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Background In the general population, low serum magnesium (Mg) levels are associated with poor outcomes and death. While limited data suggest that low baseline Mg levels may be associated with higher mortality in hemodialysis (HD) patients, the impact of changes in Mg over time is unknown. Study Design We examined the association of time-varying serum Mg levels with all-cause mortality using multivariable time-dependent survival models adjusted for clinical characteristics and other time-varying laboratory measures. Setting & Participants 9,359 maintenance HD patients treated in a large dialysis organization between 2007 and 2011. Predictor Time-varying serum Mg levels across 5 Mg increments (<1.8, 1.8–<2.0, 2.0–<2.2, 2.2–<2.4, ≥2.4 mg/dl). Outcomes All-Cause Mortality Results 2,636 individuals died over 5 years. Time-varying serum Mg <2.0 mg/dl was associated with higher mortality after adjustment for demographics and co-morbidities including hypertension, diabetes, and malignancies (reference: Mg 2.2–<2.4 mg/dL): adjusted HRs for serum Mg <1.8 and 1.8–<2.0 mg/dl were 1.39 (95% CI, 1.23–1.58; p<0.001) and 1.20 (95% CI, 1.06–1.36; p=0.004), respectively. Some associations were attenuated to the null after incremental adjustment for laboratory tests, particularly serum albumin. However among patients with serum albumin measurements, low albumin levels (<3.5 g/dl) and Mg <2.0 mg/dl was associated with an additional death risk (adjusted HR, 1.17; 95% CI, 1.05–1.31; p=0.004), while patients with high serum albumin levels (≥3.5 g/dl) exhibited low death risk (adjusted HRs of 0.53 and 0.53 [p≤0.001] for Mg <2.0 mg/dl and ≥2.0 mg/dl, respectively; reference: albumin <3.5 g/dl and Mg ≥2.0 mg/dl). Limitations Causality cannot be determined, and residual confounding cannot be excluded given the observational study design. Conclusions Lower serum Mg levels are associated with higher mortality in HD patients including in those with hypoalbuminemia. Interventional studies are warranted to examine whether correction of hypomagnesemia ameliorates adverse outcomes in this population.

BACKGROUND Red cell distribution width (RDW) is an index of red blood cell volume variability that has historically been used as a marker of iron-deficiency anemia. More recently, studies have shown that elevated RDW is associated with higher mortality risk in the general population. However, there is lack of data demonstrating the association between RDW and mortality risk in hemodialysis (HD) patients. We hypothesized that higher RDW levels are associated with higher mortality in HD patients. STUDY DESIGN Retrospective observational study using a large HD patient cohort. SETTING & PARTICIPANTS 109,675 adult maintenance HD patients treated in a large dialysis organization January 1, 2007–December 31, 2011. PREDICTOR Baseline and time-varying RDW, grouped into 5 categories: <14.5%, 14.5%–<15.5%, 15.5%–<16.5%, 16.5%–<17.5% and ≥ 17.5%. RDW 15.5%–<16.5% was used as the reference category. OUTCOME All-cause mortality. RESULTS The mean age of study participants was 63±15 (SD) years and the study cohort was 44% female. In baseline and time-varying analyses, there was a graded association between higher RDW levels and incrementally higher mortality risk. Receiver operating characteristic, net reclassification analysis and integrated discrimination improvement analyses demonstrated that RDW is a stronger predictor of mortality as compared with traditional markers of anemia such as hemoglobin, ferritin, and iron saturation. LIMITATIONS Lack of comprehensive data that may be associated with both RDW and HD patient outcomes, such as blood transfusion data, socioeconomic status, and other unknown confounders; therefore the possibility of residual confounding could not be excluded. Also, lack of information on cause of death; thus, cardiovascular mortality outcomes could not be examined. CONCLUSIONS In HD patients, higher RDW levels are associated with incrementally higher mortality risk. RDW is also a stronger predictor of mortality than traditional laboratory markers of anemia. Further studies are needed to determine the mechanisms underlying the association between RDW and mortality.

