Serial SARS-CoV-2 Receptor-Binding Domain Antibody Responses in Patients Receiving Dialysis.
Annals of internal medicine
SARS-CoV-2 Vaccine Acceptability in Patients on Hemodialysis: A Nationwide Survey.
Journal of the American Society of Nephrology : JASN
BACKGROUND: Assessing the evolution of SARS-CoV-2 immune response among patients receiving dialysis can define its durability in a highly clinically relevant context because patients receiving dialysis share the characteristics of persons most susceptible to SARS-CoV-2 infection.OBJECTIVE: To evaluate the persistence of SARS-CoV-2 receptor-binding domain (RBD) IgG in seroprevalent patients receiving dialysis.DESIGN: Prospective.SETTING: Nationwide sample from dialysis facilities.PATIENTS: 2215 patients receiving dialysis who had evidence of SARS-CoV-2 infection as of July 2020.MEASUREMENTS: Remainder plasma from routine monthly laboratories was used to measure semiquantitative RBD IgG index value over 6 months.RESULTS: A total of 2063 (93%) seroprevalent patients reached an assay detectable response (IgG index value ?1). Most (n = 1323, 60%) had responses in July with index values classified as high (IgG ?10); 1003 (76%) remained within this stratum. Adjusted median index values declined slowly but continuously (July vs. December values were 21 vs. 13; P < 0.001). The trajectory of the response did not vary by age group, sex, race/ethnicity, or diabetes status. Patients without an assay detectable response (n = 137) were more likely to be White and in the younger (18 to 44 years) or older (?80 years) age groups and less likely to have diabetes and hypoalbuminemia.LIMITATION: Lack of data on symptoms or reverse transcriptase polymerase chain reaction diagnosis, cohort of persons who survived infection, and use of a semiquantitative assay.CONCLUSION: Despite impaired immunity, most seropositive patients receiving dialysis maintained RBD antibody levels over 6 months. A slow and continual decline in median antibody levels over time was seen, but no indication that subgroups with impaired immunity had a shorter-lived humoral response was found.PRIMARY FUNDING SOURCE: Ascend Clinical Laboratories.
View details for DOI 10.7326/M21-0256
View details for PubMedID 34000201
Coronavirus Disease 2019 in Patients with End-Stage Kidney Disease on Hemodialysis in Guatemala.
Kidney international reports
BACKGROUND: Patients on dialysis are at increased risk for COVID-19-related complications. However, a substantial fraction of patients on dialysis belong to groups more likely to be hesitant about vaccination.METHODS: With the goal of identifying strategies to increase COVID-19 vaccine uptake among patients on hemodialysis, we conducted a nationwide vaccine acceptability survey, partnering with a dialysis network to distribute an anonymized English and Spanish language online survey in 150 randomly selected facilities in the United States. We used logistic regression to evaluate characteristics of vaccine-hesitant persons.RESULTS: A total of 1515 (14% of eligible) patients responded; 20% of all responders, 29% of patients aged 18-44 years, and 29% of Black responders reported being hesitant to seek the COVID-19 vaccine, even if the vaccine was considered safe for the general population. Odds of vaccine hesitancy were higher among patients aged 18-44 years versus those 45-64 years (odds ratio [OR], 1.5; 95% confidence interval [95% CI], 1.0 to 2.3), Black patients versus non-Hispanic White patients (OR, 1.9; 95% CI, 1.3 to 2.7), Native Americans or Pacific Islanders versus non-Hispanic White patients (OR, 2.0; 95% CI, 1.1 to 3.7), and women versus men (OR, 1.6; 95% CI, 1.2 to 2.0). About half (53%) of patients who were vaccine hesitant expressed concerns about side effects. Responders' main information sources about COVID-19 vaccines were television news and dialysis staff (68% and 38%, respectively).CONCLUSIONS: A substantial proportion of patients receiving in-center hemodialysis in the United States are hesitant about seeking COVID-19 vaccination. Facilitating uptake requires outreach to younger patients, women, and Black, Native American, or Pacific Islander patients, and addressing concerns about side effects.
View details for DOI 10.1681/ASN.2021010104
View details for PubMedID 33927004
Laboratory correlates of SARS-CoV-2 seropositivity in a nationwide sample of patients on dialysis in the U.S.
