Showing papers by "Mark Unruh published in 2012"
TL;DR: Frequent in-center hemodialysis compared with conventional in- center hemodIALysis improved self-reported physical health and functioning but had no significant effect on objective physical performance.
Abstract: Summary Background and objectives Relatively little is known abouttheeffects of hemodialysis frequency on the disability of patients with ESRD. Design, setting, participants, & measurements This study examined changes in physical performance and selfreported physical health and functioning among subjects randomized to frequent (six times per week) compared withconventional(threetimesperweek)hemodialysisinboththeFrequentHemodialysisNetworkdaily(n=245) and nocturnal (n=87) trials. The main outcome measures were adjusted change in scores over 12 months on the short physical performance battery (SPPB), RAND 36-item health survey physical health composite (PHC), and physical functioning subscale (PF) based on the intention to treat principle. Results Overall scores for SPPB, PHC, and PF were poor relative to population norms and in line with other studies in ESRD. In the Daily Trial, subjects randomized to frequent compared with conventional in-center hemodialysis experienced no significant change in SPPB (adjusted mean change of 20.2060.19 versus 20.4160.21, P=0.45) but experienced significant improvement in PHC (3.460.8 versus 0.460.8, P=0.009) and a relatively large change in PF that did not reach statistical significance. In the Nocturnal Trial, there were no significant differences among subjects randomized to frequent compared with conventional hemodialysis in SPPB (adjusted mean change of 20.9260.44 versus 20.4160.43, P=0.41), PHC (2.761.4 versus 2.161.5, P=0.75), or PF (23.163.5 versus 1.163.6, P=0.40). Conclusions Frequent in-center hemodialysis compared with conventional in-center hemodialysis improved self-reported physical health and functioning but had no significant effect on objective physical performance. There were no significant effects of frequent nocturnal hemodialysis on the same physical metrics. Clin J Am Soc Nephrol 7: ccc–ccc, 2012. doi: 10.2215/CJN.10601011
98 citations
TL;DR: Results support screening for sleep-disordered breathing (SDB) in patients with nocturia, but the mechanisms underlying the relationship betweenNocturia and cardiovascular morbidity requires further study.
Abstract: Background: Nocturia has been independently associated with cardiovascular morbidity and all-cause mortality, but such studies did not adjust for sleep-disordered breathing (SDB), which may have mediated such a relationship. Our aims were to determine whether an association between nocturia and cardiovascular morbidity exists that is independent of SDB. We also determined whether nocturia is independently associated with SDB. Methodology/Principal Findings: In order to accomplish these aims we performed a cross-sectional analysis of the Sleep Heart Health Study that contained information regarding SDB, nocturia, and cardiovascular morbidity in a middle-age to elderly community-based population. In 6342 participants (age 63611 [SD] years, 53% women), after adjusting for known confounders such as age, body mass index, diuretic use, diabetes mellitus, alpha-blocker use, nocturia was independently associated with SDB (measured as Apnea Hypopnea index .15 per hour; OR 1.3; 95%CI, 1.2–1.5). After adjusting for SDB and other known confounders, nocturia was independently associated with prevalent hypertension (OR 1.23; 95%CI 1.08– 1.40; P = 0.002), cardiovascular disease (OR 1.26; 95%CI 1.05–1.52; P = 0.02) and stroke (OR 1.62; 95%CI 1.14–2.30; P = 0.007). Moreover, nocturia was also associated with adverse objective alterations of sleep as measured by polysomnography and self-reported excessive daytime sleepiness (P,0.05). Conclusions/Significance: Nocturia is independently associated with sleep-disordered breathing. After adjusting for SDB, there remained an association between nocturia and cardiovascular morbidity. Such results support screening for SDB in patients with nocturia, but the mechanisms underlying the relationship between nocturia and cardiovascular morbidity requires further study. MeSH terms: Nocturia, sleep-disordered breathing, obstructive sleep apnea, sleep apnea, polysomnography, hypertension.
85 citations
TL;DR: The association between resistant hypertension and sleep apnea appeared robust in ESRD, suggesting OSA may contribute to resistant hypertension or both may be linked to a common underlying process such as volume excess.
