Current Medical Research and Opinion最新文献

Chronic kidney disease affects over 36 million Americans, with more than 800,000 progressing to end-stage kidney disease (ESKD). Treatment with kidney transplantation offers superior survival, quality of life, and cost-effectiveness compared with dialysis, yet access remains limited. Hyperphosphatemia is a highly prevalent and modifiable complication of ESKD that contributes to cardiovascular disease, mineral bone disorder, and potential pulmonary dysfunction. Additionally, elevated serum phosphate has been linked to transplant graft failure and adverse post-transplant outcomes. Although normal phosphate levels are not formally required for transplant eligibility, they are frequently considered as part of transplant readiness assessments. Persistent gaps between clinical guideline recommendations and real-world serum phosphate control, despite dialysis, dietary restrictions, and phosphate binder therapy, underscore the need for individualized and more effective treatment strategies. Because transplant candidacy may be influenced by serum phosphate levels, phosphate management should be viewed not just as correction of a laboratory abnormality, but as a strategy to improve transplant access, promote health equity, and enhance long-term outcomes. Real-world tracking of transplant readiness metrics by serum phosphate levels will be essential to assessing the impact of new therapies and support transparent and equitable organ allocation. Effective phosphate management may reduce time on dialysis, improve graft and patient survival, and lower healthcare costs. In this context, managing hyperphosphatemia is a clinical and strategic imperative in advancing kidney health.

Introduction: Colorectal cancer (CRC) screening is recommended for average-risk adults, yet completion of the screening process requires follow-up colonoscopy after a positive stool-based test (SBT). Until recently, patients frequently faced out-of-pocket costs for follow-up colonoscopy, which was classified as a diagnostic procedure. In November 2022, coordinated federal policies were issued to eliminate patient cost-sharing for this procedure across commercial and Medicare insurance, effective January 2023. This study evaluated changes in follow-up colonoscopy utilization before and after implementation of these policies.

Methods: We conducted a retrospective cohort study using a large, nationally representative health care claims resource linked with laboratory data from January 1, 2022, to December 1, 2023. Adults aged 45-75 years who underwent colonoscopy were included. Follow-up colonoscopy (a diagnostic colonoscopy performed within six months of a positive SBT) was the primary endpoint. An interrupted time series design with a seasonally adjusted segmented autoregressive model estimated changes before (January-December 2022) and after (January-November 2023) cost-sharing elimination.

Results: Among 10,841,411 individuals undergoing colonoscopy, follow-up procedures comprised 3.59% (95% CI, 3.18-3.99) before implementation. Following policy enactment, there was an immediate 41.2% relative increase (absolute increase 1.48% [95% CI, 1.25-1.71]; p < .001), sustained through November 2023.

Conclusion: Elimination of patient cost-sharing for follow-up colonoscopy was associated with an immediate and sustained increase in utilization after positive stool-based tests. While other contextual factors may have contributed, these findings suggest that financial policy interventions can improve completion of the CRC screening process.

Background: Hyperkalemia is a common and clinically significant complication among patients receiving renin-angiotensin-aldosterone system inhibitors (RAASi). Despite their well-established cardiovascular and renal benefits, RAASi use is often limited by hyperkalemia, leading to treatment modification or discontinuation. Real-world adherence to potassium management strategies remains inconsistent, particularly in high-risk populations.

Objective: This study aimed to determine the incidence and severity of hyperkalemia among RAASi users, identify associated risk groups, and assess its influence on clinical decisions and patient outcomes.

Methods: We conducted a retrospective cohort study involving 905 adult patients attending outpatient clinics at King Abdulaziz Medical City, Jeddah. All patients were on RAASi therapy and followed for a mean duration of 29.8 months.

Results: Hyperkalemia (K⁺ ≥5.1 mmol/L) was observed in 295 patients, yielding an overall incidence of 32.8% (95% CI: 30-36%). Most cases were mild (74.6%), with moderate and severe hyperkalemia accounting for 19.0% and 6.4%, respectively. Recurrence occurred in over half of the affected patients, with decreasing intervals between successive episodes. Risk factors significantly associated with hyperkalemia included age ≥75 years, diabetes, congestive heart failure, and reduced eGFR. RAASi therapy was discontinued in 6.2%, and down-titrated in 4.5% of patients due to hyperkalemia. Adverse clinical events included emergency visits (2.1%), hospitalizations (1.7%), arrhythmias (0.3%), and dialysis (0.2%).

