Background/Aims: Few published data describe survival rates for pediatric end-stage renal disease (ESRD) patients. We aimed to describe one-year mortality rates for US pediatric ESRD patients over a 15-year period. Methods: In this retrospective cohort study, we used the US Renal Data System database to identify period-prevalent cohorts of patients aged younger than 19 for each year during the period 1995-2010. Yearly cohorts averaged approximately 1,200 maintenance dialysis patients (60% hemodialysis, 40% peritoneal dialysis) and 1,100 transplant recipients. Patients were followed for up to 1 year and censored at change in modality, loss to follow-up, or death. We calculated the unadjusted model-based mortality rates per time at risk, within each cohort year, by treatment modality (hemodialysis, peritoneal dialysis, transplant) and patient characteristics; percentage of deaths by cause; and overall adjusted odds of mortality by characteristics and modality. Results: Approximately 50% of patients were in the age group 15-18, 55% were male, and 45% were female. The most common causes of ESRD were congenital/reflux/obstructive causes (55%) and glomerulonephritis (30%). One-year mortality rates showed evidence of a decrease in the number of peritoneal dialysis patients (6.03 per 100 patient-years, 1995; 2.43, 2010; p = 0.0263). Mortality rates for transplant recipients (average 0.68 per 100 patient-years) were consistently lower than the rates for all dialysis patients (average 4.36 per 100 patient-years). Conclusions: One-year mortality rates differ by treatment modality in pediatric ESRD patients.

BackgroundHospitalization for cardiovascular disease (CVD) is common among patients receiving maintenance dialysis, but patterns of readmissions following cardiovascular events are underexplored.Methods and ResultsIn this retrospective analysis of prevalent, Medicare‐eligible patients receiving dialysis in 2012–2013, all live‐discharge hospitalizations attributed to CVD were ascertained. Rates of all‐cause, CVD‐related, and non–CVD‐related readmissions and death in the ensuing 10 and 30 days were calculated. Multinomial logistic modeling was used to assess the relationship between potential explanatory factors and outcomes of interest. Among 142 210 analyzed hospitalizations, mean age at time of index CVD hospitalization was 64.9±14.1 years; 50.4% of index hospitalizations were for women, and 41.4% were for white patients. Fully 15.6% and 34.2% of CVD hospitalizations resulted in readmission within 10 and 30 days, respectively; less than half of readmissions were CVD related (42.5%, 10 days; 43.1%, 30 days). Death within 30 days, regardless of readmission, occurred after 4.5% of index hospitalizations; 51.2% were attributed to CVD. Compared with ages 65 to 69 years, younger age tended to be associated with increased readmission risk (adjusted relative risk for ages 18–44 years: 1.55; 95% confidence interval, 1.48–1.63). Readmission risk did not differ between white and black patients, but risk of death without readmission was markedly lower for black patients (relative risk: 0.60; 95% confidence interval, 0.55–0.67).ConclusionsRoughly 1 in 3 CVD hospitalizations resulted in 30‐day readmission; nearly 1 in 20 was followed by death within 30 days. Risk of death without readmission was higher for white than black patients, despite no difference in risk of readmission.