2021; 16 (4): e0249466
Introduction: COVID-19 is public health concern across the world. Data on the epidemiology among patients on hemodialysis in Latin America and low and middle-income countries is limited.Methods: Using electronic medical records from the second largest dialysis network in Guatemala, we performed a retrospective analysis of all adult patients on hemodialysis with the diagnosis of COVID-19 to estimate incidence of infection, and describe the demographics, comorbidities, and outcomes. We stratified incidence rate by region. We reviewed data from May 1 to July 31, 2020, with outcome data ascertained up to August 28, 2020.Results: Of 3201 patients undergoing hemodialysis, 325 patients were diagnosed with COVID-19 (incidence rate: 102 per 1,000 patients on hemodialysis, compared with 3 per 1,000 in the general population). Incidence was higher in the Central region (207 per 1,000) and lowest in the Southeast region with 33 per 1,000, and unlike in the general population, incidence was lower in Guatemalan city. Mean age of the COVID-19 diagnosed patients was 51.1 (SD 14.8) years, and 84 (25.8%) were female. The median length of hospital stay was 12 days [IQR 10-16]. 229 (69.8%) of the patients recovered, 90 patients died (27.7%), and 6 (1.8%) patients were still in the hospital at the time of last follow-up.Conclusion: In summary, incidence of diagnosed COVID-19 in Guatemalan patients on hemodialysis was much higher than reported in the general population, with outcomes similar to those described in high income countries. Rural regions had higher incidence rates than the major metropolitan area.
View details for DOI 10.1016/j.ekir.2021.01.028
View details for PubMedID 33532670
Challenges in the provision of kidney care at the largest public nephrology center in Guatemala: a qualitative study with health professionals.
2020; 21 (1): 71
Patients on dialysis are at high risk for death due to COVID-19, yet a significant proportion do survive as evidenced by presence of SARS-CoV-2 antibodies in 8% of patients in the U.S. in July 2020. It is unclear whether patients with seropositivity represent the subgroup with robust health status, who would be more likely to mount a durable antibody response. Using data from a July 2020 sample of 28,503 patients receiving dialysis, we evaluated the cross-sectional association of SARS-CoV-2 seropositivity with laboratory surrogates of patient health. In separate logistic regression models, we assessed the association of SARS-CoV-2 seropositivity with seven laboratory-based covariates (albumin, creatinine, hemoglobin, sodium, potassium, phosphate, and parathyroid hormone), across the entire range of the laboratory and in comparison to a referent value. Models accounted for age, sex, region, race and ethnicity, and county-level COVID-19 deaths per 100,000. Odds of seropositivity for albumin 3 and 3.5 g/dL were 2.1 (95% CI 1.9-2.3) and 1.3 (1.2-1.4) respectively, compared with 4 g/dL. Odds of seropositivity for serum creatinine 5 and 8 mg/dL were 1.8 (1.6-2.0) and 1.3 (1.2-1.4) respectively, compared with 12.5 mg/dL. Lower values of hemoglobin, sodium, potassium, phosphate, and parathyroid hormone were associated with higher odds of seropositivity. Laboratory values associated with poorer health status and higher risk for mortality were also associated with higher likelihood of SARS-CoV-2 antibodies in patients receiving dialysis.
View details for DOI 10.1371/journal.pone.0249466
View details for PubMedID 33857168
CKD Care and Research in Guatemala: Overview and Meeting Report.
Kidney international reports
2020; 5 (9): 1567?75
Chronic kidney disease (CKD) is increasing worldwide, and the majority of the CKD burden is in low- and middle-income countries (LMICs). However, there is wide variability in global access to kidney care therapies such as dialysis and kidney transplantation. The challenges health professionals experience while providing kidney care in LMICs have not been well described. The goal of this study is to elicit health professionals' perceptions of providing kidney care in a resource-constrained environment, strategies for dealing with resource limitations, and suggestions for improving kidney care in Guatemala.Semi-structured interviews were performed with 21 health professionals recruited through convenience sampling at the largest public nephrology center in Guatemala. Health professionals included administrators, physicians, nurses, technicians, nutritionists, psychologists, laboratory personnel, and social workers. Interviews were recorded and transcribed in Spanish. Qualitative data from interviews were analyzed in NVivo using an inductive approach, allowing dominant themes to emerge from interview transcriptions.Health professionals most frequently described challenges in providing high-quality care due to resource limitations. Reducing the frequency of hemodialysis, encouraging patients to opt for peritoneal dialysis rather than hemodialysis, and allocating resources based on clinical acuity were common strategies for reconciling high demand and limited resources. Providers experienced significant emotional challenges related to high patient volume and difficult decisions on resource allocation, leading to burnout and moral distress. To improve care, respondents suggested increased budgets for equipment and personnel, investments in preventative services, and decentralization of services.Health professionals at the largest public nephrology center in Guatemala described multiple strategies to meet the rising demand for renal replacement therapy. Due to systems-level limitations, health professionals faced difficult choices on the stewardship of resources that are linked to sentiments of burnout and moral distress. This study offers important lessons in Guatemala and other countries seeking to build capacity to scale-up kidney care.