Conclusion: Hyperkalemia affects nearly one-third of RAASi users, often prompting de-escalation of therapy. Proactive monitoring and management strategies are necessary to maintain the benefits of RAAS inhibition, especially in high-risk groups.

Objective: Administrative claims databases are used to study the care of congenital cytomegalovirus (cCMV), yet the use of International Classification of Diseases, (ICD-9/10) codes for cCMV have not been validated. This study examines the accuracy of ICD-based codes for cCMV infection.

Methods: Infants cared for at a quaternary children's hospital (2013-2023) that had an ICD-based diagnosis for cCMV or CMV Infection at ≤90 days of age were included. Medical record data was abstracted. True Positive cases were defined as those with an ICD code AND clinical and laboratory evidence consistent with cCMV. False Positive cases were defined as those with an ICD code without evidence of cCMV. Positive predictive value (PPV) and sensitivity for each diagnostic code at different age cutoffs were calculated within the cohort. Multinomial regression examined characteristics of the infant with odds of being a True Positive case of cCMV.

Results: Of the 108 infants with ICD-9/10 codes for cCMV, 35% were false positives. PPV for ICD-9/10-CM codes for cCMV, CMV Infection, and Either code predicting actual cCMV were 0.86, 0.36, and 0.68 at age ≤45 days. PPV was the highest at ≤21 days of age, and for all codes sensitivity increased with patient age. Multinomial logistic regression found the age of the first diagnostic code ≤21 days (vs. >) (OR = 4.11, 95% CI 1.45-12.03), having an ICD-9/10-CM diagnostic code of cCMV (vs. CMV Infection) (OR = 10.87, 95% CI 3.64-32.47), and having Clinical Signs at Birth (vs. none) (OR = 8.4, 95% CI 2.72-25.81) to be associated with greater odds of having a True Positive case of cCMV (vs. Not cCMV).

Conclusions: Administrative claims case definitions for cCMV were more likely to be accurate when assigned at a younger age. Studies using case definitions for cCMV that include the presence of codes for either cCMV or CMV Infection may be biased given the high proportion of false positives demonstrated in this study.

Introduction: A positive result from a multi-target stool DNA (mt-sDNA) test, fecal immunochemical test (FIT), or fecal occult blood test (FOBT) requires a timely follow-up colonoscopy (FU-CY) to minimize colorectal cancer (CRC) incidence and reduce CRC-related mortality. This study aimed to assess differences in FU-CY adherence between patients who received a positive mt-sDNA or FIT/FOBT result by payer type.

Methods: This retrospective analysis utilized a large national claims database linked to the Exact Sciences Laboratories database, covering over 20 million individuals. Eligible patients were 45-75 years old with a positive result between 1 January 2017 and 30 June 2022, with the first test result serving as the index date. Primary outcomes included FU-CY adherence and time to colonoscopy completion.

Results: A total of 362,646 (mt-sDNA n = 292,300; FIT/FOBT n = 70,346) patients were identified. Overall adherence to FU-CY was significantly (p < .001) higher for the mt-sDNA test cohort (77.1%) compared to the FIT/FOBT cohort (45.1%). Among payer types, mt-sDNA test adherence was highest for commercial insurance (80.7%) and lowest for Medicaid (69.8%); for FIT/FOBT, adherence among commercially insured patients (42.3%) was lower than other payer types (47.4-47.9%). Regression analyses confirmed significantly higher FU-CY adherence (p < .001) for mt-sDNA across payer types, sex, and race/ethnicity. Within 180 days, FU-CY rates ranged from 62.7%-74.9% for mt-sDNA versus 36.1%-42.5% for FIT/FOBT.

Conclusion: In this large national study, adherence to FU-CY was substantially higher following mt-sDNA versus FIT/FOBT across payer types, with notably higher completion within 180 days for mt-sDNA test.

Background: Colorectal cancer (CRC) is the second leading cause of U.S. cancer mortality. This study evaluated the utilization of CRC screening modalities from 2017 to 2023.

Methods: This retrospective, cross-sectional study analyzed data from 2017 to 2023 using a national multi-payer claims database, supplemented with laboratory data related to CRC screening. Patients aged 45-75 years, at average risk for CRC, with no prior CRC diagnosis, and who had continuous health insurance enrollment for 24 months (from January 1 of the baseline year to December 31 of the study year) were included. Annual proportions for colonoscopy, multi-target stool DNA (mt-sDNA) test, fecal immunochemical test/fecal occult blood test (FIT/FOBT), and other modalities were assessed, along with sociodemographic factors. Descriptive statistics and chi-square tests were used to assess utilization trends across the years.

