Publications by authors named "Shahab Bozorgmehri"

23 Publications

  • Page 1 of 1

Validation of aorta-lesion-attenuation difference on preoperative contrast-enhanced computed tomography scan to differentiate between malignant and benign oncocytic renal tumors.

Abdom Radiol (NY) 2021 Mar 4. Epub 2021 Mar 4.

Department of Urology, University of Florida College of Medicine, Gainesville, FL, 32610, USA.

Objectives: We previously noted that the aorta-lesion-attenuation difference (ALAD) determined on CT scan discriminated well between chromophobe RCC and oncocytoma. The current evaluation seeks to validate these initial findings in a second cohort of nephrectomy patients.

Methods: A retrospective review of preoperative CT scans and surgical pathology was performed on patients undergoing nephrectomy for small, solid renal masses. ALAD was calculated by measuring the difference in Hounsfield units (HU) between the aorta and the lesion of interest on the same image slice on preoperative CT scan. The discriminative ability of ALAD to differentiate malignant pathology from oncocytoma was evaluated by sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under curve (AUC) using ROC analysis.

Results: Twenty-one preoperative CT scans and corresponding pathology reports were reviewed and included in the validation cohort. ALAD values were calculated during the excretory and nephrographic phases. Compared to the training cohort, patients in the validation cohort were significantly older (62 versus 59 years old), had larger tumors (3.7 versus 2.7 cm), and higher stage disease (59% versus 79% T1a disease). Nephrographic ALAD was able to differentiate malignant pathology from oncocytoma in the training and validation cohorts with a sensitivity of 84% versus 73%, specificity of 86% and 67%, PPV of 98% versus 91%, and NPV of 33% versus 35%. The AUC for malignant pathology versus oncocytoma in the validation cohort was 0.72 (95% CI 0.63-0.82). Nephrographic ALAD was able to differentiate chromophobe RCC from oncocytoma in the training and validation cohorts with a sensitivity of 100% versus 67%, specificity of 86% versus 67%, PPV of 75% versus 43%, and NPV of 100% versus 84%. The AUC for chromophobe RCC versus oncocytoma in the validation cohort was 0.72 (95% CI 0.48-0.96).

Conclusions: The ability of ALAD to discriminate between chromophobe RCC and oncocytoma was diminished in the validation cohort compared to the training cohort, but remained significant. The current findings support further investigation in the role of ALAD in the management of patients with indeterminate diagnoses of oncocytic neoplasm.
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http://dx.doi.org/10.1007/s00261-021-02971-7DOI Listing
March 2021

Association of early initiation of dialysis with all-cause and cardiovascular mortality: A propensity score weighted analysis of the United States Renal Data System.

Hemodial Int 2021 Apr 28;25(2):188-197. Epub 2021 Feb 28.

Division of Nephrology, Hypertension & Transplantation, University of Florida, Gainesville, Florida, USA.

Background: Early initiation of maintenance hemodialysis has been associated with excess mortality in some studies, but the effects on cardiovascular (CV) mortality has not been studied. Moreover, whether the increased mortality is due to co-morbidities or early initiation of dialysis is unclear. We used a propensity score weighted analysis of the United States Renal Data System (USRDS) to examine how the estimated glomerular filtration rate (eGFR) at initiation of dialysis affects total and CV mortality.

Methods: Association between tertiles of eGFR at initiation of hemodialysis and all-cause and CV mortality were assessed in 676,196 adult patients who initiated hemodialysis between 2006 and 2014, using inverse probability of treatment weighting (IPTW) weighted multivariable regression models.

Results: The intermediate (eGFR 8.7 to <13.0 mL/min) and early start groups (eGFR ≥13.0 mL/min) had a 42% and 93% increased all-cause mortality, respectively compared to late (eGFR < 8.7), start group (unadjusted hazard ratio (HR) = 1.42; 95% CI, 1.41-1.43 and HR = 1.93; 95%CI, 1.91-1.94, respectively). This association was attenuated but remained significant in propensity weighted multivariable analysis (adjusted HR = 1.13; 95%CI, 1.12-1.14 for intermediate and HR = 1.37; 95%CI, 1.36-1.39, for early start, respectively). The CV mortality was similarly increased (adjusted HR = 1.08; 95%CI, 1.07-1.10 and HR = 1.23; 95%CI, 1.21-1.24, for intermediate and early start, respectively). In patients with cystic kidney disease, all-cause mortality was increased with early start, but there were no differences in CV mortality between groups.

Conclusions: Early initiation of dialysis is associated with increased all-cause and CV mortality. Our observations support delaying hemodialysis according to the eGFR values.
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http://dx.doi.org/10.1111/hdi.12912DOI Listing
April 2021

Utilization of CMS pre-ESRD Kidney Disease Education services and its associations with the home dialysis therapies.

Perit Dial Int 2020 Dec 1:896860820975586. Epub 2020 Dec 1.

Division of Nephrology, 158428North Florida/South Georgia Veteran Healthcare System, Gainesville, FL, USA.

Background: Kidney Disease Education (KDE) has been shown to improve informed dialysis selection and home dialysis use, two long-held but underachieved goals of US nephrology community. In 2010, the Center for Medicare and Medicaid Services launched a policy of KDE reimbursements for all Medicare beneficiaries with advanced chronic kidney disease. However, the incorporation of KDE service in real-world practice and its association with the home dialysis utilization has not been examined.