Abstract: Objectives
To explore the relationship between obstructive sleep apnea (OSA) and resistant hypertension in chronic kidney disease (CKD) and end-stage renal disease (ESRD).
54 citations
TL;DR: It is suggested that interventions to address racial disparities in KT incorporate key nonmedical risk factors in patients as well as demographic, psychosocial, and cultural factors.
Abstract: Background Although end-stage kidney disease in African Americans (AAs) is four times greater than in whites, AAs are less than one half as likely to undergo kidney transplantation (KT). This racial disparity has been found even after controlling for clinical factors such as comorbid conditions, dialysis vintage and type, and availability of potential living donors. Therefore, studying nonmedical factors is critical to understanding disparities in KT. Methods We conducted a longitudinal cohort study with 127 AA and white patients with end-stage kidney disease undergoing evaluation for KT (December 2006 to July 2007) to determine whether, after controlling for medical factors, differences in time to acceptance for transplant is explained by patients' cultural factors (e.g., perceived racism and discrimination, medical mistrust, religious objections to living donor KT), psychosocial characteristics (e.g., social support, anxiety, depression), or transplant knowledge. Participants completed two telephone interviews (shortly after initiation of transplant evaluation and after being accepted or found ineligible for transplant). Results Results indicated that AA patients reported higher levels of the cultural factors than did whites. We found no differences in comorbidity or availability of potential living donors. AAs took significantly longer to get accepted for transplant than did whites (hazard ratio=1.49, P=0.005). After adjustment for demographic, psychosocial, and cultural factors, the association of race with longer time for listing was no longer significant. Conclusions We suggest that interventions to address racial disparities in KT incorporate key nonmedical risk factors in patients.
48 citations
TL;DR: Suggestible evidence of a greater prevalence of stroke at greater values of the apnea-hypopnea index is found in an overweight and obese population with T2DM.
Abstract: Study Objectives: Type 2 diabetes mellitus (T2DM) and obstructive sleep apnea (OSA) are common, increasingly recognized as comorbid conditions, and individually implicated in the development of cardiovascular disease (CVD). We sought to determine the association between OSA and CVD in an overweight and obese population with T2DM.
46 citations
TL;DR: The CKD prevalence in this village is comparable to a previously studied Nicaraguan coffee-farming region and much lower than previously screened portions of northwestern Nicaragua.
Abstract: BACKGROUND: Chronic kidney disease (CKD) is found at epidemic levels in certain populations of the Pacific Coast in northwestern Nicaragua especially in younger men. There are knowledge gaps concer ...
36 citations
University of Illinois at Chicago1, Edward Hines, Jr. VA Hospital2, Medical University of South Carolina3, University of Mississippi4, Johns Hopkins University5, Morehouse School of Medicine6, Columbia University7, Meharry Medical College8, Cleveland Clinic9, University of Utah10, Ohio State University11, National Institutes of Health12, University of Alabama at Birmingham13, Charles R. Drew University of Medicine and Science14, University of Pittsburgh15
TL;DR: An association between CKD and low HRQOL is demonstrated, and the need for longitudinal studies to examine this association in the future is highlighted.
36 citations
TL;DR: Early evaluation and management of sleep-disordered breathing in patients with CKD may provide an opportunity to improve cognitive function, and in a subgroup analysis of older adults, there were no significant differences in cognitive testing between the groups with and without sleep- Disordered breathing.
36 citations
TL;DR: How carefully constructed questionnaires with equivalent reliability as long annual surveys, such as KDQOL, can be more quickly completed by using novel technology, which can be transmitted from the patient to the clinician and back to the bedside in minutes rather than in weeks is detailed.
Abstract: An outcome can take many forms in the health care of an individual. Common measures in clinical research may include mortality, time to ESRD, or change in glomerular filtration rate. While a patient surely may share an interest with a clinician regarding these endpoints, individual life priorities expectedly vary. Outcomes of great value to a clinician (or their performance quality measures) may not be shared by their patient. While continued education and efforts in effective communication may help each party understand the reasons behind these differences, the time required to foster such dialogues remains a major hurdle for most clinicians. Through the use of contemporary computers such as smartphones, tablets, and laptops, healthcare providers can gain meaningful insight from patient-reported data such as pain, sleep, and sexual function. This review will detail how carefully constructed questionnaires with equivalent reliability as long annual surveys, such as KDQOL, can be more quickly completed by using novel technology, which can be transmitted from the patient to the clinician and back to the bedside in minutes rather than in weeks.