Results: Colonoscopy remained the most commonly used screening modality, with its share increasing slightly from 53.0% in 2017 to 58.7% in 2023. The mt-sDNA test proportion increased significantly from 2.4% in 2017 to 20.4% in 2023, while the proportion of FIT/FOBT declined significantly, from 44% to 20.4%. Similarly, significant age-related shifts in screening utilization were observed, with colonoscopy proportion increasing from 48.1% to 61.6%, mt-sDNA rising from 0.0% to 24.0%, and FIT/FOBT declining from 50.8% to 14.1% in the 45-49 age group from 2017 to 2023.

Conclusion: CRC screening utilization shifted significantly from 2017 to 2023, with increased colonoscopy and mt-sDNA use and a marked decline in FIT/FOBT. Continued monitoring is critical to ensure equitable access to effective modalities.

Introduction: The purpose of this study was to describe the clinical burden and healthcare resource utilization (HCRU) among patients with sickle cell disease (SCD) and recurrent vaso-occlusive crises (VOCs) and patients with transfusion-dependent β-thalassemia (TDT) in the Netherlands.

Methods: This retrospective cohort study identified two patient populations, one cohort with SCD and recurrent VOCs and the other with TDT from the PHARMO Data Network (1 January 2014-31 December 2020). Key inclusion criteria were diagnosis of SCD and ≥2 VOCs per year for 2 consecutive years following the diagnosis for SCD; or diagnosis of β-thalassemia and ≥8 red blood cell transfusions (RBCTs) per year for 1 year following the diagnosis for β-thalassemia. Complications and HCRU were evaluated for each cohort.

Results: A total of 383 patients with SCD and recurrent VOCs and a total of 54 patients with TDT were identified with mean ages at index of 26.9 (standard deviation [SD]: 14.4) years and 17.7 (SD: 15.2) years, respectively. Patients with SCD and recurrent VOCs experienced an average of 7.0 VOCs per patient per year (PPPY). The most common acute complication was acute chest syndrome (34.9%), and the most common chronic complications were bone and joint complications (12.0%). Patients had a mean of 2.5 inpatient hospitalizations and 7.0 outpatient visits PPPY.Patients with TDT received an average of 13.0 RBCTs PPPY. The most common acute complication was infection (5.6%), and the most common chronic complication was transfusion-induced iron overload (33.3%). Patients had a mean of 11.3 inpatient hospitalizations, mainly driven by transfusion-related hospitalizations, and 8.4 outpatient visits PPPY.

Conclusion: Patients with SCD and recurrent VOCs and patients with TDT in the Netherlands sustain substantial clinical complications and HCRU mainly related to VOCs and regular RBCTs, respectively.

Background: Evidence on the biochemical phenotypes of primary aldosteronism and their link to renal function in Chinese populations is limited. This study explored the associations of plasma aldosterone concentration (PAC), plasma renin concentration (PRC), and the aldosterone-to-renin ratio (ARR) with renal function.

Methods: In this cross-sectional study of 1700 participants from Southwest China, associations between PAC, PRC, ARR, and renal parameters (serum creatinine [SCR], blood urea nitrogen [BUN], estimated glomerular filtration rate [eGFR]) were analyzed using a generalized linear mixed model. Dose-response relationships were assessed with P-trend and restricted cubic spline (RCS) analyses. A structural equation model evaluated the mediating effect of blood pressure.

Results: Higher log-transformed PAC was associated with elevated SCR (β = 0.451, 95% CI: 0.329, 0.573) and BUN (β = 0.370, 95% CI: 0.278, 0.462), and reduced eGFR (β = -0.263, 95% CI: -0.331, -0.194). RCS analyses confirmed linear dose-response relationships. These associations were more pronounced in males than females. Renin-Angiotensin-Aldosterone System (RAS) inhibitor use mitigated the positive association between PAC and BUN. Systolic blood pressure mediated a small proportion of the effect of PAC on SCR (2.4%) and eGFR (2.6%).

Conclusion: A continuous spectrum of PAC is associated with renal impairment in this Chinese cohort, with stronger effects observed in males. The use of RAS inhibitors may attenuate this aldosterone-related renal impairment.