Testing for Tuberculosis in CKD Patients

See Laskin et al,pages 22-32;Rogerson et al,pages 33-43; andNellore & Kotton,pages 3-5.

The optimal test for assessingactive and latent TB in the ESRDpopulation or prior to immuno-suppresion therapy remains un-certain. This month’s AJKD in-cludes 2 reports that comparethe utility of the tuberculin skintest (TST) to the recently devel-oped interferon � release assays(IGRAs). Rogerson and col-leagues systematically reviewedall studies that assessed theasso-ciation of TST or IGRA resultswith clinical risk factors for la-tent TB in ESRD patients andfound that ELISA-based IGRAsare likely to be the more accu-rate diagnostic tool for these patients. Meanwhile, Laskin et al compared thecost-effectiveness of these 2 approaches in screening children with idiopathicnephritic syndrome for latent TB prior to immunosuppression. As Nellore andKotton point out in their accompanying editorial, the finding from Laskin et althat universal TST screening is only cost-effective in areas where TB affects almostone-fifth of the population reinforces that sophisticated tests do not replace theimportance of taking a comprehensive history in rational, economic health care.

The Potential Risks of ESAs

See Koulouridis etal, pages 44-56; andChaknos & Berns,pages 6-8.

Recentevidencedemonstratesa linkbetweentargetinghigherhemoglobinlevelswithESAs and increased cardiovascularmorbidity and mortality; however, thefundamentalquestionremainswhetherthe use of high dose ESAs is culpable.This month, Koulouridis and col-leagues examine this question by per-forming a meta-regression of random-ized controlled trials. The authorsconclude that higher ESA dose may beassociated with all-cause mortality andcardiovascularcomplicationsindepen-dent of target hemoglobin level in pa-tientswithCKD.AccordingtoeditorialistsChaknosandBerns,thisreportemphasizestheneedtomovetowardadefinitiveclinicaltrialthataddressesthespecificquestionofanESAdose-riskrelationshiprather thanaone-size-fits-all targethemoglobin.

0

20

40

60

80

100

Mor

talit

y ra

te (p

er 1

000

pers

on-y

ears

)

0 10,000 20,000 30,000

Mean ESA dose (epoetin alpha–equivalent units/week)

.

.

.

.

.

.

Radiological evidenceLeeTriverioSeyhanSubtotal (I-squared = 0.0%, p = 0.401)

Medical historySeyhanLeeSubtotal (I-squared = 0.0%, p = 0.515)

Contact historyTriverioSeyhanWinthropSubtotal (I-squared = 0.0%, p = 0.560)

ImmunosuppressionLeeSubtotal (I-squared = .%, p = .)

High risk nationalityLeeChungLeeTriverioSubtotal (I-squared = 0.0%, p = 0.746)

BCG vaccinationTriverioSeyhanLeeSubtotal (I-squared = 25.4%, p = 0.262)

Study

201020092009

20092010

200920092008

2010

2009201020102009

200920092010

Year

6.32 (1.04, 38.41)1.60 (0.30, 8.46)5.96 (1.83, 19.42)4.29 (1.83, 10.03)

3.78 (0.89, 16.12)1.92 (0.46, 8.03)2.68 (0.97, 7.43)

4.20 (0.62, 28.67)5.50 (1.54, 19.66)2.30 (0.83, 6.37)3.36 (1.61, 7.01)

1.48 (0.51, 4.26)1.48 (0.51, 4.26)

0.41 (0.01, 21.91)2.86 (0.06, 146.99)0.91 (0.02, 46.77)3.83 (0.58, 25.14)2.25 (0.53, 9.61)

0.10 (0.02, 0.45)0.40 (0.14, 1.13)0.40 (0.16, 1.00)0.30 (0.14, 0.63)

ROR (95% CI)

22.2225.9851.80100.00

49.3250.68100.00

14.6533.3152.04100.00

100.00100.00

13.3113.5813.5859.53100.00

20.3636.5343.11100.00

Weight%

6.32 (1.04, 38.41)1.60 (0.30, 8.46)5.96 (1.83, 19.42)4.29 (1.83, 10.03)

