SummaryAdequate pre-dialysis care reduces mortality among end-stage renal disease (ESRD) patients. We tested the hypothesis that individuals with ESRD due to sickle cell disease (SCD-ESRD) receiving pre-ESRD care have lower mortality compared to individuals without pre-ESRD care. We examined the association between mortality and pre-ESRD care in incident SCD-ESRD patients who started haemodialysis between 1 June, 2005 and 31 May, 2009 using data provided by the Centers for Medicare and Medicaid Services (CMS). SCD-ESRD was reported for 410 (0Á1%) of 442 017 patients. One year after starting dialysis, 108 (26Á3%) patients with incident ESRD attributed to SCD died; the hazard ratio (HR) for mortality among patients with SCD-ESRD compared to those without SCD as the primary cause of renal failure was 2Á80 (95% confidence interval [CI] 2Á31-3Á38). Patients with SCD-ESRD receiving pre-dialysis nephrology care had a lower death rate than those with SCD-ESRD who did not receive predialysis nephrology care (HR = 0Á67, 95% CI 0Á45-0Á99). The one-year mortality rate following an ESRD diagnosis was almost three times higher in individuals with SCD when compared to those without SCD but with ESRD and could be attenuated by pre-dialysis nephrology care.

No abstract

SummaryBackgroundThe length of time that people with HIV on antiretroviral therapy (ART) with viral load suppression will be able to continue before developing viral rebound is unknown. We aimed to investigate the rate of first viral rebound in people that have achieved initial suppression with ART, to determine factors associated with viral rebound, and to use these estimates to predict long-term durability of viral suppression.MethodsThe UK Collaborative HIV Cohort (UK CHIC) Study is an ongoing multicentre cohort study that brings together in a standardised format data on people with HIV attending clinics around the UK. We included participants who started ART with three or more drugs and who had achieved viral suppression (≤50 copies per mL) by 9 months after the start of ART (baseline). Viral rebound was defined as the first single viral load of more than 200 copies per mL or treatment interruption (for ≥1 month). We investigated factors associated with viral rebound with Poisson regression. These results were used to calculate the rate of viral rebound according to several key factors, including age, calendar year at start of ART, and time since baseline.ResultsOf the 16 101 people included, 4519 had a first viral rebound over 58 038 person-years (7·8 per 100 person-years, 95% CI 7·6–8·0). Of the 4519 viral rebounds, 3105 (69%) were defined by measurement of a single viral load of more than 200 copies per mL, and 1414 (31%) by a documented treatment interruption. The rate of first viral rebound declined substantially over time until 7 years from baseline. The other factors associated with viral rebound were current age at follow-up and calendar year at ART initiation (p<0·0001) and HIV risk group (p<0·0001); higher pre-ART CD4 count (p=0·0008) and pre-ART viral load (p=0·0003) were associated with viral rebound in the multivariate analysis only. For 1322 (29%) of the 3105 people with observed viral rebound, the next viral load value after rebound was 50 copies per mL or less with no regimen change. For HIV-positive men who have sex with men, our estimates suggest that the probability of first viral rebound reaches a plateau of 1·4% per year after 45 years of age, and 1·0% when accounting for the fact that 29% of viral rebounds are temporary elevations.InterpretationA substantial proportion of people on ART will not have viral rebound over their lifetime, which has implications for people with HIV and the planning of future drug development.FundingUK Medical Research Council.

Background The Centers for Medicare & Medicaid Services (CMS) established a national goal of 66% arterio-venous fistula (AVF) use among prevalent hemodialysis (HD) patients for the current Fistula First Breakthrough Initiative (FFBI). The feasibility of achieving the goal has been debated. We examined contemporary patterns of AVF use among prevalent patients to assess the potential for attaining the goal by dialysis facilities and their associated end-stage renal disease (ESRD) Networks in the United States (US). Study Design Observational study. Setting and Participants US dialysis facilities with a mean HD patient census of 10 or more over the 40 month study period, January 2007 to April 2010. Outcomes and Measurements Mean changes in facility-level AVF use and the percent of facilities achieving the 66% prevalent AVF goal within the US and each Network. Results US mean prevalent AVF use within dialysis facilities increased from 45.3% to 55.5% (P < 0.001) in the US but varied substantially across regions. The percent of facilities achieving the 66% AVF use goal increased from 6.4% to 19.0% (P < 0. 001). Over the 40 months, 35.9% of facilities achieved the CMS goal at least one month. On average, these facilities sustained mean (SD) use of 66% or greater for 12.9 (11.7) months. Casemix and other facility characteristics explained 20% of the variation in the proportion of facility patients using an AVF in the last measured month, leaving substantial unexplained variability. Limitations This analysis is limited by the absence of facilities’ case-mix data over time and the national scope of the initiative precludes use of a comparison group. Conclusions Achieving the CMS goal of 66% prevalent AVF use is feasible for individual dialysis facilities. There is a need to reduce regional variation before the CMS goal can be fully realized for US hemodialysis facilities.

Trinquart L, Mounier-Vehier C, Sapoval M, et al. Hypertension 2010;56: 525-32.Conclusion: Renal artery vascularization in patients with fibromuscular disease (FMD) by angioplasty or surgery yields moderate benefits, with significant variation among studies. Blood pressure outcome is strongly influenced by patient age.Summary: Surgery and percutaneous renal artery angioplasty are both used to treat renal artery stenosis. Benefit for revascularization of atherosclerotic renal arteries stenosis is limited (Nordmann AJ, Cochrane Database Syst Rev 2003:CD002944; Balk E et al, Ann Intern Med 2006;145:901-12; Wheatley K et al, N Engl J Med 2009;361:1953-62). The limited benefit of revascularization of atherosclerotic renal artery stenosis is thought to reflect underlying renal parenchymal disease associated with age. However, patients with FMD are younger (30s and 40s), with normal kidney function. FMD patients are also primarily women. No randomized control trials and no comprehensive systematic reviews have assessed blood pressure outcome with revascularization for renal artery stenosis secondary to FMD. The primary objective of this systematic review was to assess the rate of hypertension cure after renal artery revascularization in patients with hypertension and FMD renal artery stenosis. Other objectives were to assess technical success rates of revascularization, risk of complication, and to explore variation of outcomes across subgroups. This systematic review includes studies of both surgical and percutaneous revascularization of FMD renal artery stenosis.The authors selected 47 angioplasty studies involving 1660 patients and 23 surgical studies involving 1014 patients. Using the definition of cure particular to each study, combined rates of hypertension cure were estimated to be 46% (95% CI, 40%-52%) after angioplasty and 58% (95% CI, 53%-62%) after surgery. There was substantial variation across studies. Patient age and time of publication were negatively associated with the probability of being "cured." Cure rates using the current definition of hypertension cure (blood pressure Ͻ140/90 mm Hg, without treatment) were only 36% after angioplasty and 54% after surgery, respectively. Risk of periprocedural complications were 12% after angioplasty and 17% after surgery, with fewer major complications after angioplasty (6%) vs surgery (15%).Comment: This is the largest meta-analysis reported on this subject. Overall, this study found that the probability of cure for revascularization of renal artery stenosis secondary to FMD was negatively associated with age, known duration of hypertension, medial-type FMD, time of publication, and a more strict definition of cure. Future studies of revascularization for renal artery stenosis should include standardization of the definition of blood pressure cure using the current criteria of a blood pressure Ͻ140/90 mm Hg, without treatment, as the definition of cure. Because only one patient in three has a normal blood pressure after percutaneous renal artery revascularization...