Methods: Using the 2016 US Renal Data System linked to end-stage renal disease (ESRD) and pre-ESRD Medicare claim data, we identified all adult incident ESRD patients with active Medicare benefits at their first-ever dialysis during the study period (1 January 2010 to 31 December 2014). From these, we identified those who had at least one KDE service code before their dialysis initiation (KDE cohort) and compared them to a parsimoniously matched non-KDE control cohort in 1:4 proportions for age, gender, ESRD network, and the year of dialysis initiation. The primary outcome was home dialysis use at dialysis initiation, and secondary outcomes were home dialysis use at day 90 and anytime through the course of ESRD.

Results: Of the 369,968 qualifying incident ESRD Medicare beneficiaries with their first-ever dialysis during the study period, 3469 (0.9%) received KDE services before dialysis initiation. African American race, Hispanic ethnicity, and the presence of congestive heart failure and hypoalbuminemia were associated with significantly lower odds of receiving KDE services. Multivariate analyses showed that KDE recipients had twice the odds of initiating dialysis with home modalities (15.0% vs. 6.9%; adjusted odds ratio (aOR):95% confidence interval (CI) 2.0:1.7-2.4) and had significantly higher odds using home dialysis throughout the course of ESRD (home dialysis use at day 90 (17.6% vs. 9.9%, aOR:CI 1.7:1.4-1.9) and cumulatively (24.7% vs. 15.1%, aOR:CI 1.7:1.5-1.9)).

Conclusions: Utilization of pre-ESRD KDE services is associated with significantly greater home dialysis utilization in the incident ESRD Medicare beneficiaries. The very low rates of utilization of these services suggest the need for focused systemic evaluations to identify and address the barriers and facilitators of this important patient-centered endeavor.
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http://dx.doi.org/10.1177/0896860820975586DOI Listing
December 2020

Improved ability to achieve target trough levels with liquid versus capsule tacrolimus in kidney transplant patients with HIV on protease inhibitor- or cobicistat-based regimens.

Transpl Infect Dis 2020 Nov 20:e13517. Epub 2020 Nov 20.

Division of Nephrology, Hypertension & Renal Transplantation, Department of Medicine, University of Florida, Gainesville, FL, USA.

HIV + patients are commonly accepted for kidney transplantation. However, patients on protease inhibitor (PI)- or cobicistat (cobi)-based regimens have trouble achieving optimal tacrolimus (Tac) levels. Our study compared the ability to achieve target levels using liquid versus immediate-release capsule Tac in kidney transplant patients with HIV on PI- or cobi-based regimens. The study included four kidney transplant patients who were converted to liquid Tac due to inability to achieve acceptable drug levels on the capsule formulation. Tac trough levels were analyzed retrospectively to compare target levels before and after conversion. The individual patient time in the therapeutic range (TTR) was calculated using Rosendaal's linear interpolation method, and the difference between before and after conversion TTR was determined. In combined data, 44.63% of all Tac trough levels were within the target range after conversion to liquid Tac compared to 22.07% prior to conversion (P < .001). Furthermore, 3.31% and 7.44% of Tac trough levels were lower than 3 ng/mL or higher than 12 ng/mL, respectively, after conversion compared to 11.72% (P = .0564) and 24.14% (P < .0001) prior to conversion. The overall mean TTR was 45.1% after conversion to liquid Tac compared to 16.2% prior to conversion (P = .097). Finally, the coefficient of variation for Tac trough levels was 42.6 after conversion compared to 56.4 prior to conversion. A significantly improved ability to achieve target trough Tac levels was achieved with liquid Tac extemporaneous versus capsule formulation in kidney transplant patients with HIV taking a PI- or cobi-based regimen.
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http://dx.doi.org/10.1111/tid.13517DOI Listing
November 2020

A pilot study of immunosuppression resumption following BK viremia resolution.

Transpl Infect Dis 2021 Apr 29;23(2):e13508. Epub 2020 Nov 29.

Medicine- Nephrology, University of Florida, Gainesville, FL, USA.

Background: Immunosuppression reduction for BK viremia is associated with de novo humoral responses, which are a risk factor for rejection and graft loss. In this pilot project, we tested a protocol of immunosuppression resumption to standard dose after viral clearance for optimal protection against humoral immunity in patients undergoing treatment for BK viremia.

Methods: Thirty-six consecutive kidney transplant recipients who developed BK viremia from 7/1/2014 to 11/18/2016 underwent immunosuppression reduction. After 4 weeks of absent viremia, mycophenolate mofetil (MMF) was increased by 500mg/day every 2 weeks up to standard dosage, followed by increase of tacrolimus trough levels to 5-7 ng/mL. If viremia recurred during the increase, immunosuppression was reduced in this same stepwise fashion, with stepwise increase again after 2 months of negative viremia.

Results: Mean tacrolimus trough level (ng/mL) was 8.3 ± 2.7 at viremia onset, 5.3 ± 3.6 at resolution, and 5.6 ± 2.0 at study end date. Mean daily dose (mg) of MMF was 1574 ± 355 at onset, 910 ± 230 at resolution, and 1377 ± 451 at study end date. Only one patient developed low level viremia recurrence (peak 2875 copies/mL) during the period of immunosuppression resumption that ultimately resolved.

Conclusions: The results of our pilot project indicate that following BK viremia resolution, resumption of standard immunosuppression can be achieved safely without BK viremia recurrence. Larger trials with long-term follow up are required to determine whether such an approach improves long-term graft survival.
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http://dx.doi.org/10.1111/tid.13508DOI Listing
April 2021

Preventive care for patients with end-stage kidney disease: crossroads between nephrology and primary care.

Semin Dial 2020 07 24;33(4):330-337. Epub 2020 Jun 24.

Division of General Internal Medicine, Hypertension, and Renal Transplantation, University of Florida College of Medicine, Gainesville, Florida.

