Browsing by Subject "Dialysis"

Now showing 1 - 4 of 4
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    End Stage Renal Disease due to Multiple Myeloma in the United States, 2001-2010
    (2017-12) Reule, Scott
    Abstract. While the management of myeloma and light chain deposition disease (“MM”) has changed considerably in the last decade, it is unknown how the burden of associated end-stage renal (ESRD) has evolved. Methods. United States Renal Data System data (n = 1,048,683) for the years 2001-2010 were used to calculate incidence rates and outcomes of MM (n = 12,704, 1.3%). Results. Compared to 2001-2002, standardized incidence ratios declined to 0.8 for 2009-2010. Characteristics of MM patients included older age (≥ 65, 63.7% vs. 43.7%) and white race (76.3% vs. 65.1%). Multiple myeloma was associated with a greater likelihood of death (adjusted hazards ratio [AHR] 2.3) and a lower likelihood of listing for (AHR 0.2) a kidney transplant. While hazards ratios for listing increased over time (AHR 1.06 for 2009-2010 Vs. 2001-2002), those for transplant and death did not (AHRs 0.6 and 0.9, respectively). Regional variation in outcomes was apparent, as patients in the South were more likely to die (AHR 1.04 Vs. the Northeast), and more likely to not be listed (AHR 2.4) nor receive a transplant (AHR 2.9). Conclusions. While ESRD due to MM has declined in the United States, outcomes on dialysis remain poor and exhibit substantial geographic variation.
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    Keeping your kidneys healthy with diabetes.
    (2012-07-24) Sweeney, Margaret
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    Retrospective Analysis of Prescription Drug Claims, with Applications to Risk Score Construction and Treatment of Heart Failure in End Stage Renal Disease
    (2015-05) Weinhandl, Eric
    There are more than 450,000 patients receiving chronic dialysis in the US. Patients with end stage renal disease are statutorily eligible for Medicare, regardless of age. Due to high prevalence of poverty, many are dually enrolled in Medicare and Medicaid and are automatically enrolled in Part D (prescription drug insurance). This dissertation comprises 3 studies involving prescription drug claims in dialysis patients. In the first study, I constructed and validated risk scores based on Part D claims in incident and prevalent dialysis patients. Comorbidity indices derived from administrative data are typically based on diagnosed diseases, but the middling sensitivity of diagnosis codes limits the accuracy of these indices. In contrast, prescription drug claims are bona fide evidence of medication dispensation. I investigated aspects of newly developed scores and compared their performance in predicting risk with older scores based on diseases. In the second study, I assessed the efficacy and safety of pharmacologic inhibition of the renin-angiotensin system in dialysis patients with congestive heart failure. ACE inhibitors and ARBs are recommended for the treatment of heart failure with reduced ejection fraction. However, pivotal clinical trials all excluded patients on dialysis. I used propensity score matching to identify matched controls for treated patients that were newly dispensed an ACE inhibitor or ARB shortly after discharge from hospitalization for heart failure. I described the relative hazards of mortality and morbidity with treatment. In the third study, I assessed relative hazards of death and hospitalization associated with 4 ACE inhibitors and 2 ARBs in dialysis patients with congestive heart failure. The existence of class effects is generally presumed, but not necessarily supported by evidence regarding clinical outcomes. I showed that the most widely used agent (lisinopril) in this patient population is not necessarily associated with best outcomes.
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    The timing of arteriovenous fistula placement and medicare costs during dialysis initiation.
    (2011-02) Solid, Craig Anthony
    Although considered a rare disease in 1972 when its treatment was added to the Medicare program, the incidence and prevalence of total kidney failure, called End Stage Renal Disease (ESRD), has grown substantially in the last half-century. There are now over 500,000 patients with ESRD, comprising about 1% of all Medicare patients but accounting for over 6% of total expenditures. There were over 110,000 incident ESRD patients in 2006, projected to grow to over 150,000 by the year 2020, with a total of almost 800,000 ESRD patients by that time (Gilbertson, 2005; USRDS, 2008, Vol 2, Fig 2.1). Although kidney transplants have become more common, organ shortages as well as the complex disease burden of patients result in the majority of patients having their ESRD treated by clinic-provided hemodialysis (HD). This process, which represents the type of renal replacement therapy for 90% of new ESRD patients, involves pumping a patient's blood through an external dialysis machine to filter and clean the blood before returning it to the body. This process requires a vascular access be placed in the patient to allow the blood to flow from the patient to the dialysis machine and back again. There are two main types of vascular access: a temporary catheter, which is simply a plastic tube inserted through the skin and into a vein, and an internal access, which connects an artery and vein together to produce a strong location from which blood can be drawn. The internal access is called an arteriovenous fistula (AVF) if the vein and artery are joined directly together. If they are joined with a synthetic tube it is called an arteriovenous graft (AVG). Catheters are quick to insert, cost very little and can be used almost immediately. However, they are prone to infections and complications like clotting. AVFs and AVGs, on the other hand, are surgically created, causing them to be more expensive and require time to mature before they can be used. However, since they are completely internal they are much less at risk for infections and complications. For those who are good candidates for an AVF, the timing of their AVF placement in relation to dialysis initiation can be classified into three distinct groups: (i) those who have had an AVF placed early enough so that it is mature and ready for use when it is time to begin chronic dialysis; (ii) those who have had an AVF placed prior to dialysis initiation that has not had enough time to mature, forcing them to begin dialysis using temporary catheters until the AVF is ready; and (iii) those who do not have an AVF placed until after they have already begun regular dialysis, resulting in the full maturation time occurring while they dialyze with catheters. The main research question I wish to address is: Does having a mature AVF at the start of dialysis result in a net cost-savings to Medicare compared to either: having an AVF in place but not yet mature at initiation, or having an AVF placed soon after the start of dialysis? Currently, Medicare makes a few exceptions regarding coverage of ESRD patients for those not already Medicare eligible. While Medicare does not have any exceptions involving AVF placement prior to dialysis, if doing do would actually result in lower overall costs it might benefit Medicare to make such an exception.