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      The Survival of Roma Minority Patients on Chronic Hemodialysis Therapy - A Romanian Multicenter Survey

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          Abstract

          Objective

          The Roma minority represents the largest ethnic group in Central and South-East European countries. Data regarding the mortality in Roma hemodialysis subjects are limited. We evaluated the 3 year mortality of ESRD Roma patients treated with hemodialysis (HD).

          Study Design and Setting

          Our prospective cohort study included 600 ESRD patients on HD therapy recruited from 7 HD centers, from the main geographical regions of Romania. The median age of the patients was 56 (19) years, 332 (55.3%) being males, 51 (8.5%) having Roma ethnicity.

          Results

          Roma ESRD patients initiate dialysis at a younger age, 47.8 years vs. 52.3 years (P = 0.017), present higher serum albumin (P = 0.013) and higher serum phosphate levels (P = 0.021). In the Roma group, the overall 3 year mortality was higher when compared to Caucasians (33.3% vs. 24.8%). The multivariate survival analysis revealed that being of Roma ethnicity is an independent risk factor for mortality (HR = 1.74; 95% CI = 1.04–2.91; P = 0.035).

          Conclusions

          Roma patients with ESRD initiate HD therapy at a younger age as compared to Caucasians. They have a higher 3 year mortality rate and are dying at a younger age. Roma ethnicity represents an independent risk factor for mortality in our cohort.

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          Most cited references36

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          APOL1 risk variants, race, and progression of chronic kidney disease.

          Among patients in the United States with chronic kidney disease, black patients are at increased risk for end-stage renal disease, as compared with white patients. In two studies, we examined the effects of variants in the gene encoding apolipoprotein L1 (APOL1) on the progression of chronic kidney disease. In the African American Study of Kidney Disease and Hypertension (AASK), we evaluated 693 black patients with chronic kidney disease attributed to hypertension. In the Chronic Renal Insufficiency Cohort (CRIC) study, we evaluated 2955 white patients and black patients with chronic kidney disease (46% of whom had diabetes) according to whether they had 2 copies of high-risk APOL1 variants (APOL1 high-risk group) or 0 or 1 copy (APOL1 low-risk group). In the AASK study, the primary outcome was a composite of end-stage renal disease or a doubling of the serum creatinine level. In the CRIC study, the primary outcomes were the slope in the estimated glomerular filtration rate (eGFR) and the composite of end-stage renal disease or a reduction of 50% in the eGFR from baseline. In the AASK study, the primary outcome occurred in 58.1% of the patients in the APOL1 high-risk group and in 36.6% of those in the APOL1 low-risk group (hazard ratio in the high-risk group, 1.88; P<0.001). There was no interaction between APOL1 status and trial interventions or the presence of baseline proteinuria. In the CRIC study, black patients in the APOL1 high-risk group had a more rapid decline in the eGFR and a higher risk of the composite renal outcome than did white patients, among those with diabetes and those without diabetes (P<0.001 for all comparisons). Renal risk variants in APOL1 were associated with the higher rates of end-stage renal disease and progression of chronic kidney disease that were observed in black patients as compared with white patients, regardless of diabetes status. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others.).
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            Renal osteodystrophy in the first decade of the new millennium: analysis of 630 bone biopsies in black and white patients.

            Renal osteodystrophy occurs early during loss of kidney function. There are 26 million American patients with chronic kidney disease (CKD), and almost all patients with CKD stage 5 have abnormal bone histology. Six hundred and thirty bone biopsies from adult CKD-5 patients on dialysis were evaluated by histomorphometry and analyzed using the turnover (T), mineralization (M), and volume (V) classification. There were racial differences; whites exhibited predominantly low turnover (62%), whereas blacks showed mostly normal or high turnover (68%). A mineralization defect was observed in only 3% of patients. In whites, cancellous bone volume was low, normal, or high in approximately the same number of patients, whereas in blacks, cancellous bone volume was high in two-thirds of the patients. More than 80% of blacks and whites with low cancellous bone volume had thin trabeculae owing to low bone formation. Cortical thickness was low in half the whites, whereas it was normal in three-quarters of blacks. Cortical porosity was high in 50% of whites, whereas three-quarters of blacks had high porosity. In summary, the TMV system gives relevant information. It should be expanded to include the architecture of cancellous and cortical bone. There are racial differences. Low bone volume and low bone turnover are more frequent than heretofore appreciated, whereas mineralization defects nowadays are observed rarely in adults. These findings call for an adjustment of the current therapeutic paradigm that takes into consideration race and risk of low bone volume and turnover. The latter have been shown to be associated with increased vascular calcifications. Copyright © 2011 American Society for Bone and Mineral Research.
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              Statistical Inference Methods for Two Crossing Survival Curves: A Comparison of Methods