Patients with end-stage kidney disease (ESKD) undergoing maintenance hemodialysis (HD) might expect their nephrologists to coordinate all their healthcare needs. We performed a survey among adult patients with ESKD undergoing HD in two outpatient dialysis centers at the University of Florida to identify differences in characteristics between patients with and without primary care providers (PCP) and to explore the association of PCP utilization with adherence to preventive health measures. Of the 132 participants, 89.4% reported having a PCP. This group was more likely to be female, older, and with higher education level. Having a PCP was associated with influenza, pneumococcal, and tetanus/Tdap vaccinations as well as screening for tuberculosis, depression, hypertension, and dyslipidemia. The PCP group had statistically significant higher rates of influenza immunization (89.8% vs 71.4%, P = .04) as well as screening for hypertension (93.2% vs 64.3%, P = .04) and depression (78.8% vs 42.9%, P = .004), compared to the group without PCP, in the multivariable analysis. Having a PCP is associated with higher rates of influenza vaccination and screening for depression and hypertension. These findings could have important implications as far as identifying patients with ESKD at risk for fragmented care and potential gaps in optimal preventive care.
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http://dx.doi.org/10.1111/sdi.12889DOI Listing
July 2020

Prevalence and correlates of sleep apnea among US Veterans with chronic kidney disease.

J Sleep Res 2020 08 7;29(4):e12981. Epub 2020 Jan 7.

Division of General Medicine, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA.

The prevalence and correlates of sleep apnea (SA) among Veterans with chronic kidney disease (CKD), a population at high risk of both SA and CKD, are unknown. We performed a cross-sectional analysis of 248 Veterans (18-89 years) selected only for presence of moderate to severe CKD. All participants underwent full, unattended polysomnography, measurement of renal function and a sleepiness questionnaire. Logistic regression with backward selection was used to identify predictors of prevalent SA (apnea-hypopnea index [AHI, ≥15 events/hr] and prevalent nocturnal hypoxia [NH, % of total sleep time spent at <90% oxygen saturation]). The mean age of our cohort was 73.2 ± 9.6 years, 95% were male, 78% were Caucasian and the mean body mass index (BMI) was 30.3 ± 4.8 kg/m . The prevalence of SA was 39%. There was no difference in daytime sleepiness among those with and without SA. In the final model, older age, higher BMI and diabetes mellitus (DM) were associated with higher odds of SA, after controlling for age, BMI, race and sex. Higher BMI, DM, unemployed/retired status, current smoking and higher serum bicarbonate level were associated with prevalent NH. To sum, SA was common among Veterans with moderate to severe CKD. Although some traditional risk factors for SA were associated with SA in this population, sleepiness did not correlate with SA. Further study is needed to validate our findings and understand how best to address the high burden of SA among Veterans with CKD.
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http://dx.doi.org/10.1111/jsr.12981DOI Listing
August 2020

Renin-Angiotensin-Aldosterone System Optimization for Acute Decompensated Heart Failure Patients (ROAD-HF): Rationale and Design.

Am J Cardiovasc Drugs 2020 Aug;20(4):373-380

Division of Nephrology, University of Florida, Gainesville, FL, USA.

Introduction: The long-term benefits of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) on outcomes in patients with chronic congestive heart failure are well-known, making them one of the most widely prescribed medications. However, the administration of ACEIs/ARBs in acute decompensated heart failure (ADHF) can increase the risk of morbidity and mortality secondary to worsening renal function (WRF). A decrease in estimated glomerular filtration rate (eGFR) during the treatment of ADHF has been associated with an increase in mortality proportional to the degree of WRF.

Aim: The aim of our study is to determine whether withholding ACEIs/ARBs during the initial 72 h of admission in patients with ADHF will prevent WRF and allow more effective diuresis.

Methods: Four hundred and thirty patients will be randomized to the intervention (withholding ACEIs/ARBs) or control (continue/start ACEIs/ARBs) arms for 72 h. Primary outcomes include rates of acute kidney injury (AKI), patient global assessment, and change in kinetic eGFR over 72 h, while secondary outcomes include change in weight, fluid balance, change in signs and symptoms of congestion, change in renal function, change in urinary biomarkers (tissue inhibitor of metalloproteinases 2 [TIMP-2] × insulin-like growth factor-binding protein 7 [IGFBP7]), patients experiencing treatment failure, hospital length of stay (LOS), cost analysis, mortality within 30 days, and hospital readmissions over 30 days and 1 year.

Conclusion: This prospective clinical trial will prove if withholding ACEIs/ARBs will prevent AKI in ADHF. It will help us understand the complex interactions between the heart and kidney, and delineate the best treatment strategy for ADHF. Holding ACEIs/ARBs might help preserve renal function, and decrease hospital LOS, readmission rates, and cost of care in ADHF.

Registration: ClinicalTrials.gov identifier: NCT03695120.
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http://dx.doi.org/10.1007/s40256-019-00389-7DOI Listing
August 2020

Opioid Safety and Concomitant Benzodiazepine Use in End-Stage Renal Disease Patients.

Pain Res Manag 2019 20;2019:3865924. Epub 2019 Oct 20.

Division of Pain Medicine, Department of Anesthesiology, University of Florida, Gainesville, FL, USA.

Background: Opioid use is common in end-stage renal disease (ESRD) patients. However, safety of individual opioids and concomitant benzodiazepine use has not been studied.

Objective: To study the epidemiology of opioid and concomitant benzodiazepine use in ESRD population. To study the clinical safety profile of individual opioids in patients on hemodialysis.

Design: Retrospective analysis of the U.S. Renal Data System. A comprehensive review of the current literature was performed to update currently used opioid safety classification.