View details for DOI 10.1186/s12882-020-01732-w
View details for PubMedID 32111173
Characteristics and Outcomes of Individuals With Pre-existing Kidney Disease and COVID-19 Admitted to Intensive Care Units in the United States.
American journal of kidney diseases : the official journal of the National Kidney Foundation
On October 14-15, 2019, the 1st Symposium to Promote Chronic Kidney Disease (CKD) Research in Guatemala was held in Guatemala City, Guatemala. The Symposium hosted more than 50 attendees, including health care professionals, policy makers, researchers, and leaders of nongovernmental organizations. The meeting's objectives were to (1) share clinical and health delivery experiences, (2) disseminate local research, and (3) establish consensus priorities for future research. In this report, we review the state of CKD nephrology in Guatemala, summarize experiences shared during the meeting from representatives of the clinical settings in Guatemala where CKD care is provided, and describe consensus priorities for future research.
View details for DOI 10.1016/j.ekir.2020.06.020
View details for PubMedID 32954082
View details for PubMedCentralID PMC7486195
Screening for chronic kidney disease in a community-based diabetes cohort in rural Guatemala: a cross-sectional study.
2018; 8 (1): e019778
Underlying kidney disease is an emerging risk factor for more severe COVID-19 illness. We examined the clinical courses of critically ill COVID-19 patients with and without pre-existing kidney disease and investigated the association between degree of underlying kidney disease and in-hospital outcomes.Retrospective cohort study SETTINGS & PARTICIPANTS: 4,264 critically ill COVID-19 patients (143 dialysis patients, 521 chronic kidney disease [CKD] patients, and 3,600 patients without CKD) admitted to ICUs at 68 hospitals in the United States.Presence (versus absence) of pre-existing kidney disease OUTCOME(S): In-hospital mortality (primary); respiratory failure, shock, ventricular arrhythmia/ cardiac arrest, thromboembolic event, major bleed, and acute liver injury (secondary) ANALYTICAL APPROACH: We used standardized differences to compare patient characteristics (values >0.10 indicate a meaningful difference between groups) and multivariable adjusted Fine and Gray survival models to examine outcome associations.Dialysis patients had a shorter time from symptom onset to ICU admission compared to other groups (median [quartile 1-quartile 3] days: 4 [2-9] for dialysis patients; 7 [3-10] for CKD patients; 7 [4-10] for patients without pre-existing kidney disease). More dialysis patients (25%) reported altered mental status than those with CKD (20%, standardized difference = 0.12) and no kidney disease (12%, standardized difference = 0.36). Half of dialysis and CKD patients died within 28-days of ICU admission versus 35% of patients without pre-existing kidney disease. Compared to patients without pre-existing kidney disease, dialysis patients had a higher risk of 28-day in-hospital death (adjusted HR 1.41; 95% CI 1.09, 1.81), while patients with CKD had an intermediate risk (adjusted HR 1.25; 95% CI 1.08, 1.44).Potential residual confounding CONCLUSIONS: Findings highlight the high mortality of individuals with underlying kidney disease and severe COVID-19, underscoring the importance of identifying safe and effective COVID-19 therapies for this vulnerable population.
View details for DOI 10.1053/j.ajkd.2020.09.003
View details for PubMedID 32961244
Treatment of end-stage renal disease with continuous ambulatory peritoneal dialysis in rural Guatemala.
BMJ case reports
Screening is a key strategy to address the rising burden of chronic kidney disease (CKD) in low-income and middle-income countries. However, there are few reports regarding the implementation of screening programmes in resource-limited settings. The objectives of this study are to (1) to share programmatic experiences implementing CKD screening in a rural, resource-limited setting and (2) to assess the burden of renal disease in a community-based diabetes programme in rural Guatemala.Cross-sectional assessment of glomerular filtration rate (GFR) and urine albumin.Central Highlands of Guatemala.We enrolled 144 adults with type 2 diabetes in a community-based CKD screening activity carried out by the sponsoring institution.Prevalence of renal disease and risk of CKD progression using Kidney Disease: Improving Global Outcomes definitions and classifications.We found that 57% of the sample met GFR and/or albuminuria criteria suggestive of CKD. Over half of the sample had moderate or greater increased risk for CKD progression, including nearly 20% who were classified as high or very high risk. Hypertension was common in the sample (42%), and glycaemic control was suboptimal (mean haemoglobin A1c 9.4%±2.5% at programme enrolment and 8.6%±2.3% at time of CKD screening).The high burden of renal disease in our patient sample suggests an imperative to better understand the burden and risk factors of CKD in Guatemala. The implementation details we share reveal the tension between evidence-based CKD screening versus screening that can feasibly be delivered in resource-limited global settings.
