Showing papers by "Mark Unruh published in 2008"

Intensity of renal support in critically ill patients with acute kidney injury

Abstract: We randomly assigned critically ill patients with acute kidney injury and failure of at least one nonrenal organ or sepsis to receive intensive or less intensive renal-replacement therapy. The primary end point was death from any cause by day 60. In both study groups, hemodynamically stable patients underwent intermittent hemodialysis, and hemodynamically unstable patients underwent continuous venovenous hemodiafiltration or sustained low-efficiency dialysis. Patients receiving the intensive treatment strategy underwent intermittent hemodialysis and sustained low-efficiency dialysis six times per week and continuous venovenous hemodiafiltration at 35 ml per kilogram of body weight per hour; for patients receiving the less-intensive treatment strategy, the corresponding treatments were provided thrice weekly and at 20 ml per kilogram per hour. Results Baseline characteristics of the 1124 patients in the two groups were similar. The rate of death from any cause by day 60 was 53.6% with intensive therapy and 51.5% with less-intensive therapy (odds ratio, 1.09; 95% confidence interval, 0.86 to 1.40; P = 0.47). There was no significant difference between the two groups in the duration of renalreplacement therapy or the rate of recovery of kidney function or nonrenal organ failure. Hypotension during intermittent dialysis occurred in more patients randomly assigned to receive intensive therapy, although the frequency of hemodialysis sessions complicated by hypotension was similar in the two groups. Conclusions Intensive renal support in critically ill patients with acute kidney injury did not decrease mortality, improve recovery of kidney function, or reduce the rate of nonrenal organ failure as compared with less-intensive therapy involving a defined dose of intermittent hemodialysis three times per week and continuous renal-replacement therapy at 20 ml per kilogram per hour. (ClinicalTrials.gov number, NCT00076219.)

Subjective and objective sleep quality and aging in the sleep heart health study

Abstract: OBJECTIVES: To examine the extent to which subjective and objective sleep quality are related to age independent of chronic health conditions. DESIGN: Cross-sectional study. SETTING: The Sleep Heart Health Study (SHHS) is a multicenter study designed to determine the cardiovascular consequences and the natural history of sleep disordered breathing. PARTICIPANTS: Five thousand four hundred seven community-dwelling adults who participated in the SHHS (mean age 63, range 45–99; 52% women). MEASUREMENTS: Unattended home polysomnography (PSG) and sleep questionnaires. RESULTS: Older age was associated with shorter sleep time, diminished sleep efficiency, and more arousals in men and women. In men, age was independently associated with more Stage 1 and Stage 2 sleep and less slow-wave (Stage 3 to 4) and rapid eye movement sleep. In women, older age was less strongly associated according to linear trend with sleep stage. Conversely, poor subjective sleep quality was not associated with older age in men, but older women had more trouble falling asleep, and there was a trend toward older women having more problems with waking up during the night and waking up too early. Associations between self-report and directly measured sleep time and sleep latency were low to moderate across age groups (correlation coefficient=0.06–0.32). CONCLUSION: Older age was more strongly associated with poorer sleep according to PSG in men than women, yet the subjective report of poor sleep with older age was stronger in women. The higher prevalence of chronic health conditions, including sleep apnea, in older adults did not explain changes of sleep parameters with aging and age–sex differences in these relationships.

Health-related quality of life in nephrology research and clinical practice.

Abstract: Physical, psychosocial, and lifestyle disturbances, along with physical and emotional symptoms, have been shown to impact the health-related quality of life (HRQOL) of those dependent on renal replacement therapy. The value of HRQOL measurement as a tool to improve clinical care has been recognized by patients, clinical investigators, and health care providers. The potential importance of HRQOL assessment lies in the additional information it provides and the impact it has on the clinical decision-making process between a patient and a physician. There remain a multitude of challenges facing renal providers who wish to incorporate HRQOL measurement to improve patient care. These challenges include the clinician's understanding of the conceptual model of HRQOL, the quality of the scientific process that contributed to the current literature on HRQOL, a willingness of the clinician to incorporate HRQOL information into clinical practice, and the logistic difficulties of collecting and applying HRQOL data in a busy practice setting. Arguably, optimizing HRQOL may be the most substantial impact the health care team will have on the person with kidney failure. In order to implement HRQOL assessment at the point of care, providers may consider using computer adaptive testing and scoring algorithms using item response theory, which will allow adequate reliability for interpretation of change among individuals. Moreover, the effective assessment and interpretation of HRQOL will be aided by continued publication of norms, outcomes of randomized controlled trials, and continued experience of investigators and clinicians.

Adherence to the medical regimen during the first two years after lung transplantation.