Participants: ESRD patients ≥18 years on hemodialysis who were enrolled in Medicare A and B and Part D between 2006 and 2012, excluding those with malignancy.

Main Measures: Hospital admission with diagnosis of prescription opioid overdose within 30, 60, and 90 days of prescription; death due to opioid overdose.

Results: Annually, the percentage of patients prescribed any opioid was 52.2%. Overall trend has been increasing except for a small dip in 2011, despite which the admissions due to opioid overdose have been rising. 30% of those who got a prescription for opioids also got a benzodiazepine prescription. 56.5% of these patients received both prescriptions within a week of each other. Benzodiazepine use increased the odds of being on opioids by 3.27 (CI 3.21-3.32) and increased the odds of hospitalization by 50%. Opioids considered safe such as fentanyl and methadone were associated with 3 and 6 folds higher odds of hospitalization within 30 days of prescription. Hydrocodone had the lowest odds ratio (1.9, CI 1.8-2.0).

Conclusions: Concurrent benzodiazepine use is common and associated with higher risk of hospitalization due to opioid overdose. Possible opioid-associated hospital admission rate is 4-5 times bigger in ESRD population than general population. Current safety classification of opioids in these patients is misleading, and even drugs considered safe based on pharmacokinetic data are associated with moderate to very high risk of hospitalization. We propose a risk-stratified classification of opioids and suggest starting to use them in all ESRD patients.
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http://dx.doi.org/10.1155/2019/3865924DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854236PMC
March 2020

External Validation of the qSOFA Score in Emergency Department Patients With Pneumonia.

J Emerg Med 2019 Dec 15;57(6):755-764. Epub 2019 Nov 15.

Division of Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts.

Background: Pneumonia is the leading cause of sepsis. In 2016, the 3 International Consensus Conference for Sepsis released the Quick Sepsis-Related Organ Failure Assessment (qSOFA) to identify risk for poor outcomes in sepsis.

Objective: We sought to externally validate qSOFA in emergency department (ED) patients with pneumonia and compare the accuracy of qSOFA to systemic inflammatory response syndrome score (SIRS), Confusion, Respiratory Rate and Blood Pressure (CRB), Confusion, Respiratory Rate, Blood Pressure and Age (CRB-65), and DS CRB-65, which is based on the CRB-65 score and includes two additional items-presence of underlying comorbid disease and blood oxygen saturation.

Methods: A subgroup analysis of U.S. Critical Illness and Injury Trials Group (USCIITG-Lung Injury Prevention Study [LIPS]; ClinicalTrials.gov ID: NCT00889772) prospective cohort. The primary outcome was in-hospital mortality. Secondary outcomes were measures of intensive care unit (ICU) utilization. Sensitivity, specificity, and area under the curve (AUC) were reported.

Results: From March to August 2009, 5584 patients were enrolled; 713 met inclusion criteria. Median age was 61 years (interquartile range 49-75 years). SIRS criteria had the highest sensitivity for death (89%) and lowest specificity (25%), while CRB had the highest specificity (88%) and lowest sensitivity (31%), followed by qSOFA (80% and 53%, respectively). This trend was maintained for the secondary outcomes. There was no significant difference in the AUC for death using qSOFA (AUC 0.75; 95% confidence interval [CI] 0.66-0.84), SIRS (AUC 0.70; 95% CI 0.61-0.78), CRB (AUC 0.71; 95% CI 0.62-0.80), CRB-65 (AUC 0.71; 95% CI 0.63-0.80), and DS CRB-65 (AUC 0.73; 95% CI 0.64-0.82).

Conclusions: In this multicenter observational study of ED patients hospitalized with pneumonia, we found no significant differences between qSOFA and SIRS for predicting in-hospital death. In addition, several popular pneumonia-specific severity scores performed nearly identically to qSOFA score in predicting death and ICU utilization. Validation is needed in a larger sample.
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http://dx.doi.org/10.1016/j.jemermed.2019.08.043DOI Listing
December 2019

High dose vitamin D supplementation does not rescue bone loss following Roux-en-Y gastric bypass in female rats.

Bone 2019 10 19;127:172-180. Epub 2019 Jun 19.

Department of Urology, North Florida/South Georgia Veterans Affairs Medical Center and University of Florida, Gainesville, FL, United States of America. Electronic address:

Postoperative bone loss and increased fracture risk associated with Roux-en-Y gastric bypass (RYGB) have been attributed to vitamin D/calcium malabsorption and resultant secondary hyperparathyroidism (HPT). Adequate vitamin D supplementation (VDS), particularly in an older female population, reduces incidence of secondary HPT but the effect on bone loss and fracture risk remains unclear. To investigate whether VDS corrects the RYGB bone phenotype, 41 obese adult female rats were randomized to RYGB with 1000 IU (R1000) or 5000 IU (R5000) vitamin D/kg food or a sham surgical procedure with either paired (PF) or ad libitum (AL) feeding. Bone turnover markers, urinary calcium/creatinine ratio (CCR), and serum calciotropic and gut hormones were assessed throughout a 14-week postoperative period. Femurs were analyzed by micro-computed tomography (μCT), three-point bending test, and histomorphometry. 1000 IU animals had low 25‑hydroxyvitamin D (25(OH)D), high serum parathyroid hormone (PTH), and very low urine CCR levels. 5000 IU corrected the 25(OH)D and secondary HPT but did not increase urine CCR or serum levels of 1,25‑dihydroxyvitamin D (1,25(OH)D) significantly between RYGB groups. Compared to sham animals at 14 weeks, RYGB animals had significantly higher serum osteocalcin (OCN) and C-terminal telopeptide (CTX) levels. The gut hormone peptide tyrosine tyrosine hormone (PYY) was higher in the RYGB groups, and leptin was lower. μCT and biomechanical testing revealed RYGB females had decreased cortical and trabecular bone volume and weaker, stiffer bone than controls. Histomorphometry showed decreased bone volume and increased osteoid volume with increased mineral apposition rate in RYGB compared to controls. No differences in bone phenotype were identified between 1000 IU and 5000 IU groups, and osteoclast numbers were comparable across all four groups. Thus, in our model, 5000 IU VDS corrected vitamin D deficiency and secondary HPT but did not rescue RYGB mineralization rate nor the osteomalacia phenotype. Longer studies in this model are required to evaluate durability of these detrimental effects. Our findings not only underscore the importance of lifelong repletion of both calcium and vitamin D but also suggest that additional factors affect skeletal health in this population.
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http://dx.doi.org/10.1016/j.bone.2019.06.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6708762PMC
October 2019