30 citations
TL;DR: Health-related quality of life may provide clinicians with additional information to help identify patients at high risk of mortality after AKI that required renal replacement therapy, after adjusting for clinical risk factors.
Abstract: Summary Background and objectives This study examined the relationship between health-related quality of life and subsequent mortality among AKI survivors treated with renal replacement therapy. Design, setting, participants, & measurements Multivariable Cox regression models were used to assess the associations between Health Utilities Index Mark 3 (HUI3) and ambulation, emotion, cognition, and pain scores at 60 days and all-cause mortality at 1 year in 60-day AKI survivors (n=439 with evaluable HUI3 assessments) from a randomized multicenter study comparing less- with more-intensive renal replacement therapies. Results The median 60-day HUI3 index score was 0.32. Patients with evaluable HUI3 data who died between 60 days and 1 year (n=99) were more likely to have lower 60-day median HUI3 scores, higher comorbidity scores, and longer initial hospital stays, and they were more likely to be dialysis-dependent. A 0.1 higher HUI3 index score was associated with a 17% decrease (hazard ratio, 0.83; 95% confidence interval 0.77–0.89) in all-cause mortality after controlling for clinical risk factors. Similar associations were observed for HUI3 ambulation, emotion, cognition, and pain attribute scores. Conclusions Health-related quality of life measured by HUI3 is an independent predictor of mortality among survivors of AKI after adjusting for clinical risk variables. Poor ambulation and other health-related quality of life attributes are also associated with increased risk of death. Health-related quality of life may provide clinicians with additional information to help identify patients at high risk of mortality after AKI that required renal replacement therapy.
26 citations
TL;DR: Risk of death associated with diabetes in ESRD increases over time and suggests that an increasing risk of death among diabetes may be underappreciated when using conventional survival models.
Abstract: Diabetes is the most common risk factor for end-stage renal disease (ESRD) and has been associated with increased risk of death. In order to better understand the influence of diabetes on outcomes in hemodialysis, we examine the risk of death of diabetic participants in the HEMODIALYSIS (HEMO) study. In the HEMO study, 823 (44.6%) participants were classified as diabetic. Using the Schoenfeld residual test, we found that diabetes violated the proportional hazards assumption. Based on this result, we fit two non-proportional hazard models: Cox’s time varying covariate model (Cox-TVC) that allows the hazard for diabetes to change linearly with time and Gray’s time-varying coefficient model. Using the Cox-TVC, the hazard ratio (HR) for diabetes increased with each year of follow up (p = 0.02) for all cause mortality. Using Gray’s model, the HR for diabetes ranged from 1.41 to 2.21 (p <0.01). The HR for diabetes using Gray’s model exhibited a different pattern, being relatively stable at 1.5 for the first 3 years in the study and increasing afterwards. Risk of death associated with diabetes in ESRD increases over time and suggests that an increasing risk of death among diabetes may be underappreciated when using conventional survival models.
TL;DR: In 2000, representatives of the transplant community convened for a meeting on living donation in an effort to provide recommendations to promote the welfare of living donors as mentioned in this paper, and one key recommendation included in the consensus statement was that all transplant centers which have performed living donor surgeries have an independent living donor advocate (ILDA) whose only focus is on the best interest of the donor.
TL;DR: Event-related distress is common in CKD and CKD5 patients and is associated with worse depressive symptoms and greater somatic and emotional symptom burden, even with adjustments for age and gender.