View details for DOI 10.1136/bmjopen-2017-019778
View details for PubMedID 29358450
View details for PubMedCentralID PMC5781190
Perceptions and utilization of generic medicines in Guatemala: a mixed-methods study with physicians and pharmacy staff.
BMC health services research
2017; 17 (1): 27
A 42-year-old indigenous Maya man presented to a non-profit clinic in rural Guatemala with signs, symptoms and laboratory values consistent with uncontrolled diabetes. Despite appropriate treatment, approximately 18 months after presentation, he was found to have irreversible end-stage renal disease (ESRD) of uncertain aetiology. He was referred to the national public nephrology clinic and subsequently initiated home-based continuous ambulatory peritoneal dialysis. With primary care provided by the non-profit clinic, his clinical status improved on dialysis, but socioeconomic and psychological challenges persisted for the patient and his family. This case shows how care for people with ESRD in low- and middle-income countries requires scaling up renal replacement therapy and ensuring access to primary care, mental healthcare and social work services.
View details for DOI 10.1136/bcr-2017-223641
View details for PubMedID 29705734
View details for PubMedCentralID PMC5931272
A quality improvement project using statistical process control methods for type 2 diabetes control in a resource-limited setting.
International journal for quality in health care : journal of the International Society for Quality in Health Care
2017; 29 (4): 593?601
Access to low-cost essential generic medicines is a critical health policy goal in low-and-middle income countries (LMICs). Guatemala is an LMIC where there is both limited availability and affordability of these medications. However, attitudes of physicians and pharmacy staff regarding low-cost generics, especially generics for non-communicable diseases (NCDs), have not been fully explored in Guatemala.Semi-structured interviews with 30 pharmacy staff and 12 physicians in several highland towns in Guatemala were conducted. Interview questions related to perceptions of low-cost generic medicines, prescription and dispensing practices of generics in the treatment of two NCDs, diabetes and hypertension, and opinions about the roles of pharmacy staff and physicians in selecting medicines for patients. Pharmacy staff were recruited from a random sample of pharmacies and physicians were recruited from a convenience sample. Interview data were analyzed using a thematic approach for qualitative data as well as basic quantitative statistics.Pharmacy staff and physicians expressed doubt as to the safety and efficacy of low-cost generic medicines in Guatemala. The low cost of generic medicines was often perceived as proof of their inferior quality. In the case of diabetes and hypertension, the decision to utilize a generic medicine was based on multiple factors including the patient's financial situation, consumer preference, and, to a large extent, physician recommendations.Interventions to improve generic medication utilization in Guatemala must address the negative perceptions of physicians and pharmacy staff toward low-cost generics. Strengthening state capacity and transparency in the regulation and monitoring of the drug supply is a key goal of access-to-medicines advocacy in Guatemala.
View details for DOI 10.1186/s12913-017-1991-z
View details for PubMedID 28086866
View details for PubMedCentralID PMC5234139
A Patient Navigation System to Minimize Barriers for Peritoneal Dialysis in Rural, Low-Resource Settings: Case Study From Guatemala.
Kidney international reports
2017; 2 (4): 762?65
Trends of Cannabis Use Disorder in the Inpatient: 2002 to 2011.
The American journal of medicine
2017; 130 (6): 678?87.e7
Quality improvement (QI) is a key strategy for improving diabetes care in low- and middle-income countries (LMICs). This study reports on a diabetes QI project in rural Guatemala whose primary aim was to improve glycemic control of a panel of adult diabetes patients.Formative research suggested multiple areas for programmatic improvement in ambulatory diabetes care.This project utilized the Model for Improvement and Agile Global Health, our organization's complementary healthcare implementation framework.A bundle of improvement activities were implemented at the home, clinic and institutional level.Control charts of mean hemoglobin A1C (HbA1C) and proportion of patients meeting target HbA1C showed improvement as special cause variation was identified 3 months after the intervention began. Control charts for secondary process measures offered insights into the value of different components of the intervention. Intensity of home-based diabetes education emerged as an important driver of panel glycemic control.Diabetes QI work is feasible in resource-limited settings in LMICs and can improve glycemic control. Statistical process control charts are a promising methodology for use with panels or registries of diabetes patients.
View details for DOI 10.1093/intqhc/mzx051
View details for PubMedID 28486632
Navigating Bureaucracy: Accompanying Indigenous Maya Patients with Complex Health Care Needs in Guatemala
2016; 75 (4): 305?14
Argininemia as a cause of severe chronic stunting in a low-resource developing country setting: a case report.