Long-term Recurrence Rates in Uric Acid Stone Formers With or Without Medical Management.

Urology 2019 Sep 31;131:46-52. Epub 2019 May 31.

Department of Urology, University of Florida, Gainesville, FL.

Objective: To determine if medical therapy affects long-term clinical outcomes in uric acid stone formers (UASF).

Methods: We identified 53 UASF who had complete stone clearance following stone procedure by computed tomography (CT) and had ≥1 postoperative 24-hour urine collection and a clinical follow-up ≥6 months with a surveillance CT scan. Patients were divided into "adherent to medical therapy" (compliance with potassium citrate ± allopurinol verified by computerized pharmacy data) or nonadherent groups. Primary outcomes were CT stone recurrence rate and need for surgical stone intervention.

Results: We found 28 of 53 (53%) adherent and 25 of 53 (47%) nonadherent individuals (14 declined medication, 11 intolerant). With median follow-up of 24 months, no significant differences were noted between groups in regards to stone recurrence (32%; P = .99) or in 24-hour urine pH compared to baseline or follow-up (range 5.46-5.62; P = 0.06). Adherent patients, however, had smaller CT stone recurrence sizes (6.3 ± 3.8 vs 11.8 ± 6.2 mm, P = .02), were 28% less likely to require stone surgery compared to those without therapy (P <.01), and trended toward longer time intervals without recurrence (23.1 ± 18.8 vs 10.5 ± 7.5 months, P = .10) compared to nonadherents. Study confounders included a variety of medication dosages and adherences, limited nonadherent follow-up, and small study number.

Conclusion: UASF adherent to medical therapy had smaller recurrence sizes and fewer surgical interventions vs nonadherent, highlighting the protective role of potassium citrate in UA stone disease. The comparable urine pH and stone recurrence rates between groups, however, underscore areas for improvement in future UA stone prevention strategies.
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http://dx.doi.org/10.1016/j.urology.2019.05.023DOI Listing
September 2019

What do the US advanced kidney disease patients want? Comprehensive pre-ESRD Patient Education (CPE) and choice of dialysis modality.

PLoS One 2019 9;14(4):e0215091. Epub 2019 Apr 9.

Division of Nephrology, Hypertension, and Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, United States of America.

Improvement in Home Dialysis (HoD) utilizations as a mean to improve the patient reported and health services outcomes, has been a long-held goal of the providers and healthcare system in United States. However, measures to improve HoD rates have yielded limited success so far. Lack of patient awareness of chronic kidney disease (CKD) and its management options, is one of the important barriers against patient adoption of HoD. Despite ample evidence that Comprehensive pre-ESERD Patient Education (CPE) improves patient awareness and informed HoD choice, use of CPE among US advanced CKD patients is low. Need for significant resources, lack of validated data showing unequivocal and reproducible benefits, and the lack of validated CPE protocols proven to have consistent efficacy in improving not only patient awareness but also HoD rates in US population, are major limitations deterring adoption of CPE in routine clinical practice. We recently demonstrated that if a structured, protocol based CPE is integrated within the routine nephrology care for patients with advanced CKD, it substantially improves informed HoD choice and utilizations. However, this requires establishing CPE resources within each nephrology practice. Efficacy of a stand-alone CPE model, independent of clinical care, has not been examined till date. In this report we report the efficacy of our structured CPE protocol, delivered outside the realm of routine nephrology care-as a stand-alone patient education program, in a geographically distant region, and show that: when provided opportunity for informed dialysis choice, a majority of advanced CKD patients in US would prefer HoD. We also show that initiating CPE leads to accelerated growth in HoD utilizations and reduces disparities in HoD utilizations, goals for system improvements. Finally, the reproducibility of our structured CPE protocol with consistent efficacy data suggest that initiating such programs at institutional levels has the potential to improve informed dialysis selection and HoD rates across any similar large healthcare institute within US.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0215091PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6456188PMC
December 2019

Clock gene expression is altered in veterans with sleep apnea.

Physiol Genomics 2019 03 18;51(3):77-82. Epub 2019 Jan 18.

Department of Medicine, Division of Nephrology, University of Florida , Gainesville, Florida.