Abstract: Background. Non-dialysis-dependent chronic kidney disease (CKD) and dialysis-dependent Stage 5 CKD (CKD5) are associated with a significant physical and psychosocial burden. Little is known, however, about the impact of stressful life events on CKD and CKD5 patients. This study aimed to determine the prevalence of stressful life events in CKD and CKD5 patients and identify the factors correlated with high levels of event-related distress. Methods. This cross-sectional study’s sample consisted of 181 patients (91 with non-dialysis-dependent CKD Stages 4 and 5, 90 with CKD5) who filled out the Impact of Event Scale (IES), which measures subjective distress related to stressful life events. Other measures included scores from the Medical Outcomes Study Short Form-36, Patient Health Questionnaire-9 (PHQ-9) and Dialysis Symptom Index (DSI). Results. One hundred and three subjects reported stressors on the IES. Almost half the stressors (49.5%) related to personal health; the rest fell into other categories. There were significant differences between the no stressor, low event-related distress and high event-related distress groups in age (P < 0.001), PHQ-9 score (P < 0.001) and DSI score (P ¼ 0.002). After adjustment, PHQ-9 score was associated with high event-related distress [odds ratio (OR) 1.20, 95% confidence interval (CI) 1.10–1.32], as was DSI score (OR 1.04, 95% CI 1.02–1.07) in a separate model. Conclusions. Event-related distress is common in CKD and CKD5 patients. High event-related distress is associated with worse depressive symptoms and greater somatic and emotional symptom burden, even with adjustments for age and gender. The renal practitioner may need to address patients’ event-related distress in order to provide optimal care.
TL;DR: The rising prevalence of NCD risk factors among even the poorest subjects suggests that an epidemiologic transition in underway in western and central Nicaragua whereby NCD prevalence is shifting to all segments of society.
Abstract: OBJECTIVE: To describe the prevalence of noncommunicable disease (NCD) risk factors (overweight/obesity, tobacco smoking, and alcohol consumption) and identify correlations between these and sociodemographic characteristics in western and central Nicaragua. METHODS: This was a cross-sectional study of 1 355 participants from six communities in Nicaragua conducted in September 2007-July 2009. Demographic and NCD risk-related health behavior information was collected from each individual, and their body mass index (BMI), blood pressure, diabetes status, and renal function were assessed. Data were analyzed using descriptive statistics, bivariate analyses, and (non-stratified and stratified) logistic regression models. RESULTS: Of the 1 355 study participants, 22.0% were obese and 55.1% were overweight/obese. Female sex, higher income, and increasing age were significantly associated with obesity. Among men, lifelong urban living correlated with obesity (Odds Ratio [OR] = 4.39, 1.18-16.31). Of the total participants, 31.3% reported ever smoking tobacco and 47.7% reported ever drinking alcohol. Both tobacco smoking and alcohol consumption were strikingly more common among men (OR = 13.0, 8.8-19.3 and 15.6, 10.7-22.6, respectively) and lifelong urban residents (OR = 2.42, 1.31-4.47 and 4.10, 2.33-7.21, respectively). CONCLUSIONS: There was a high prevalence of obesity/overweight across all income levels. Women were much more likely to be obese, but men had higher rates of tobacco and alcohol use. The rising prevalence of NCD risk factors among even the poorest subjects suggests that an epidemiologic transition in underway in western and central Nicaragua whereby NCD prevalence is shifting to all segments of society. Raising awareness that health clinics can be used for chronic conditions needs to be priority.
TL;DR: Findings underscore the burden of clinically symptomatic PVD in HD patients and its impact on morbidity and mortality and underscore the need for prompt initiation of therapy to prevent its progression.
Abstract: Background. In patients with end-stage renal disease, peripheral vascular disease (PVD) is prevalent. We assessed the extent to which severity of PVD predicts mortality, hospitalizations and health-related quality of life (HRQOL) in hemodialysis (HD) patients enrolled in the Hemodialysis (HEMO) Study. Methods. We performed a subanalysis of the HEMO Study, a randomized controlled trial. Adjusted predictors of PVD were analyzed through a multivariable stepwise ordinal logistic model. Relationships between PVD severity and mortality and hospitalizations were determined with Cox proportional hazards models. Relationships between PVD severity and HRQOL were modeled via linear regression and generalized estimating equations. Results. Older age, diabetes, non-African-American race, ischemic heart disease, cerebrovascular disease and longer transplant wait time were associated with more severe PVD. Patients with severe PVD were more likely to suffer from all-cause mortality [hazard ratio (HR) 1.77, 95% confidence interval 1.30– 2.40, P < 0.001], cardiac death [HR 1.89 (95% confidence interval 1.15–3.11), P = 0.001] and infectious death [HR 1.75 (95% confidence interval 1.30–2.34), P < 0.001]. Increasing PVD severity was also associated with first cardiac hospitalization or all-cause mortality (P = 0.05) and first cardiac hospitalization or cardiac death (P = 0.03). HRQOL scores were lower for patients with increasingly severe PVD. Conclusions. These findings underscore the burden of clinically symptomatic PVD in HD patients and its impact on morbidity and mortality. Whether early detection of PVD and prompt initiation of therapy to prevent its progression in the HD population would improve HRQOL and survival outcomes remain to be proven.