Home dialysis, which comprises peritoneal dialysis (PD) or home hemodialysis (home HD), offers patients with ESRD greater flexibility and independence. Although ESRD disproportionately affects racial/ethnic minorities, data on disparities in use and outcomes with home dialysis are sparse. We analyzed data of patients who initiated maintenance dialysis between 2007 and 2011 and were admitted to any of 2217 dialysis facilities in 43 states operated by a single large dialysis organization, with follow-up through December 31, 2011 (n=162,050, of which 17,791 underwent PD and 2536 underwent home HD for $91 days). Every racial/ethnic minority group was significantly less likely to be treated with home dialysis than whites. Among individuals treated with in-center HD or PD, racial/ethnic minorities had a lower risk for death than whites; among individuals undergoing home HD, only blacks had a significantly lower death risk than whites. Blacks undergoing PD or home HD had a higher risk for transfer to in-center HD than their white counterparts, whereas Asians or others undergoing PD had a lower risk than whites undergoing PD. Blacks irrespective of dialysis modality, Hispanics undergoing PD or in-center HD, and Asians and other racial groups undergoing in-center HD were significantly less likely than white counterparts to receive a kidney transplant. In conclusion, there are racial/ethnic disparities in use of and outcomes with home dialysis in the United States. Disparities in kidney transplantation evident for blacks and Hispanics undergoing home dialysis are similar to those with in-center HD. Future studies should identify modifiable causes for these disparities.

Background Medication non-adherence is a known risk factor for adverse outcomes in the general population. However, little is known about the association of pre-dialysis medication adherence among patients with advanced chronic kidney disease with mortality following their transition to dialysis. Study Design Observational study. Setting & Participants 32,348 US veterans who transitioned to dialysis during 2007–2011. Predictors Adherence to treatment with cardiovascular drugs, ascertained from pharmacy database records using proportion of days covered (PDC) and persistence during the pre-dialysis year. Outcomes Post-dialysis initiation all-cause and cardiovascular mortality, using Cox models with adjustment for confounders. Results The mean age of the cohort was 72±11 (SD) years, among whom 96% were male, 74% were white, 23% were African American, and 69% were diabetic. During median follow-up of 23 (IQR, 9–36) months, 18,608 patients died. Among patients with PDC >80%, there were 14,006 deaths (mortality rate, 283 [95% CI, 278–288]/1000 patient-years [PY]); among patients with PDC >60%–80%, there were 3,882 deaths (mortality rate, 294 [95% CI, 285–304]/1000 PY); among patients with PDC ≤60%, there were 720 deaths (mortality rate, 291 [95% CI, 271–313]/1000 PY). Compared to patients with PDC >80%, adjusted HR for post-dialysis initiation all-cause mortality for patients with PDC >60%–80% was 1.12 (95% CI, 1.08–1.16) and for patients with PDC ≤60% was 1.21 (95% CI, 1.11–1.30). In addition, compared to patients showing medication persistence, adjusted HR risk for post-dialysis initiation all-cause mortality for patients with non-persistence was 1.11 (95% CI, 1.05–1.16). A similar trend was detected for cardiovascular mortality and in subgroup analyses. Limitations Large number of missing values; the results may not be generalizable to women or the general US population. Conclusions Pre-dialysis cardiovascular medication non-adherence is an independent risk factor for post-dialysis mortality among advanced chronic kidney disease patients transitioning to dialysis. Further studies are needed to assess whether interventions targeting adherence improve survival after dialysis initiation.

Introduction: Approximately 291 million women worldwide are HPV DNA carriers. Studies have indicated that having multiple sexual partners may lead to higher HPV transmission. Thus female sex workers (FSWs) may be at greater risk of infection compared to the general population. Herein we review publications with data on FSW cervical HPV test results. We also examine variations of HPV prevalence and risk behaviors by region. Knowledge of prevalent HPV types in FSWs may lead to improved prevention measures and assist in understanding vaccination in high-risk groups.Methods: We conducted a review of the literature by searching PUBMED using the terms “prostitution” or “female sex workers”, “human papillomavirus” or “HPV”, and “prevalence” or “PCR” to find articles. We excluded studies without HPV testing or HPV type specific results, or unconventional HPV testing.Results: A total of 35 peer-reviewed publications were included in our review. High risk HPV types 16 and 18 ranged from 1.1-38.9‰ in prevalence. In addition to high-risk HPV types, newer studies reported non-carcinogenic HPV types also of high prevalence. The most prevalent HPV types reported among FSWs included HPV 6 (11.5%), 16 (38.9%), 18 (23.1%), 31 (28.4%), 52 (32.7%), and 58 (26.0%).Conclusions: Female sex workers have an overall high prevalence of HPV infection of high-risk types as evident through various testing methods. FSWs are thought to be at increased risk of cervical cancer because of high HPV exposure. This highlights the need for HPV and cervical prevention campaigns tailored to FSWs.