Clock gene dysregulation has been shown to underlie various sleep disorders and may lead to negative cardio-metabolic outcomes. However, the association between sleep apnea (SA) and core clock gene expression is unclear. We performed a cross-sectional analysis of 49 Veterans enrolled in a study of SA outcomes in veterans with chronic kidney disease, not selected for SA or sleep complaints. All participants underwent full polysomnography and next morning whole blood collection for clock gene expression. We defined SA as an apnea-hypopnea index ≥15 events/h; nocturnal hypoxemia(NH) was defined as ≥10% of total sleep time spent at <90% oxygen saturation. We used quantitative real-time PCR to compare the relative gene expression of clock genes between those with and without SA or NH. Clock genes studied were Bmal1, Ck1δ, Ck1ε, Clock, Cry1, Cry2, NPAS2, Per1, Per2, Per3, Rev-Erb-α, RORα, and Timeless. Our cohort was 90% male, mean age was 71 yr (SD 11), mean body mass index was 30 kg/m (SD 5); 41% had SA, and 27% had NH. Compared with those without SA, Per3 expression was reduced by 35% in SA ( P = 0.027). Compared with those without NH, NPAS2, Per1, and Rev-Erb-α expression was reduced in NH (50.4%, P = 0.027; 28.7%, P = 0.014; 31%, P = 0.040, respectively). There was no statistical difference in expression of the remaining clock genes by SA or NH status. Our findings suggest that SA or related NH and clock gene expression may be interrelated. Future study of 24 h clock gene expression in SA is needed to establish the role of clock gene regulation on the pathway between SA and cardio-metabolic outcomes.
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http://dx.doi.org/10.1152/physiolgenomics.00091.2018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6459375PMC
March 2019

Using Aorta-Lesion-Attenuation Difference on Preoperative Contrast-enhanced Computed Tomography Scan to Differentiate Between Malignant and Benign Renal Tumors.

Urology 2019 03 12;125:123-130. Epub 2018 Dec 12.

Urology, University of Florida College of Medicine, Gainesville, FL.

Objective: To evaluate the ability of Aorta-Lesion-Attenuation Difference (ALAD) to differentiate malignant renal tumors from renal oncocytomas.

Methods: A retrospective review of preoperative computed tomography (CT) scans and surgical pathology was performed on patients undergoing partial nephrectomy for small, solid renal masses. ALAD was calculated by measuring the difference in Hounsfield units (HU) between the aorta and the lesion of interest on the same image slice on preoperative CT scan. The discriminative ability of ALAD to differentiate malignant pathology from oncocytoma was evaluated by sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under curve (AUC) using receiver operating characteristic analysis.

Results: A total of 227 preoperative CT scans and corresponding pathology reports were reviewed. ALAD values were calculated during the excretory and nephrographic phases. Nephrographic ALAD was able to differentiate malignant pathology from oncocytoma using a HU threshold of 24 with a sensitivity of 84%, specificity of 86%, PPV of 98%, and NPV of 33%. The AUC for malignant pathology vs oncocytoma was 0.86 (95% confidence intervals 0.77-0.96). Nephrographic ALAD was able to differentiate chromophobe renal cell carcinoma (RCC) from oncocytoma using a HU threshold of 24 with a sensitivity of 100%, specificity of 86%, PPV of 75%, and NPV of 100%. The AUC for chromophobe RCC vs oncocytoma was 0.98 (95% confidence intervals 0.91-1.00).

Conclusion: ALAD discriminates well between chromophobe RCC and oncocytoma, which may aid in the management of patients with indeterminate diagnoses of oncocytic neoplasm on diagnostic needle biopsy. Further validation of ALAD will be necessary prior to routine use in clinical practice.
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http://dx.doi.org/10.1016/j.urology.2018.11.036DOI Listing
March 2019

Evaluation of Intraoperative Versus Postoperative Adjuvant Mitomycin C with Nephroureterectomy for Urothelial Carcinoma of the Upper Urinary Tract.

Bladder Cancer 2018 Oct 29;4(4):389-394. Epub 2018 Oct 29.

Department of Urology, University of Florida College of Medicine, Gainesville, FL, USA.

Background: Results of randomized trials support a single dose of intravesical chemotherapy following radical nephroureterectomy (RNU) for urothelial carcinoma.

Objective: To evaluate the impact of the timing of intravesical mitomycin C (MMC) administration on the rate of bladder tumor recurrence (BTR) following RNU.

Methods: We performed a retrospective review of patients who underwent RNU for upper tract urothelial carcinoma (UTUC) and received intravesical MMC between 2008 and 2016. Patients were categorized into two separate groups based on the timing of MMC administration: patients who received MMC intraoperatively (IO) and patients who received MMC on post-operative day 1 or later (PO). Our primary endpoint was BTR rate within the first year after surgery.

Results: Fifty-one patients met our inclusion criteria: (IO: = 30; PO: = 21). There were no statistically significant differences in baseline characteristics of age, gender, race, surgical approach, tumor grade, tumor stage, surgical margins, nodal status, concomitant CIS, or history of bladder cancer. The median length of follow-up for each group was 22 months for IO and 12 months for PO ( = 0.10). The estimated probability of 1-year BTR rates for the IO and PO groups were 16% and 33%, respectively ( = 0.09). Cox analysis noted that the IO patients had a significantly lower rate of BTR in the first year postoperatively (HR = 0.113, 95% CI = 0.28-0.63, = 0.01).

Conclusions: The use of intraoperative MMC at the time of RNU was associated with a decrease in the risk of 1-year recurrence within the bladder.
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http://dx.doi.org/10.3233/BLC-180174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6218108PMC
October 2018

Career Expectations and Preferences of Urology Residency Applicants.

Urology 2019 01 11;123:44-52. Epub 2018 Oct 11.

University of Florida Department of Urology, Gainesville, FL.

Objective: To survey the characteristics, career goals, and practice preferences of current urology applicants.

Methods: An anonymous survey was emailed to applicants pursuing a residency position at the University of Florida for the 2017-2018 academic year Urology Match. The survey included questions on demographics, motivating factors to pursue urology, plans for fellowship training, and anticipated and desired practice patterns.

