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NKF 2007 Spring Clinical Meetings Abstracts
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PROSPECTIVE QUALITY OF LIFE EVALUATION IN PATIENTS UNDERGOING TREATMENT OF RENAL CELL CARCINOMA: INTERIM ANALYSIS Surena Matin, Louis Pisters, Yisheng Li, and Patricia Parker. The University of Texas M. D. Anderson Cancer Center, Houston, Texas. Treatment options for localized renal cell carcinoma (RCC) have rapidly expanded in the past 10 years to include laparoscopic surgery, nephron-sparing surgery (NSS), and watchful waiting (WW). We present the interim results of a prospective quality of life (QOL) evaluation in patients undergoing various forms of treatment for RCC. Patients undergoing laparoscopic, open, radical, and NSS renal procedures, or who were undergoing WW for a renal mass were enrolled in an IRB-approved study assessing QOL using several measures. Questionnaires were administered at multiple time points. A total of 218 patients have been enrolled to date on 3 IRB-approved protocols. Physical component scores (PCS) were different between patients undergoing laparoscopic (N=29) and open (N=24) surgery at the 1 month time point (p=0.01), with laparoscopy patients having higher scores, but were not significant for the other time points. Mental component scores (MCS) were also significantly different between laparoscopic and open groups at 1 month (p=0.015), with open surgery having higher scores. No PCS or MCS were significantly different between patients undergoing radical (N=20) versus NSS (N=33) at any time point. When evaluating the baseline QOL of patients undergoing surgery versus WW, those undergoing surgery had greater distress from intrusive thoughts and behaviors (p=0.002) and avoidance (p<0.001). At this interim, laparoscopy seems to be associated with better shortterm PCS, while short-term MCS favored patients undergoing open surgery. Patients undergoing watchful waiting of a small renal mass seem to be less distressed by their diagnosis. We suspect, however, that these popular instruments do not have enough sensitivity to measure relevant QOL outcomes in a patient population in whom renal reserve, the threat of dialysis, pain, and cancer recurrence or progression may be significant components that are unmeasured. A validated questionnaire specifically designed to evaluate the QOL of patients undergoing treatment for localized RCC is needed, and is currently being developed as part of a fourth protocol at our institution.
LONGITUDINAL COST ANALYSIS OF CHRONIC KIDNEY PATIENTS IN TAIWAN Lih-Wen Mau, Herng-Chia Chiu, Shang-Jyh Hwang, Allan J. Collins, Robert N. Foley. Unites States Renal Data System Coordinating Center, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA. Kaohsiung Medical University, Kaohsiung, Taiwan Not many studies have explored chronic kidney disease (CKD) costs in Taiwan, though CKD has become a global public health issue. The present longitudinal cost analysis of CKD in Taiwan was intended to examine medical services utilization by CKD patient characteristics and comorbid conditions. The study design was a retrospective secondary data analysis based on a 1% randomized sample of the National Health Insurance (NHI) claims data in Taiwan. From 2000 to 2004, the CKD patients accounted for 3.9% to 4.3% of total NHI annual expenditures; about 40% of the total CKD costs were spent on hospitalization (as shown in the following figure).Those aged 45 to 64 years had the highest share of total CKD costs. Those CKD patients with hypertension accounted for more than 50% of CKD costs annually. Although the current findings are descriptive, they can serve as a solid basis for further cross-national comparison of CKD costs. Distributions of Outpatient and Inpatient Costs for CKD Patients in Taiwan 100%
80%
60% Outpatient costs 40%
Inpatient costs
20%
0% 2000
2001
2002 Year
2003
2004
A59
139
TRAANSPLANATION HOSPITALIZATION AND QUALITY OF CARE FOR ESRD PATIENTS IN TAIWAN FROM 1996-2004 Lih-Wen Mau, Yao-Min Hung, Shang-Jyh Hwang, Herng-Chia Chiu, Allan J. Collins, Robert N. Foley. Unites States Renal Data System Coordinating Center, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA. Kaohsiung Medical University, Kaohsiung, Taiwan Taiwan has the highest incidence of end-stage renal disease (ESRD) world-wide, as reported by the United States Renal Data System. This study examined length of stay of transplantation hospitalization and associated medical costs and quality of care for kidney transplants in Taiwan. Based on the claims data from the Bureau of National Health Insurance, 1,310 ESRD patients receiving kidney transplants from 1996 to 2004 were studied. Measurement of transplantation hospitalization focused on length of stay and associated total costs incurred during transplantation surgery. In-hospital mortality and 14- and 30-day readmissions were indictors of quality of care. Mean age was 38.2 years (SD, 11.7) for the transplant sample. Average length of stay for transplantation surgery was 18.8 days. Total hospitalization costs averaged NT$ 227,514 (about US$ 7,198). The in-hospital mortality rate was 2.6%; re-admission rates were 9.3% within 14 days of discharge and 16.3% within 30 days. Significant risk factors of longer hospital stays and higher inpatient costs for transplantation surgery included diabetes, cardiovascular disease, infection, and rejection (P < 0.05). For adverse outcomes of transplantation, cerebrovascular disease, cardiovascular disease, and rejection were significantly associated with higher probability of in-hospital mortality (P < 0.05). The transplants with infection problems had an adjusted odds ratio of 1.82 for 30-day readmissions. The current findings confirm significant associations between comorbid conditions and higher inpatient service utilization of kidney transplants, which supports the importance of clinical requirements for transplant candidates. The risk probability of inhospital mortality and readmission of kidney transplants could be reduced by the management of hospital infection and acute rejection.