              A common problem that is encountered in medical applications is the overall homogeneity of survival distributions when two survival curves cross each other. A survey demonstrated that under this condition, which was an obvious violation of the assumption of proportional hazard rates, the log-rank test was still used in 70% of studies. Several statistical methods have been proposed to solve this problem. However, in many applications, it is difficult to specify the types of survival differences and choose an appropriate method prior to analysis. Thus, we conducted an extensive series of Monte Carlo simulations to investigate the power and type I error rate of these procedures under various patterns of crossing survival curves with different censoring rates and distribution parameters. Our objective was to evaluate the strengths and weaknesses of tests in different situations and for various censoring rates and to recommend an appropriate test that will not fail for a wide range of applications. Simulation studies demonstrated that adaptive Neyman’s smooth tests and the two-stage procedure offer higher power and greater stability than other methods when the survival distributions cross at early, middle or late times. Even for proportional hazards, both methods maintain acceptable power compared with the log-rank test. In terms of the type I error rate, Renyi and Cramér—von Mises tests are relatively conservative, whereas the statistics of the Lin-Xu test exhibit apparent inflation as the censoring rate increases. Other tests produce results close to the nominal 0.05 level. In conclusion, adaptive Neyman’s smooth tests and the two-stage procedure are found to be the most stable and feasible approaches for a variety of situations and censoring rates. Therefore, they are applicable to a wider spectrum of alternatives compared with other tests.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                19 May 2016
                2016
                : 11
                : 5
                : e0155271
                Affiliations
                [1 ]Department of Nephrology, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
                [2 ]Department of Internal Medicine, ‘Victor Babes’ University of Medicine and Pharmacy, Municipal Clinical Emergency Hospital, Timisoara, Romania
                [3 ]Department of Obstetrics and Gynecology, ‘Victor Babes’ University of Medicine and Pharmacy, Municipal Hospital, Timisoara, Romania
                [4 ]B Braun Avitum Dialysis Center Timisoara, Timisoara, Romania
                [5 ]Department of Diabetes and Metabolic Diseases, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
                [6 ]Department of Medical Informatics and Biostatistics, ‘Victor Babes’ University of Medicine and Pharmacy, County Emergency Hospital, Timisoara, Romania
                [7 ]Department of Nephrology and Internal Medicine, University of Medicine “Gr. T. Popa” Iasi, Hospital “C. I. Parhon” Iasi, Iasi, Romania
                Postgraduate Medical Institute, INDIA
                Author notes

                Competing Interests: The authors have no conflict of interest. Adalbert Schiller is medical consultant for BBraun Avitum Ltd, Romania. The BBraun Avitum Ltd Romania provided support in the form of salaries for author Oana Schiller, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

                Conceived and designed the experiments: FG DL DS AC AS. Performed the experiments: FG DL DS RT FB AM OS MM MDD AC AS. Analyzed the data: BT. Wrote the paper: FG DL AS OS AC RT MDD FB MM BT. Revised the manuscript critically for important intellectual content: FG AC MDD AS RT FB AM MM BT. Edited and approved the final version of the article: FG DL DS OS RT BT FB MDD MM AM AC AS.

                Article
                PONE-D-16-02801
                10.1371/journal.pone.0155271
                4873236
                27196564
                bcb0b692-d947-4620-b9b0-5966818674ec
                © 2016 Gadalean et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 20 January 2016
                : 26 April 2016
                Page count
                Figures: 1, Tables: 6, Pages: 12
                Funding
                Funded by: 'Victor Babes' University of Medicine and Pharmacy
                Award ID: PIII-C2-PCFI-2015/2016
                Award Recipient :
                This research project was funded by an internal grant from the University of Medicine and Pharmacy ‘‘Victor Babes’’ Timisoara, PIII-C2-PCFI-2015/2016, www.umft.ro. AS received the funding. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                People and Places
                Population Groupings
                Ethnicities
                Romani People
                Medicine and Health Sciences
                Epidemiology
                Ethnic Epidemiology
                Medicine and Health Sciences
                Nephrology
                Chronic Kidney Disease
                Medicine and Health Sciences
                Nephrology
                Medical Dialysis
                People and Places
                Demography
                Death Rates
                Biology and Life Sciences
                Population Biology
                Population Metrics
                Death Rates
                Medicine and Health Sciences
                Vascular Medicine
                Coronary Artery Disease
                Medicine and Health Sciences
                Vascular Medicine
                Vascular Diseases
                Peripheral Vascular Disease
                Physical sciences
                Chemistry
                Chemical compounds
                Organic compounds
                Vitamins
                Vitamin D
                Physical sciences
                Chemistry
                Organic chemistry
                Organic compounds
                Vitamins
                Vitamin D
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                All relevant data are within the paper.

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