Results: A total of 151 of 295 applicants completed the survey, mean age 26.9± SD 2.3. Males had a higher interest in academics/research, cancer, men's health, and minimally invasive surgery technology. Females had a higher interest in public health, surgery, and mixture of surgical and medical management. A total of 64.1% planned on completing a fellowship. Males had a higher interest in urologic oncology and endourology. Females had a higher interest in female pelvic medicine and reconstructive surgery, andrology and sexual medicine, and pediatric urology. A total of 76.9% anticipated having an academic affiliation, 68.9% working in an urban setting, and 98% working full-time, with no difference based on gender. For desired quality of life after residency, maximum number of hours considered acceptable was 51-60 (36.4%) and 61-70 (35.1%). Regarding an acceptable call schedule, most considered 2-4 nights per month reasonable. Most felt an acceptable starting salary was $250,000-$400,000 and $200,001-$350,000 for private practice and academic urology, respectively.

Conclusion: Current urology applicants desire to work in academics, urban settings, and pursue subspecialty fellowship training. What they consider acceptable work hours, call schedule, and financial compensation appear compatible with the current practice of urology.
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http://dx.doi.org/10.1016/j.urology.2018.07.070DOI Listing
January 2019

Distinct renal outcomes for transcatheter aortic valve replacement and surgical repair.

Clin Exp Nephrol 2018 Aug 2;22(4):977-978. Epub 2017 Dec 2.

Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, FL, 32610, USA.

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http://dx.doi.org/10.1007/s10157-017-1511-9DOI Listing
August 2018

Age, Body Mass Index, and Gender Predict 24-Hour Urine Parameters in Recurrent Idiopathic Calcium Oxalate Stone Formers.

J Endourol 2017 Dec;31(12):1335-1341

1 Department of Urology, University of Florida College of Medicine , Gainesville, Florida.

Introduction And Objective: Despite guidelines, routine 24-hour urine testing is completed in <10% of high-risk, recurrent stone formers. Using surrogates for metabolic testing, such as key patient characteristics, could obviate the cost and burden of this test while providing information needed for proper stone prevention counseling.

Methods: We performed a retrospective study of 392 consecutive patients from 2007 to 2014 with ≥2 lifetime stone episodes, >70% calcium oxalate by mineral analysis, and ≥1 24-hour urine collection. We compared mean 24-hour urine values by age in decades. We used logistic regression and receiver operating characteristic (ROC) curve analysis to assess the predictive ability of age, gender, body mass index (BMI), and comorbidities to detect abnormal 24-hour urine parameters.

Results: The mean age of the cohort was 51 ± 16 years. Older age was associated with greater urinary oxalate (p-trend <0.001), lower urinary uric acid (UA) (p-trend = 0.007), and lower urinary pH (p-trend <0.001). A nonlinear association was noted between age and urinary calcium or citrate (calcium peaked at 40-49 years, p = 0.03; citrate nadired at 18-29 years, p = 0.001). ROC analysis of age, gender, and BMI to predict 24-hour urine abnormalities performed the best for hyperuricosuria (area under the curve [AUC] 0.816), hyperoxaluria (AUC 0.737), and hypocitraturia (AUC 0.740). Including diabetes mellitus or hypertension did not improve AUC significantly.

Conclusions: In our recurrent calcium oxalate cohort, age significantly impacted urinary calcium, oxalate, citrate, and pH. Along with gender and BMI, age can be used to predict key 24-hour urine stone risk results. These data lay the foundation for a risk prediction tool, which could be a surrogate for 24-hour urine results in recurrent stone formers, who are unwilling or unable to complete metabolic testing. Further validation of these findings is needed in other stone populations.
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http://dx.doi.org/10.1089/end.2017.0352DOI Listing
December 2017

Evaluating Region of Interest Measurement Strategies to Characterize Upper Urinary Tract Stones on Computerized Tomography.

J Urol 2017 03 27;197(3 Pt 1):715-722. Epub 2016 Oct 27.

Department of Urology, University of Florida College of Medicine (VMN), Gainesville, Florida. Electronic address:

Purpose: Computerized tomography imaging is regularly used to assess stone HU values as a surrogate for stone composition and fragility. Techniques for measuring HU values are unstandardized, leading to high variability. We investigated several region of interest measurement strategies to quantify this variability.

Materials And Methods: Patients from an institutional database who underwent preoperative computerized tomography, surgical stone extraction and stone composition analysis were identified. HU measurements were made of each patient stone using transverse/coronal slices in the abdominal/bone windows with 4 region of interest techniques, including 1) the maximum diameter region of interest, 2) the maximum diameter region of interest at all stone inclusive slices, 3) 2 equal-sized, nonoverlapping circular regions of interest and 4) 3 to 5 smaller nonoverlapping regions of interest randomly placed on the stone. Stones that were 80% or greater pure by composition were separately analyzed.

Results: A total of 172 patients were included in study. Mean ± SD stone size was 19.3 ± 15.6 mm. On subtype analysis 51 stones were calcium oxalate monohydrate, 9 were calcium oxalate dihydrate, 7 were calcium phosphate hydroxyapatite/brushite and 16 were uric acid. Mean HU values in the abdominal window for all stones identified by region of interest techniques 1 to 4 were 457 ± 253, 351 ± 210, 581 ± 363 and 587 ± 329, respectively. The distribution of means significantly differed across region of interest techniques, planes and windows when considering all stones together (p <0.0001), stones with greater than 80% calcium oxalate dihydrate (p = 0.0113) and greater than 80% calcium oxalate monohydrate (p <0.0001), and uric acid stones (p <0.0001).

