ONLINE FIRST
Steven J. Rosansky, MD; Paul Eggers, PhD; Kirby Jackson, BA; et al.
free access
Arch Intern Med. 2011;171(5):396-403. doi:10.1001/archinternmed.2010.415
BackgroundA dramatic increase in the “early start” of dialysis with an estimated glomerular filtration rate (eGFR) at least 10 mL/min/1.73 m2 has occurred in the United States since at least 1996. Several recent studies have reported a comorbidity-adjusted survival disadvantage of early start of dialysis. The current study examines a relatively “healthy” dialysis cohort to minimize confounding issues and determine whether early initiation of hemodialysis is associated with a survival benefit or harm.MethodsWe examined demographics, year of dialysis initiation, primary etiology of renal failure, and body mass index, hemoglobin, and serum albumin levels in 81 176 nondiabetic, 20- to 64-year-old, in-center incident hemodialysis patients with no reported comorbidity besides hypertension. We compared survival, using a piecewise proportional hazards model to estimate covariate-adjusted mortality hazard ratios (HRs) for eGFR at the time of initiation of dialysis. We also performed time-dependent adjusted analysis stratified by initial serum albumin levels lower than 2.5 g/dL, 2.5 to 3.49 g/dL, and 3.5 g/dL or higher (the “healthiest” group [HG]).ResultsUnadjusted 1-year mortality by eGFR ranged from 6.8% in the reference group (eGFR <5.0 mL/min/1.73 m2) to 20.1% in the highest eGFR group (≥15.0 mL/min/1.73 m2). Compared with the reference group, the HR for the HG was 1.27 (eGFR, 5.0-9.9 mL/min/1.73 m2), 1.53 (eGFR, 10.0-14.9 mL/min/1.73 m2), and 2.18 (eGFR ≥15.0 mL/min/1.73 m2) and ranged from 1.50 to 3.53 mL/min/1.73 m2 in the first year of dialysis for the early-start group.ConclusionThe increased HR during hemodialysis associated with early start in the healthiest group of patients undergoing dialysis indicates that early start of dialysis may be harmful.
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Editorial
Time to Rethink the Timing of Dialysis Initiation
Kirsten L. Johansen, MD
Arch Intern Med
S. Goya Wannamethee, PhD; A. Gerald Shaper, FRCP; Peter H. Whincup, FRCP, PhD; et al.
free access
Arch Intern Med. 2011;171(5):404-410. doi:10.1001/archinternmed.2011.2
Ian H. de Boer, MD, MS; Tessa C. Rue, MS; Patricia A. Cleary, MS; et al.
free access
Arch Intern Med. 2011;171(5):412-420. doi:10.1001/archinternmed.2011.16
Health Care Reform
Daniel P. Alford, MD, MPH; Colleen T. LaBelle, RN; Natalie Kretsch, BA; et al.
free access
Arch Intern Med. 2011;171(5):425-431. doi:10.1001/archinternmed.2010.541
ONLINE FIRST
Tamara G. Fong, MD, PhD; Richard N. Jones, ScD; James L. Rudolph, MD, SM; et al.
free access
Arch Intern Med. 2011;171(5):432-437. doi:10.1001/archinternmed.2010.423
BackgroundCognitive impairment is often unrecognized among older adults. Meanwhile, current assessment instruments are underused, lack sensitivity, or may be restricted by copyright laws. To address these limitations, we created a new brief cognitive assessment tool: the Sweet 16.MethodsThe Sweet 16 was developed in a cohort from a large post–acute hospitalization study (n = 774) and compared with the Mini-Mental State Examination (MMSE). Equipercentile equating identified Sweet 16 cut points that correlated with widely used MMSE cut points. Sweet 16 performance characteristics were independently validated in a cohort from the Aging, Demographics, and Memory Study (n = 709) using clinical consensus diagnosis, the modified Blessed Dementia Rating Scale, and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).ResultsThe Sweet 16 correlated highly with the MMSE (Spearman r, 0.94; P < .001). Validated against the IQCODE, the area under the curve was 0.84 for the Sweet 16 and 0.81 for the MMSE (P = .06). A Sweet 16 score of less than 14 (approximating an MMSE score <24) demonstrated a sensitivity of 80% and a specificity of 70%, whereas an MMSE score of less than 24 showed a sensitivity of 64% and a specificity of 86% against the IQCODE. When compared with clinical diagnosis, a Sweet 16 score of less than 14 showed a sensitivity of 99% and a specificity of 72% in contrast to an MMSE score with a sensitivity of 87% and a specificity of 89%. For education of 12 years or more, the area under the curve was 0.90 for the Sweet 16 and 0.84 for the MMSE (P = .03).ConclusionsThe Sweet 16 is simple, quick to administer, and will be available open access. The performance of the Sweet 16 is equivalent or superior to that of the MMSE.
Less Is More
Porpon Rotjanapan, MD; David Dosa, MD, MPH; Kali S. Thomas, MA
free access
Arch Intern Med. 2011;171(5):438-443. doi:10.1001/archinternmed.2011.13
Susan M. Gapstur, PhD, MPH; Eric J. Jacobs, PhD, MS; Anusila Deka, MPH; et al.
free access
Arch Intern Med. 2011;171(5):444-451. doi:10.1001/archinternmed.2010.536
Health Care Reform
Aanand D. Naik, MD; Nynikka Palmer, DrPH; Nancy J. Petersen, PhD; et al.
free access
Arch Intern Med. 2011;171(5):453-459. doi:10.1001/archinternmed.2011.70
Health Care Reform
Chad Boult, MD, MPH, MBA; Lisa Reider, MHS; Bruce Leff, MD; et al.
free access
Arch Intern Med. 2011;171(5):460-466. doi:10.1001/archinternmed.2010.540