TL;DR: Self-reported sleep quality was associated with appetite and serum creatinine, and a simple questionnaire to assess sleep disorders in dialysis patients should be administered routinely to detect those patients at risk of sleep complaints.
TL;DR: An independent association between poor mental health over time and all-cause mortality, cardiac hospitalization, and the composite of cardiac death or cardiac hospitalizations in hemodialysis patients is found.
Abstract: Summary Background and objectives Poor mental health over time is significantly associated with cardiovascular morbidity and mortality in the general population, which is the leading cause of death in dialysis patients. Most studies of dialysis patients, however, have investigated the relationship between baseline mental health measurements and all-cause mortality and not mental health measured longitudinally throughout a study and cause-specific mortality. Design, setting, participants, & measurements This study examined the association of changes in mental health over time with all-cause and cause-specific deaths and cardiac hospitalizations in the Hemodialysis study patients. Mental health was assessed at baseline and annually during the study with short form 36 mental health index scores. Poorer mental health was defined by a mental health index score≤60. Results Patients with poorer mental health at baseline were more likely to have less than a high school education and be unmarried, have significantly higher index of coexistent disease scores, and report taking β-blockers and sleep medications. Low mental health scores over time were independently associated with a decrease in survival time from all-cause mortality by −0.06 (−0.10, −0.03; P P =0.01) and composite of first cardiac hospitalization or cardiac death by −0.04 (−0.07, −0.02; P Conclusions This study found an independent association between poor mental health over time and all-cause mortality, cardiac hospitalization, and the composite of cardiac death or cardiac hospitalization in hemodialysis patients. The results underscore the importance of attention to mental health related to cardiac complications and even death in dialysis patients.
TL;DR: High-quality studies exploring the burdens and costs to patients, caregivers, and society are necessary before widespread adoption can be advocated, as many patients are likely to opt out of short daily HD.
TL;DR: The results may help identify donors who are at greater risk for poor health maintenance behaviors after donation and suggest areas of health behavior that should be the focus of education sessions before donation.
Abstract: Context and Objective—Donating a kidney may provide an opportunity for donors to reevaluate their health maintenance behaviors (eg, regular exercise, smoking cessation, medical checkups). Although the effect of donation on donors' health, quality of life, and financial outcomes has received growing attention, no studies have examined whether donation is related to changes in health maintenance behaviors. The study aims were to (1) describe and compare kidney donors' health maintenance behaviors before and after donation, and (2) determine the correlates of health maintenance behaviors after donation.Design, Setting, Participants and Measures—We conducted a telephone-interview study with 85 randomly selected laparoscopic kidney donors in a major US transplant center to assess health behaviors before and after donation, postdonation characteristics (eg, quality of life, postsurgical pain), and demographics.Results—Sample demographics included a median age of 48 years; 55% were female, 82% were white, 71% we...
TL;DR: A high prevalence of pain and poor sleep in patients with ESRD in two dialysis units in Washington, DC, between 2001 and 2003 with follow-up of the cohort for survival through 2005, supports the position that patient-reported outcomes may present an important tool to improve the quality of life and the survival duration of patients with PSA.