2016; 16 (1): 142
The nationwide prevalence of cannabis use/abuse has more than doubled from 2002 to 2011. Whether the outpatient trend is reflected in the inpatient setting is unknown. We examined the prevalence and incidence of cannabis abuse/dependence as determined by discharge coding in a 10-year (2002-2011) National Inpatient Sample, as well as various trends among demographics, comorbidities, and hospitalization outcomes.Cannabis abuse/dependence was identified on the basis of International Classification of Diseases, 9th Revision, Clinical Modification codes 304.3* and 305.2* in adults aged 18 years or more. We excluded cases coded "in remission." National estimates of trends and matched-regression analyses were conducted.Overall, 2,833,567 (0.91%) admissions with documented cannabis abuse/dependence were identified, patients had a mean age of 35.12 ± 0.06 years, 62% were male, and there was an increasing trend in prevalence from 0.52% to 1.34% (P <.001). The mean Charlson Comorbidity Index was 0.47 ± 0.006, and inpatient mortality was 0.41%. All of the above demonstrated an increasing trend (P <.001). Mean length of stay was 6.23 ± 0.06 days. The top primary discharge diagnoses were schizoaffective/mood disorders, followed by psychotic disorders and alcoholism. Asthma prevalence in nontobacco smokers had a steeper increase in the cannabis subgroup than in the noncannabis subgroup (P = .002). Among acute pancreatitis admissions, cannabis abusers had a shorter length of stay (-11%) and lower hospitalization costs (-7%) than nonabusers.Cannabis abuse/dependence is on the rise in the inpatient population, with an increasing trend toward older and sicker patients with increasing rates of moderate to severe disability. Psychiatric disorders and alcoholism are the main associated primary conditions. Cannabis abuse is associated with increased asthma incidence in nontobacco smokers and decreased hospital resource use in acute pancreatitis admissions.
View details for DOI 10.1016/j.amjmed.2016.12.035
View details for PubMedID 28161344
Implementation and Outcomes of a Comprehensive Type 2 Diabetes Program in Rural Guatemala.
2016; 11 (9): e0161152
Argininemia is rare inborn error of metabolism which, when untreated, presents in late infancy with growth delay and developmental regression. In developed countries, argininemia is diagnosed early by newborn screening and is treated immediately with a protein-restricted diet. In developing countries, diagnosis may be delayed by the assumption that stunting is related to malnutrition alone.We describe the diagnosis and treatment of argininemia in a 60-month-old Kaqchikel Maya girl in rural Guatemala. The patient initially presented with severe stunting and developmental regression. The initial diagnosis of argininemia was made by a screening test in dried blood spots and confirmed with urine and serum amino acid profiles. The patient was treated with a low-protein diet using locally available foods, leading to significant improvement in her growth and development.This case demonstrates that the identification, diagnosis and treatment of IEM in developing countries are increasingly feasible, as well as ethically imperative. Providers working with malnourished children in developing countries should suspect IEM in malnourished children who do not respond to standard therapies.
View details for DOI 10.1186/s12887-016-0668-9
View details for PubMedID 27549856
View details for PubMedCentralID PMC4994184
The burden of chronic, non-communicable diseases such as diabetes is growing rapidly in low- and middle-income countries. Implementing management programs for diabetes and other chronic diseases for underserved populations is thus a critical global health priority. However, there is a notable dearth of shared programmatic and outcomes data from diabetes treatment programs in these settings.We describe our experiences as a non-governmental organization designing and implementing a type 2 diabetes program serving Maya indigenous people in rural Guatemala. We detail the practical challenges and solutions we have developed to build and sustain diabetes programming in this setting.We conduct a retrospective chart review from our electronic medical record to evaluate our program's performance. We generate a cohort profile, assess cross-sectional indicators using a framework adapted from the literature, and report on clinical longitudinal outcomes.A total of 142 patients were identified for the chart review. The cohort showed a decrease in hemoglobin A1C from a mean of 9.2% to 8.1% over an average of 2.1 years of follow-up (p <0.001). The proportions of patients meeting glycemic targets were 53% for hemoglobin A1C < 8% and 32% for the stricter target of hemoglobin A1C < 7%.We first offer programmatic experiences to address a gap in resources relating to the practical issues of designing and implementing global diabetes management interventions. We then present clinical data suggesting that favorable diabetes outcomes can be attained in poor areas of rural Guatemala.
View details for DOI 10.1371/journal.pone.0161152
View details for PubMedID 27583362
View details for PubMedCentralID PMC5008811