140
ATYPICAL PRESENTATION OF THROMBOTIC MICROANGIOPATHY Finnian R. Mc Causland, Liam F. Casserly, Cornelius J. Cronin Mid-Western Regional Hospital, Ireland This report details a family with thrombotic microangiopathy (TMA) spanning three generations. The index case A, age 21, was initially referred for evaluation of proteinuria. Preliminary investigations revealed hypertension, normal renal function, normal renal size by ultrasound and sub-nephrotic range proteinuria. A percutaneous renal biopsy was performed revealing a pattern consistent with chronic TMA. A’s mother has spastic paraparesis and underwent renal biopsy 20 years ago; she was initially given a diagnosis of adult-onset nephronophthisis. She progressed to end-stage kidney disease (ESKD) and required 7 months of haemodialysis before receiving a cadaveric renal transplant. A’s maternal aunt had spastic paraparesis, seizure disorder and also carried a diagnosis of nephronophthisis. She too progressed to ESKD and received a renal transplant, but passed away before further evaluation. A second maternal aunt attends the Nephrology clinic with hypertension, renal impairment and sub-nephrotic rage proteinuria. A’s two brothers were evaluated and found to have renal impairment, sub-nephrotic range proteinuria and hypertension. A renal biopsy revealed histology consistent with TMA in one of the brothers. Finally, A’s maternal grandmother and grand-aunt were known to have kidney disease. It is unclear from records whether they were given a formal diagnosis. Thrombophilia screens and von Willebrand Factor protease cleaving activity have been normal in all patients tested. In addition Factor H and Factor I levels in A, as well as genetic analysis for Factor H mutations, were all normal. Given the strong pedigree of kidney disease and the presence of TMA on two recent biopsies, it is likely that this family all suffer from the same disease process. Further genetic testing is in progress but has failed to identify a specific diagnosis as yet. This series highlights the myriad of clinical conditions that can lead to a pattern of TMA.
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138
PROSPECTIVE QUALITY OF LIFE EVALUATION IN PATIENTS UNDERGOING TREATMENT OF RENAL CELL CARCINOMA: INTERIM ANALYSIS Surena Matin, Louis Pisters, Yisheng Li, and Patricia Parker. The University of Texas M. D. Anderson Cancer Center, Houston, Texas. Treatment options for localized renal cell carcinoma (RCC) have rapidly expanded in the past 10 years to include laparoscopic surgery, nephron-sparing surgery (NSS), and watchful waiting (WW). We present the interim results of a prospective quality of life (QOL) evaluation in patients undergoing various forms of treatment for RCC. Patients undergoing laparoscopic, open, radical, and NSS renal procedures, or who were undergoing WW for a renal mass were enrolled in an IRB-approved study assessing QOL using several measures. Questionnaires were administered at multiple time points. A total of 218 patients have been enrolled to date on 3 IRB-approved protocols. Physical component scores (PCS) were different between patients undergoing laparoscopic (N=29) and open (N=24) surgery at the 1 month time point (p=0.01), with laparoscopy patients having higher scores, but were not significant for the other time points. Mental component scores (MCS) were also significantly different between laparoscopic and open groups at 1 month (p=0.015), with open surgery having higher scores. No PCS or MCS were significantly different between patients undergoing radical (N=20) versus NSS (N=33) at any time point. When evaluating the baseline QOL of patients undergoing surgery versus WW, those undergoing surgery had greater distress from intrusive thoughts and behaviors (p=0.002) and avoidance (p<0.001). At this interim, laparoscopy seems to be associated with better shortterm PCS, while short-term MCS favored patients undergoing open surgery. Patients undergoing watchful waiting of a small renal mass seem to be less distressed by their diagnosis. We suspect, however, that these popular instruments do not have enough sensitivity to measure relevant QOL outcomes in a patient population in whom renal reserve, the threat of dialysis, pain, and cancer recurrence or progression may be significant components that are unmeasured. A validated questionnaire specifically designed to evaluate the QOL of patients undergoing treatment for localized RCC is needed, and is currently being developed as part of a fourth protocol at our institution.
