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      Hospitalizations for Bacterial Endocarditis after Initiation of Chronic Dialysis in the United States

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          Aims: Bacterial endocarditis is a significant cause of morbidity and mortality but has not been studied in a national population of end-stage renal disease patients. Methods: 327,993 dialysis patients in the United States Renal Data System initiated from 1 January 1992 to 30 June 1997 were analyzed in a historical cohort study of hospitalized bacterial endocarditis (ENDO, ICD9 Code 421.x). Renal transplant recipients were excluded. Results: Hemodialysis patients had an age-adjusted incidence ratio for ENDO of 17.86 (95% confidence interval, 6.62–48.90) and peritoneal dialysis patients 10.54 (95% CI, 0.71– 158.13, not statistically significant) compared to the general population in 1996 (the National Hospital Discharge Survey). 6.1% of patients with ENDO underwent valve replacement surgery. In multivariate analysis, hemodialysis (vs. peritoneal dialysis), earlier year of dialysis, cardiac disease, and lower serum creatinine and albumin were associated with increased risk of ENDO. In Cox regression analysis, patients with ENDO had increased mortality, relative risk 1.48 (95% CI 1.45–1.73). Conclusions: Patients on chronic dialysis were at increased risk for ENDO compared to the general population. The risk for peritoneal dialysis patients was not statistically significant, possibly due to the smaller numbers of patients on this modality. Hemodialysis (vs. peritoneal dialysis) and comorbidities were the strongest risk factors for ENDO identified.

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          Effect of waiting time on renal transplant outcome.

          Numerous factors are known to impact on patient survival after renal transplantation. Recent studies have confirmed a survival advantage for renal transplant patients over those waiting on dialysis. We aimed to investigate the hypothesis that longer waiting times are more deleterious than shorter waiting times, that is, to detect a "dose effect" for waiting time. We analyzed 73,103 primary adult renal transplants registered at the United States Renal Data System Registry from 1988 to 1997 for the primary endpoints of death with functioning graft and death-censored graft failure by Cox proportional hazard models. All models were corrected for donor and recipient demographics and other factors known to affect outcome after kidney transplantation. A longer waiting time on dialysis is a significant risk factor for death-censored graft survival and patient death with functioning graft after renal transplantation (P < 0.001 each). Relative to preemptive transplants, waiting times of 6 to 12 months, 12 to 24 months, 24 to 36, 36 to 48, and over 48 months confer a 21, 28, 41, 53, and 72% increase in mortality risk after transplantation, respectively. Relative to preemptive transplants, waiting times of 0 to 6 months, 6 to 12 months, 12 to 24 months, and over 24 months confer a 17, 37, 55, and 68% increase in risk for death-censored graft loss after transplantation, respectively. Longer waiting times on dialysis negatively impact on post-transplant graft and patient survival. These data strongly support the hypothesis that patients who reach end-stage renal disease should receive a renal transplant as early as possible in order to enhance their chances of long-term survival.
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            Effect of the use or nonuse of long-term dialysis on the subsequent survival of renal transplants from living donors.

            The effect on allograft survival of the transplantation of kidneys from living donors without the previous initiation of long-term dialysis is controversial. Using data from the U.S. Renal Data System, we performed a retrospective cohort study of 8481 patients who were or who were not treated by long-term dialysis before receiving a kidney transplant from a living donor. The relative rate of allograft failure for patients who received a transplant without previously undergoing long-term dialysis, as compared with patients who underwent long-term dialysis before transplantation, was assessed by proportional-hazards analysis, with adjustment for potential confounding variables, including the transplantation center and median household income. The association between the receipt of a kidney transplant from a living donor without previous dialysis ("preemptive transplantation") and the risk of biopsy-confirmed acute rejection within six months after transplantation was evaluated by conditional logistic-regression analysis, with adjustment for the transplantation center. Transplantation of a kidney from a living donor without previous long-term dialysis was associated with a 52 percent reduction in the risk of allograft failure during the first year after transplantation (rate ratio, 0.48; P=0.002), an 82 percent reduction during the second year (rate ratio, 0.18; P=0.001), and an 86 percent reduction during subsequent years (rate ratio, 0.14; P=0.001), as compared with transplantation after dialysis. The reduction in the rate of allograft failure during the first year was attenuated when adjustment was made for the timing of acute rejection within the first year (rate ratio, 0.69; 95 percent confidence interval, 0.44 to 1.10; P=0.10). Increasing duration of dialysis was associated with increasing odds of rejection within six months after transplantation (P=0.001). Preemptive transplantation of kidneys from living donors without the previous initiation of dialysis is associated with longer allograft survival than transplantation performed after the initiation of dialysis.
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              Possible influence of the prospective payment system on the assignment of discharge diagnoses for coronary heart disease.

              The prospective payment system, under which diagnosis-related groups (DRGs) are used to reimburse hospitals for the care of Medicare patients, replaced the fee-for-service method of payment in Rhode Island in 1983 and in Massachusetts in 1985. Changes in financial incentives resulting from the use of the DRG system may have influenced the assignment of discharge diagnostic codes away from those with lower reimbursement toward codes with higher reimbursement. We collected data from the hospital records of patients 35 through 74 years of age who were discharged with codes 410 through 414 (representing various categories of coronary heart disease) of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The patients were discharged from seven hospitals in two New England communities (one in Rhode Island and one in Massachusetts) between 1980 and 1988. The rates of diagnosis of various forms of coronary heart disease were determined by studying ICD-9-CM hospital discharge codes (codes 410 and 411 for acute forms of coronary heart disease and codes 412, 413, and 414 for chronic forms) and by using a computerized diagnostic algorithm designed to detect definite myocardial infarction and fatal coronary heart disease. The rates of definite coronary events diagnosed by the algorithm and by the study of ICD-9-CM codes 410 through 414 were constant or increased slightly during the study period. However, the frequency of assignment of codes for the acute forms of coronary heart disease (which entail higher reimbursement) rose from 35.2 percent to 48.4 percent among discharged patients with cardiac disease after the institution of DRGs. The majority of this increase was associated with the code for unstable angina pectoris. The frequency of assignment of codes for the chronic forms of coronary heart disease (which entail lower reimbursement) decreased reciprocally, from 64.8 percent to 51.6 percent (P < 0.001). Our data are consistent with the hypothesis that the prospective reimbursement system has influenced the assignment of hospital discharge codes in a way that would increase payment to hospitals. However, the data do not permit us to distinguish whether hospitals began to assign more precise diagnoses with the advent of the DRG system, or whether they began to favor diagnoses of acute conditions solely for financial reasons.

                Author and article information

                S. Karger AG
                June 2002
                03 June 2002
                : 91
                : 2
                : 203-209
                aNephrology Service, Walter Reed Army Medical Center, Washington, D.C. and Uniformed Services University of the Health Sciences, Bethesda, Md., and bNational Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, Md., USA
                58393 Nephron 2002;91:203–209
                © 2002 S. Karger AG, Basel

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                Tables: 3, References: 32, Pages: 7
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