Conclusions: HU values obtained to assess stone density vary depending on window, plane and region of interest technique. We recommend that clinicians select a single region of interest measurement technique and use it consistently to minimize interinstitutional variability.
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http://dx.doi.org/10.1016/j.juro.2016.10.066DOI Listing
March 2017

Association of Sleep Disordered Breathing with Erectile Dysfunction in Community Dwelling Older Men.

J Urol 2017 03 30;197(3 Pt 1):776-782. Epub 2016 Sep 30.

Department of Medicine (Nephrology), College of Public Health and Health Professions & College of Medicine, University of Florida, and Malcom-Randall VAMC, Gainesville, Florida.

Purpose: We investigated the association between sleep disordered breathing and erectile dysfunction in older men.

Materials And Methods: We performed a cross-sectional analysis of community dwelling men age 67 years or older enrolled in the Osteoporotic Fractures in Men Sleep Study. Participants underwent overnight polysomnography (2003 to 2005) and completed sexual health questionnaires (2005 to 2006). We defined sleep disordered breathing using the apnea-hypopnea index or nocturnal hypoxemia. Erectile dysfunction was defined using the MMAS (Massachusetts Male Aging Study) scale and, in sexually active men, the International Index of Erectile Function. We used logistic regression to examine the association between sleep disordered breathing and erectile dysfunction.

Results: Mean participant age was 76±5 years. Of the 2,676 men completing the MMAS, 70% had moderate to complete erectile dysfunction. Among 1,099 sexually active men completing the IIEF-5 (5-item International Index of Erectile Function), 26% had moderate to severe erectile dysfunction. A higher apnea-hypopnea index was associated with greater odds of MMAS defined moderate to complete erectile dysfunction after adjusting for age and study site (OR 1.39, 95% CI 1.00-1.92 for severe sleep disordered breathing vs none, p trend=0.008), but not after further adjustment for body mass index, socioeconomic status and comorbidities (OR 1.05, 95% CI 0.75-1.49, p trend=0.452). Greater nocturnal hypoxemia was associated with increased odds of MMAS defined moderate to complete erectile dysfunction (unadjusted OR 1.36, 95% Cl 1.04-1.80 vs none) but this was attenuated after adjustment for age and study site (OR 1.24, 95% CI 0.92-1.66). Sleep disordered breathing was not associated with erectile dysfunction by 5-item International Index of Erectile Function.

Conclusions: In this cross-sectional analysis in older men sleep disordered breathing was associated with higher odds of erectile dysfunction in unadjusted analyses that was largely explained by higher body mass index and increased comorbidity among men with sleep disordered breathing. Prospective studies accounting for obesity and multimorbidity would further clarify the association of sleep disordered breathing and erectile dysfunction.
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http://dx.doi.org/10.1016/j.juro.2016.09.089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5374724PMC
March 2017

National surgical quality improvement program underestimates the risk associated with mild and moderate postoperative acute kidney injury.

Crit Care Med 2013 Nov;41(11):2570-83

1Department of Anesthesiology, University of Florida, Gainesville, FL. 2Department of Surgery, University of Florida, Gainesville, FL. 3Department of Medicine, University of Florida, Gainesville, FL. 4Department of Surgery, North Florida South Georgia Veterans Affairs Medical Center, Gainesville, FL.

Objectives: In a single-center cohort of surgical patients, we assessed the association between postoperative change in serum creatinine and adverse outcomes and compared the American College of Surgeons National Surgical Quality Improvement Program's definition for acute kidney injury with consensus risk, injury, failure, loss, and end-stage kidney and Kidney Disease: Improving Global Outcomes definitions.

Design: Retrospective single-center cohort.

Setting: Academic tertiary medical center.

Patients: Twenty-seven thousand eight hundred forty-one adult patients with no previous history of chronic kidney disease undergoing major surgery.

Interventions: Risk, injury, failure, loss, and end-stage kidney defines acute kidney injury as change in serum creatinine greater than or equal to 50% while Kidney Disease: Improving Global Outcomes uses 0.3 mg/dL change from the reference serum creatinine. Since National Surgical Quality Improvement Program defines acute kidney injury as serum creatinine change greater than 2 mg/dL, it may underestimate the risk associated with less severe acute kidney injury.

Measurements And Main Results: The optimal discrimination limits for both percent and absolute serum creatinine changes were calculated by maximizing sensitivity and specificity along the receiver operating characteristic curves for postoperative complications and mortality. Although prevalence of risk, injury, failure, loss, and end-stage kidney-acute kidney injury was 37%, only 7% of risk, injury, failure, loss, and end-stage kidney-acute kidney injury patients would be diagnosed with acute kidney injury using the National Surgical Quality Improvement Program definition. In multivariable logistic models, patients with risk, injury, failure, loss, and end-stage kidney or Kidney Disease: Improving Global Outcomes-acute kidney injury had a 10 times higher odds of dying compared to patients without acute kidney injury. The optimal discrimination limits for change in serum creatinine associated with adverse postoperative outcomes were as low as 0.2 mg/dL while the National Surgical Quality Improvement Program discrimination limit of 2.0 mg/dL had low sensitivity (0.05-0.28).

Conclusions: Current American College of Surgeons National Surgical Quality Improvement Program definition underestimates the risk associated with mild and moderate acute kidney injury otherwise captured by the consensus risk, injury, failure, loss, and end-stage kidney and Kidney Disease: Improving Global Outcomes criteria.
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http://dx.doi.org/10.1097/CCM.0b013e31829860fcDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812338PMC
November 2013

Regarding the effect of physical activity on mortality.

Am J Public Health 2012 May 8;102 Suppl 2:S165; author reply S165-6. Epub 2012 Mar 8.

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http://dx.doi.org/10.2105/AJPH.2011.300623DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477904PMC
May 2012