Abstract: † The results presented in this paper have not been published previously in whole or part, except in abstract format. The care for patients with end-stage renal disease (ESRD) has focused on easily measurable processes of care outcomes such as Kt/V, hemoglobin and serum phosphorus levels. It has been thought that these metrics reflect the quality of care. Furthermore, improving these measurements would favorably influence the quality of life and survival on dialysis. However, an observational study of over 11 000 hemodialysis patients demonstrated no substantial improvement in health-related quality of life (HRQOL), despite secular changes in Kt/V, hemoglobin and serum phosphorus [1]. In addition, randomized trials testing whether increasing Kt/V or hemoglobin reduces mortality and improves the quality of life had demonstrated no substantial increase in quality or length of life [2–4]. As it turns out, these measures may not be adequate proxies for patient well-being and attention to them may not substantially increase survival. The present study by Kimmel and colleagues [5] is noteworthy because of its examination of potential associations between pain, sleep, quality of life and survival. The work of this group supports the position that patient-reported outcomes may present an important tool to improve the quality of life and the survival duration of patients with ESRD. The report measured self-reported pain and sleep in 128 patients with ESRD in two dialysis units in Washington, DC, between 2001 and 2003 with follow-up of the cohort for survival through 2005. The study population had a mean age of 57, 60% male, 91% African-American and had a mean duration of dialysis of 40 months. There was a high rate of other chronic health conditions since 48% were diabetic, 10% had HIV and the average Karnofsky score was 75. One of the strengths of this investigation is the early use of the McGill Pain questionnaire and the Pittsburgh Sleep Quality Index (PSQI). These now widely used tools provide reliable and valid measures of pain and sleep quality. In order to assess whether pain differs between the time on dialysis and non-dialysis, the investigators modified the McGill Pain questionnaire to examine the nature, location, intensity, duration and frequency of pain on and off dialysis. Dialysis pain intentionally was measured by asking the patient to disregard discomfort associated with the use of vascular access. The investigators found that a substantial proportion of ESRD patients reported pain during offdialysis (44%) time and poor sleep (45% have a PSQI score of >5). The measures of pain and sleep quality were later analyzed in relation to survival. After controlling for age, diabetes, serum albumin and HIV, non-dialysis pain was significantly associated with an increased risk of death. While this report demonstrates a high prevalence of pain and poor sleep in patients with ESRD, there are a number of limitations which should be considered when comparing these findings to other studies. First, this was a small study with limited power to demonstrate clinically meaningful associations with survival. Only 32 deaths were reported during the study and observation periods. This lack of power may explain the non-signifi
TL;DR: If, indeed, fluid overload contributes to sleep apnea and poor sleep efficiency in HD patients, then the treatment ofSleep apnea among those with ESRD could be targeted to improving volume control rather than using continuous positive airway pressure (CPAP) or an oral device, which many patients are unable to tolerate or comply with.
Abstract: The prevalence rate of sleep apnea in the hemodialysis (HD) patient population is >50% [1, 2] as compared to only 2–4% in the general population [3]. Not only does sleep apnea contribute to hypertension (HTN) and increased cardiovascular morbidity and mortality in the end-stage renal disease (ESRD) population, but it also significantly impairs their quality of life. However, large gaps in knowledge exist in our understanding of the potential mechanisms for increased sleep apnea in this vulnerable population. Traditional risk factors such as age and body mass index (BMI) do not fully account for the significant increased risk of sleep apnea in these patients [4]. As HTN and fluid overload occur almost universally in HD patients, it is possible that fluid retention may increase the risk of developing obstructive sleep apnea (OSA). If, indeed, fluid overload contributes to sleep apnea and poor sleep efficiency in HD patients, then the treatment of sleep apnea among those with ESRD could be targeted to improving volume control rather than using continuous positive airway pressure (CPAP) or an oral device, which many patients are unable to tolerate or comply with. In this issue of Nephrology Dialysis Transplantation, Elias et al. [5] addresses this important issue in their study evaluating the relationship of rostral fluid shift with OSA 1291
Journal Article•
TL;DR: At least one cardiovascular risk factor was found in half of this Nicaraguan sample and cardiovascular risk factors should be the target of educational efforts, screening, and treatment.