Abstract: BACKGROUND: Despite the importance of adherence to the medical regimen for maximizing health after lung transplantation, no prospective studies report on rates or risk factors for nonadherence in this patient population. Whether adherence levels differ in lung versus other types of transplant recipients is unknown. METHODS: A total of 178 lung recipients and a comparison group of 126 heart recipients were enrolled. Adherence in nine areas was assessed in separate patient and family caregiver interviews 2, 7, 12, 18, and 24 months posttransplant. Potential risk factors for nonadherence were obtained at the initial assessment. RESULTS: Cumulative incidence rates of persistent nonadherence (i.e., nonadherence at 0.05) in lung recipients than heart recipients for taking immunosuppressants (13% nonadherent vs. 21%, respectively), diet (34% vs. 56%), and smoking (1% vs. 8%). Lung recipients had significantly higher persistent nonadherence to completing blood work (28% vs. 17%) and monitoring blood pressure (70% vs. 59%). They had a high rate of spirometry nonadherence (62%; not measured in heart recipients). The groups did not differ in nonadherence to attending clinic appointments (27%), exercise (44%), or alcohol limitations (7%). In both groups, poor caregiver support and having only public insurance (e.g., Medicaid) increased nonadherence risk in all areas. CONCLUSIONS: Lung recipients were neither uniformly better nor worse than heart recipients in adhering to their regimen. Lung recipients have particular difficulty with some home monitoring activities. Strategies to maximize adherence in both groups should build on caregiver support and on strengthening financial resources for patient healthcare requirements.

The Influence of Age on Changes in Health‐Related Quality of Life over Three Years in a Cohort Undergoing Hemodialysis

Abstract: OBJECTIVES: To assess the extent to which persons aged 70 and older undergoing hemodialysis (HD) had greater changes in health-related quality of life (HRQOL) over 3 years than younger patients undergoing HD. DESIGN: Longitudinal. SETTING: The Hemodialysis Study (HEMO Study) was a randomized, clinical trial of the effects of HD dose and membrane flux on mortality and morbidity in patients undergoing chronic dialysis. PARTICIPANTS: Secondary analysis of the HEMO Study. MEASUREMENTS: Participants completed the Index of Well-Being (IWB) and the Kidney Disease Quality of Life—Long Form (KDQOL-LF), which also includes the Medical Outcomes Study 36-item Short Form Questionnaire (SF-36) annually. Changes in subjects those aged 70 and older were compared with changes in subjects aged 55 to 69 and 18 to 54. RESULTS: At baseline, 1,813 (98%) of HEMO participants completed HRQOL surveys. Their mean age was 58, 56% were female, 64% were black, and mean duration of dialysis was 3.8 years. In subjects with HRQOL data at the first three annual assessments, there were no substantial mean declines in the SF-36 Physical or Mental Component Summary scales over 3 years. In models incorporating effects of attrition, the differences in average change over 3 years between patients undergoing HD aged 70 and older and the younger cohorts were small in magnitude. There were high rates of adverse HRQOL events in all age groups and significantly higher composite event rates of death or clinically significant decline in HRQOL over 3 years was found in subjects aged 70 and older. CONCLUSION: Although HRQOL was impaired in the population undergoing HD, HRQOL scores at baseline reflect a better-preserved multidimensional quality of life in respondents in the HEMO Study aged 70 and older than in younger patients undergoing HD. There was no substantial relationship between age and average decline in HRQOL score over 3 years in participants in the HEMO Study.

Kidney Transplantation in Elderly People: The Influence of Recipient Comorbidity and Living Kidney Donors

Abstract: OBJECTIVES: To examine the extent to which donor and recipient characteristics were associated with transplant outcomes in elderly kidney transplant recipients. DESIGN: Retrospective review. SETTING: Single university center. PARTICIPANTS: One thousand one hundred two patients, including 266 patients aged 60 and older. MEASUREMENTS: Recipient and donor characteristics and patient and graft outcomes. RESULTS: Of the 1,102 patients included in this study, 266 (25%) were aged 60 and older, and 117 (11%) were aged 67 and older. According to Cox proportional hazards analysis, patient survival was worse in elderly recipients, although the survival outcome in the oldest group (ages 68–86) was comparable with that in their slightly younger peers (ages 61–67). Graft function did not differ according to age. Comorbidity was a significant predictor of patient survival in elderly recipients (hazard ratio (HR)=1.17, 95% confidence interval (CI)=1.03–1.34, P=.02) but not in the subset of elderly recipients of living donor kidneys (HR=1.01, 95% CI=0.8–1.3, P=.9). CONCLUSION: Older adults can achieve good outcomes with kidney transplantation, although in recipients with significant comorbid illness, careful donor selection and selective use of living donors may be vital to achieving good outcomes.

Sleep Disorders in Chronic Kidney Disease

Abstract: In the chronic kidney disease (CKD) population, problems with sleep have been linked to disability days, healthcare utilization, and quality of life (QOL) for dialysis patients The health burden associated with sleep disturbances is significant Studies in the general population have linked these problems to greater use of health services, increased use of hypnotics, and reduced functional capabilities The need to address sleep quality in the CKD population is highlighted by the 15% to 31% prevalence of hypnotic use Among incident dialysis patients, patients with poor sleep quality were more likely to report poor physical and mental well being, decreased vitality and more bodily pain While there are many causes for poor sleep in patients with kidney disease, such as depression, insomnia, restless legs, and periodic limb movements, sleep apnea may be the most common A significant percentage of end-stage renal disease patients report hypersomnolence, snoring, and even witnessed apneas Those undergoing thrice-weekly hemodialysis have been shown to have a high rate of sleep apnea, insomnia, restless legs syndrome, and excessive daytime sleepiness In the general population, sleep disorders such as sleep apnea have been associated with premature death, cardiovascular disease, depression, and poor QOL Emerging evidence suggests that sleep disorders may contribute to the high rates of medical and psychological comorbidity in CKD patients The diagnosis and treatment of sleep disorders among this high-risk population remains understudied The recommendations for therapy have been largely based on findings in the general population since studies of the CKD population have been limited in scope