysis-requiring acute kidney injury (AKI-D) incidence vs. rate of renal recovery among incident end-stage renal disease (ESRD) patients per million population across states by sex. A) male, B) female. Figure S3. Dialysis-requiring acute kidney injury (AKI-D) incidence vs. rate of renal recovery among incident end-stage renal disease (ESRD) patients per million population across states by age group. A) age 45-64 years, B) age 65-74 years, C) age 75 years or older. Table S1. The number of dialysis-requiring acute kidney injury (AKI-D) hospitalization, AKI-D incidence, the number of renal recovery cases among incident end stage renal disease (ESRD) patients, and renal recovery rate among incident ESRD patients in 18 states. (DOCX 499 kb)