Abstract: OBJECTIVE: Describe the prevalence of hypertension. DESIGN: Population based cross-sectional survey. SETTING: Six Nicaraguan communities with varying economies. PARTICIPANTS: 1,355 adults aged 20-60 years who completed both self-reported and quantitative measures of health. MAIN OUTCOME MEASURES: Prevalence of hypertension (systolic > or = 140 mm Hg, diastolic > or = 90 mm Hg, or self-reported medical history with diagnosis by a health care professional), uncontrolled hypertension (systolic > or = 140 mm Hg or diastolic > or = 90 mm Hg), diabetes (urinary glucose excretion > or = 100 mg/ dL or self-reported medical history diagnosed by a health care professional), and uncontrolled diabetes (urinary glucose excretion > or =100 mg/dL only). RESULTS: The prevalence of hypertension was 22.0% (19.2% in men, 24.2% in women). Blood pressure was controlled in 31.0% of male hypertensives and 55.1% of female hypertensives (odds ratio [OR] 2.86; 95% confidence interval [Cl] 1.74-4.69). Older age and higher body mass index were strongly associated with hypertension. Women who completed primary school had a lower risk of hypertension (OR .40; 95% Cl .19-.85) compared to those with no formal education. A history of living in both urban and rural settings was associated with lower prevalence of hypertension (OR .52; 95% CI .34-.79). Diabetes mellitus was found in 1.2% of men and 4.3% of women. Male sex was independently associated with decreased risk of diabetes (OR .31; 95% Cl .11-.86). CONCLUSIONS: At least one cardiovascular risk factor was found in half of this Nicaraguan sample. Cardiovascular risk factors should be the target of educational efforts, screening, and treatment. Ethn Dis . 2012 Spring;22(2):129-35.
TL;DR: It is found that the parameter estimates obtained under joint modeling of HEMO data are more efficient than those obtained under separate modeling of the outcome variables.
Abstract: In clinical studies, longitudinal and survival data are often obtained simultaneously from the same individual. Linear mixed effects models are widely used for analyzing longitudinal continuous outcome data, while survival models are used for analyzing time-to-event data. It is a common practice to analyze these longitudinal and time-to-event data separately. However, when multivariate outcomes are obtained from a given individual, they can be correlated by nature, and one can attain considerable gain in efficiency by jointly analyzing the outcomes. An objective of this study is to analyze such multivariate data by jointly modeling longitudinally measured continuous outcomes and time-to-event data. In this joint modeling, we formulate a joint likelihood function for both outcomes and use the maximum likelihood method to estimate the parameters in the two sub-models (longitudinal and survival models). We demonstrate the merits of joint modeling by considering a joint analysis of longitudinally measured serum albumin (biomarker) and time-to-all-cause mortality data obtained from a hemodialysis (HEMO) study. This HEMO study was a large NIH (National Institute of Health) sponsored multicenter clinical trial contrasting the effects of dialysis dose and dialysis membrane permeability in end-stage renal disease patients receiving hemodialysis. We find that the parameter estimates obtained under joint modeling of HEMO data are more efficient than those obtained under separate modeling of the outcome variables.
TL;DR: Using data from the HEMO Study, demographic, case mix, nutrition-related and quality of life (QOL) variables were explored as predictors of SD in 1805 MHD patients to determine whether SD was associated with the selected variables and Kt/V and flux randomized assignments in a longitudinal (repeated measures) model.
Abstract: We have previously shown that poorer appetite was a significant predictor of decreased sleep quality (SQ) among maintenance hemodialysis (MHD) patients. There is a gap in the literature when examining sleep duration (SD) in MHD patients and the variables that may predict SD. Using data from the HEMO Study, demographic, case mix, nutrition-related and quality of life (QOL) variables were explored as predictors of SD in 1805 MHD patients. Self-reported SD (in hrs) in the last 24 hrs was assessed annually using questions from the KDQOL instrument. A multinominal logistic regression analysis was conducted to determine whether SD (short 0–6; medium 7–9; or long 10+) was associated with the selected variables and Kt/V and flux randomized assignments in a longitudinal (repeated measures) model. At baseline, mean SD was 7.8±2.4 hrs; 33%, 43% and 24% of subjects were in the short, medium and long sleep groups, respectively. In univariate analysis, dietary protein intake, serum albumin, appetite, and QOL measures (mental component score [MCS] and physical component score [PCS]) were significant predictors of SD. In multivariate analysis, age ( P =0.008), race (White vs. Black) ( P =0.001), appetite on dialysis days (DD) ( P =0.0001), MCS and PCS ( P