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Introduction: ALL is a rare disease. Older adults with ALL have a markedly poor prognosis and higher mortality that may be attributable in part to greater comorbidity and lower use of intensive therapeutic options. Limited data are available about the real-world treatment patterns of elderly ALL patients in the US including their likelihood of receiving chemotherapy. In this study, we described treatment patterns in a population-based cohort of older adults with ALL. Methods: Using 100% Medicare ALL data from 2007-2012, we identified adults age ≥ 66 years diagnosed with ALL from 2008-2011 who were continuously enrolled in Medicare Part A and B for 12 months before ALL diagnosis (baseline period) and had Part D coverage for ≥ 30 days after diagnosis. Presence of ALL was defined by ≥1 Part A inpatient (IP)/skilled nursing facility (SNF)/home health agency (HHA)/hospice (HS) or ≥2 Part A outpatient (OP)/Part B (PB) claims carrying an ALL diagnosis code on different dates in any 2-month interval. The date of ALL diagnosis was defined as the earlier date of the 1st IP/SNF/HHA/HS claim or the 2nd of 2 OP/PB claims carrying an ALL code. Baseline comorbidity level was defined using a modified Charlson Comorbidity Index (CCI). During the follow-up period, from diagnosis to the earliest of death, disenrollment from Part A, B, and D coverage, enrollment in an HMO, or December 31, 2012, we identified chemotherapy by presence of a claim containing billing codes for a specific chemotherapy agent or chemotherapy administration; use of tyrosine kinase inhibitors (TKI) was identified by the presence of corresponding National Drug Codes within Part D pharmacy claims. We defined chemotherapy course from the first claim within 90 days of diagnosis until the last claim with a < 60-day gap between two consecutive claims for chemotherapy. Baseline patient characteristics and treatment patterns were described. Chi-square test was used to assess the differences in baseline characteristics between treatment groups. Kaplan-Meier method was used to estimate the median overall survival (OS) and the 95% confidence interval (CI) from treatment initiation. Results: Of 727 patients who met study inclusion criteria, 235 (32%) received treatment with only chemotherapy within 90 days of ALL diagnosis, 51 (7%) with chemotherapy and TKI, and 17 (2%) with only TKI. Chemotherapy-treated patients with or without TKI were younger and had lower comorbidity burden compared with patients not receiving chemotherapy (P<0.001 for age and CCI; Table). Median OS (95% CI) from treatment initiation was 10.2 (8.3-12.7) months for patients who received treatment with only chemotherapy, 18.1 (11.3-31.2) months for those with chemotherapy and TKI, and 5.8 (1.2-13.7) for those with only TKI. Among 286 (39%) chemotherapy-treated patients regardless of TKIs, the median (interquartile range [IQR]) time to chemotherapy initiation was 3 (0-11) days. Chemotherapy was administered in 209 (73%) patients in an inpatient setting with mean (SD) length of stay 22.9 (13.9) days; of these, 90 (43%) received chemotherapy only in an inpatient setting within the first chemotherapy course. There were 177 (62%), 74 (26%), and 35 (12%) patients who received 1, 2, and ≥3 chemotherapy courses, respectively, for a total of 450 chemotherapy courses with median (IQR) course duration of 53.5 (22-137) days. Overall, 68 (9%) patients had a TKI prescription filled within 90 days of diagnosis; of these, 19%, 32%, and 49% were aged 66-69, 70-74, and ≥ 75 years, respectively; 57% were female; and 79% were white. The median (IQR) time to first prescription fill date was 20 (12-34) days. Imatinib was more common as the first TKI agent (n=55; 81%) than dasatinib (n=13; 19%). In total, 20 (29%) patients switched TKI agents; of these, 16 (80%) switched from imatinib to dasatinib. Conclusions: Among elderly Medicare beneficiaries diagnosed with ALL in 2008-2011, 39% were treated with chemotherapy and 9% were prescribed a TKI within 90 days of diagnosis. Patients with advanced age and higher comorbidity level were less likely to receive chemotherapy. Median OS was 10 months for patients with only chemotherapy, 18 months for patients with chemotherapy and TKI, and 6 months for patients with only TKI. These findings demonstrate the unmet need for safe and effective treatments for elderly ALL patients. Further studies assessing the comparative effectiveness and benefit-risk of treatments are warranted. Disclosures Chia: Amgen Inc: Employment, Equity Ownership. Katz:Amgen Inc: Employment, Equity Ownership.

In adults on chronic hemodialysis, achieving a hemoglobin concentration of 12g/dl and above with erythropoiesis stimulating agents leads to increased cardiovascular events and mortality, but this may not be true in children. Therefore, we conducted a retrospective cohort study of pediatric patients (under 18) from the Centers for Medicare and Medicaid Services End Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) project (2000 to 2008) merged with the United States Renal Data System. Hemoglobin was determined from the Clinical Performance Measures data, and beginning annually on January 1st of the next year, patients were followed for up to 1 year. We determined the outcomes (mortality, hospitalization, and cardiovascular events) during follow-up by hemoglobin group at baseline. Models were adjusted for demographic and clinical characteristics of 1569 children studied. The hemoglobin 12 g/dl and above group was older, had fewer years of ESRD, and was more often transplanted. Inpatient and outpatient visits for congestive heart failure, cardiomyopathy, and valvular heart disease were most common in the hemoglobin under 10g/dl group and the frequency of these diagnoses decreased with increasing hemoglobin. The hazard ratio of all-cause mortality (0.33, 95% confidence interval 0.14-0.81) and the adjusted relative rate of all-cause hospitalizations (0.81, 0.74-0.89) were significantly lower in the hemoglobin 12 g/dl and above group. Cardiovascular hospitalizations were significantly higher in the hemoglobin under 10g/dl group (1.31, 1.05-1.64). Thus, in children on hemodialysis, hemoglobin 12g/dl and above is not associated with increased cardiovascular visits, mortality, or all-cause and cardiovascular-related hospitalizations.