LONGITUDINAL COST ANALYSIS OF CHRONIC KIDNEY PATIENTS IN TAIWAN Lih-Wen Mau, Herng-Chia Chiu, Shang-Jyh Hwang, Allan J. Collins, Robert N. Foley. Unites States Renal Data System Coordinating Center, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA. Kaohsiung Medical University, Kaohsiung, Taiwan Not many studies have explored chronic kidney disease (CKD) costs in Taiwan, though CKD has become a global public health issue. The present longitudinal cost analysis of CKD in Taiwan was intended to examine medical services utilization by CKD patient characteristics and comorbid conditions. The study design was a retrospective secondary data analysis based on a 1% randomized sample of the National Health Insurance (NHI) claims data in Taiwan. From 2000 to 2004, the CKD patients accounted for 3.9% to 4.3% of total NHI annual expenditures; about 40% of the total CKD costs were spent on hospitalization (as shown in the following figure).Those aged 45 to 64 years had the highest share of total CKD costs. Those CKD patients with hypertension accounted for more than 50% of CKD costs annually. Although the current findings are descriptive, they can serve as a solid basis for further cross-national comparison of CKD costs. Distributions of Outpatient and Inpatient Costs for CKD Patients in Taiwan 100%
80%
60% Outpatient costs 40%
Inpatient costs
20%
0% 2000
2001
2002 Year
2003
2004
A59
139
TRAANSPLANATION HOSPITALIZATION AND QUALITY OF CARE FOR ESRD PATIENTS IN TAIWAN FROM 1996-2004 Lih-Wen Mau, Yao-Min Hung, Shang-Jyh Hwang, Herng-Chia Chiu, Allan J. Collins, Robert N. Foley. Unites States Renal Data System Coordinating Center, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA. Kaohsiung Medical University, Kaohsiung, Taiwan Taiwan has the highest incidence of end-stage renal disease (ESRD) world-wide, as reported by the United States Renal Data System. This study examined length of stay of transplantation hospitalization and associated medical costs and quality of care for kidney transplants in Taiwan. Based on the claims data from the Bureau of National Health Insurance, 1,310 ESRD patients receiving kidney transplants from 1996 to 2004 were studied. Measurement of transplantation hospitalization focused on length of stay and associated total costs incurred during transplantation surgery. In-hospital mortality and 14- and 30-day readmissions were indictors of quality of care. Mean age was 38.2 years (SD, 11.7) for the transplant sample. Average length of stay for transplantation surgery was 18.8 days. Total hospitalization costs averaged NT$ 227,514 (about US$ 7,198). The in-hospital mortality rate was 2.6%; re-admission rates were 9.3% within 14 days of discharge and 16.3% within 30 days. Significant risk factors of longer hospital stays and higher inpatient costs for transplantation surgery included diabetes, cardiovascular disease, infection, and rejection (P < 0.05). For adverse outcomes of transplantation, cerebrovascular disease, cardiovascular disease, and rejection were significantly associated with higher probability of in-hospital mortality (P < 0.05). The transplants with infection problems had an adjusted odds ratio of 1.82 for 30-day readmissions. The current findings confirm significant associations between comorbid conditions and higher inpatient service utilization of kidney transplants, which supports the importance of clinical requirements for transplant candidates. The risk probability of inhospital mortality and readmission of kidney transplants could be reduced by the management of hospital infection and acute rejection.
140
ATYPICAL PRESENTATION OF THROMBOTIC MICROANGIOPATHY Finnian R. Mc Causland, Liam F. Casserly, Cornelius J. Cronin Mid-Western Regional Hospital, Ireland This report details a family with thrombotic microangiopathy (TMA) spanning three generations. The index case A, age 21, was initially referred for evaluation of proteinuria. Preliminary investigations revealed hypertension, normal renal function, normal renal size by ultrasound and sub-nephrotic range proteinuria. A percutaneous renal biopsy was performed revealing a pattern consistent with chronic TMA. A’s mother has spastic paraparesis and underwent renal biopsy 20 years ago; she was initially given a diagnosis of adult-onset nephronophthisis. She progressed to end-stage kidney disease (ESKD) and required 7 months of haemodialysis before receiving a cadaveric renal transplant. A’s maternal aunt had spastic paraparesis, seizure disorder and also carried a diagnosis of nephronophthisis. She too progressed to ESKD and received a renal transplant, but passed away before further evaluation. A second maternal aunt attends the Nephrology clinic with hypertension, renal impairment and sub-nephrotic rage proteinuria. A’s two brothers were evaluated and found to have renal impairment, sub-nephrotic range proteinuria and hypertension. A renal biopsy revealed histology consistent with TMA in one of the brothers. Finally, A’s maternal grandmother and grand-aunt were known to have kidney disease. It is unclear from records whether they were given a formal diagnosis. Thrombophilia screens and von Willebrand Factor protease cleaving activity have been normal in all patients tested. In addition Factor H and Factor I levels in A, as well as genetic analysis for Factor H mutations, were all normal. Given the strong pedigree of kidney disease and the presence of TMA on two recent biopsies, it is likely that this family all suffer from the same disease process. Further genetic testing is in progress but has failed to identify a specific diagnosis as yet. This series highlights the myriad of clinical conditions that can lead to a pattern of TMA.