3.78 (0.89, 16.12)1.92 (0.46, 8.03)2.68 (0.97, 7.43)

4.20 (0.62, 28.67)5.50 (1.54, 19.66)2.30 (0.83, 6.37)3.36 (1.61, 7.01)

1.48 (0.51, 4.26)1.48 (0.51, 4.26)

0.41 (0.01, 21.91)2.86 (0.06, 146.99)0.91 (0.02, 46.77)3.83 (0.58, 25.14)2.25 (0.53, 9.61)

0.10 (0.02, 0.45)0.40 (0.14, 1.13)0.40 (0.16, 1.00)0.30 (0.14, 0.63)

ROR (95% CI)

22.2225.9851.80100.00

49.3250.68100.00

14.6533.3152.04100.00

100.00100.00

13.3113.5813.5859.53100.00

20.3636.5343.11100.00

Weight%

1.01 .25 .5 10 20 40More common with positive TST More common with positive QuantiFERON

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Am J Kidney Dis. 2013;61(1): xxii-xxivxxii

Comparative Effectiveness Research in Nephrology

See Boulware,pages 9-12 ; andBrunelli & Rassen,pages 13-17.

Comparative effectiveness re-search (CER) is defined as re-search that compares “the ben-efits and harms of variousinterventions and strategies forpreventing, diagnosing, treatingand monitoring health conditionsin real-world settings.” Essen-tially, the goal of CER is to mea-sure treatment “effectiveness” ina manner that stakeholders inhealth care decisions deem rel-evant. This issue of AJKD features 2 editorials that discuss the significance ofcomparative effectiveness research for the nephrology community. Boulwareargues that kidney disease CER questions could address numerous goals ofcare for patients across the spectrum of CKD severity, including studies of theeffectiveness of a broad range of treatment strategies on clinical outcomes.Meanwhile, Brunelli and Rassen provide a primer on emerging analyticaltechniques applied in CER, describe a role for these techniques for nephrologyresearch, and note that these methods may help inform clinical practice ininstances when trials are not feasible or possible.

Core Curriculum: General Care of the Dialysis Patient

See Holley, pages171-183.

AJKD’s popular Core Curricu-lum series, which providesreaders with a basic analyticalframework for approachingtopics in clinical nephrology,returns this month in new for-mat that uses frequent head-ings and interspersed readinglists in a narrative presenta-tion to combine the conve-nient navigation of an outlinewith the clarity and flow ofprose. The first installment ofthis new format is Holley’s re-view of general medical careof the dialysis patient, includ-ing preventive care, healthcare counseling, and advancecare planning.

Preventive Care

• ImmunizationsHepatitis BInfluenzaH1N1TetanusPneumococcalHuman papilloma virusVaricella zoster

• Hearing and vision• Dental• Falls• Frailty

Health Care Counseling

• Exercise• Obesity and weight loss• Alcohol use• Tobacco use and cessation• Contraception and sexual dysfunction

Screening

• Cancer• Cognitive impairment• Depression

Advance Care Planning

• Resuscitation status• Designated surrogate decision maker• Physician orders for life-sustaining treatment (when

applicable)

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USRDS Annual Data Report

See Januarye-supplement.

The 2012 US Renal Data Sys-tem (USRDS) 24th AnnualData Report presents data onthe breadth of kidney diseaseand its impact on both indi-viduals and society as a whole.The first section focuses onCKD, defining its burden inthe general population and ex-amining cardiovascular andother comorbidities, adverseevents, preventive care, pre-scription medication therapy,and costs to Medicare and em-ployer group health plans. Thesecond section provides infor-mation on the size and impactof the end-stage renal disease(ESRD) population, present-ing an overview of the ESRDprogram, including new dataon changes to patient care af-ter the introduction of the bundled payment system in January 2011.

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