Genetic and environmental effects and characteristics of Japanese end-stage renal disease patients

Few studies of end-stage renal disease (ESRD) investigate genetic and environmental effects simultaneously in one racial/ethnic group. United States Renal Data System data show racial differences in primary causes of ESRD, survival rates, and causes of death. Comparing these with Japanese Society for Dialysis Therapy data, survival rates appear better for Japanese than for US patients. To explore genetic and environmental differences, we investigated incident and prevalent ESRD patient characteristics. The United States Renal Data System and Japanese Society for Dialysis Therapy databases were analyzed between 1983 and 2002 for the following patient subsets: Americans excluding Asian Americans (n=1,153,974); Asian Americans excluding Japanese Americans (n=35,983); Hawaiian and non-Hawaiian Japanese Americans by state, race, and Japanese surname (n=3932); native Japanese living in Japan (n=450,593). Japanese Americans tended to be older, male, have more diabetes and hypertension and less glomerulonephritis, and to die more often of heart failure than the other US groups. Adjusted mortality hazard ratios were 0.70 for non-Japanese Asian Americans and 0.75 for Japanese Americans vs. non-Asian Americans (1.00). Hawaiian Japanese patients tended to be older, with more diabetes and hypertension and less glomerulonephritis than the other Japanese groups; their survival rates improved after adjustment for rate of diabetes. Japanese American ESRD patients differ from Asian and non-Asian Americans, and from native Japanese, despite similar genetic make-ups. Both genetic and environmental factors may affect patient outcomes.     

Comparison of survival between short-daily hemodialysis and conventional hemodialysis using the standardized mortality ratio

More frequent hemodialysis (5 or more times weekly, both short during the day and long overnight) has been shown to improve patient well-being, reduce symptoms during and between treatments, and have beneficial effects on clinical outcomes. Because of the relatively small patient sample sizes, there are little or no data on mortality from any single study at this time. This study compares survival in 117 U.S. patients treated by short-daily hemodialysis in 2003 and 2004, with patients reported in the 2003 data from the United States Renal Data System (USRDS). Expected mortality was calculated from the USRDS and compared with observed actual mortality. The standardized mortality ratio (SMR) was used to adjust for differences in patient age, sex, race, and cause of renal failure. The SMR for the short-daily hemodialysis patients was 0.39, statistically significantly better (p < 0.005) than data from the overall U.S. population of hemodialysis patients and indicating that daily hemodialysis patients had a 61% better survival. Patients treated by short-daily hemodialysis have a better survival rate than comparable populations treated by conventional hemodialysis.     

International Comparisons of Survival on Dialysis: Are They Reliable?

Sharp discrepancies between reported survivals on maintenance hemodialysis in the United States compared with Europe and Japan have provoked broad criticism of the American system of treating irreversible uremia. Although this negative view of renal therapy in the United States is supported by the National Kidney Foundation (NKF), consensus conferences of the National Institutes of Health (NIH), and numerous social critics of the American health care system, the contention has not been sustained by appropriate statistical analysis. The United States has the world's highest treatment rate for incident kidney failure — double that in Europe. This is mainly due to universal acceptance for uremia therapy. In comparisons with Japan, studies have not taken into account unique aspects of Japanese health care and genetic differences between sampled cohorts of studied kidney patients. In fact, no properly conducted analysis has found that the quality of uremia therapy in the U.S. has been inferior to that of anywhere else. While the allegation may yet be proven true, thus far there is no scientific basis for indicting dialysis in the United States as lacking in quality or quantity when ranked with other industrialized nations.     

Nightly home hemodialysis: outcome and factors associated with survival

Nightly home hemodialysis (NHHD) has been reported to have a much better survival than the excessive mortality of thrice-weekly in-center dialysis, but the factors influencing survival of NHHD have not been investigated in detail. We studied the association of survival in a 12-year study of 87 NHHD patients from a single center evaluating demographic, sociologic, and anthropomorphic factors, diagnosis, comorbidity, vintage, and dialysis performance and efficiency. Secondly, we compared the survival of the 87 NHHD patients with that reported by the United States Renal Data System (USRDS) using standardized mortality rate (SMR). The average patient age was 52 ± 15 years, and 59% were males, 51% African Americans, and 25% had diabetes. The patients dialyzed 40 ± 6 hours weekly with a stdKt/V of 5.25 ± 0.84. Thirteen patients died. The cumulative survival was 79% at 5 years and 64% at 10 years. Using Cox proportional hazards univariate analysis, 7 of 26 factors studied were associated with mortality: less than high school education, hour of each dialysis, comorbidities, secondary renal disease, congestive heart failure, Leypoldt's eKt/V, and Daugirdas Kt/V. In backward stepwise Cox analysis, education and hour of dialysis were the only factors independently associated with survival. The standardized mortality rate was only 0.30 of that reported by the United States Renal Data System for patients on thrice-weekly hemodialysis adjusted for age, gender, race, and diagnosis. The influence of education was the most significantly associated with survival, and the duration of each dialysis treatment was important. The survival rate of NHHD patients appeared to be superior to intermittent hemodialysis.     

Differences in cardiovascular mortality rates among hemodialysis patients in the United States and Japan: The importance of background cardiovascular mortality

Mortality rates among hemodialysis patients differ greatly among the United States, Europe, and Japan and it has been hypothesized that this is mainly due to differences in practice patterns. Results from the international DOPPS study, however, indicate that differences in practice patterns among the United States, Japan, and Europe are small and not alone explanatory for the differences in mortality rates. Ethnic variability in predisposition to atherosclerotic cardiovascular disease in the general population may lead to significant differences in background cardiovascular mortality in the United States, Japan, and Europe. It is our hypothesis that cardiovascular mortality in dialysis patients is to a great extent dependent on cardiovascular background mortality of the general population. We are currently studying the relationship between all‐cause and cardiovascular death rates in countries worldwide using the WHO database. Preliminary data from 35 countries show that all‐cause and cardiovascular death rates differ significantly among regions, with Eastern European countries reporting four‐ to sevenfold higher death rates than Asian countries. A strong linear relationship between cardiovascular and all‐cause death rates is observed among these countries. The next step of our study will be to compare country‐specific cardiovascular death rates of dialysis populations with those of the respective general populations. Ethnic differences in cardiovascular morbidity and mortality may be explained by genetic variability based upon polymorphism of genes involved in the pathogenesis of atherosclerosis and myocardial infarction.     

Paradigmatic Shifts in Automobile Manufacturing

ABSTRACT

One of the greatest problems facing the U.S. auto industry is the erosion of its manufacturing base. Another is the increasing challenge from Japan, which keeps building on its solid postwar accomplishments mapped out by such pioneers as Taiichi Ohno and Shigeo Shingo. Their enduring legacy includes a reliance on the firm's human resources for maintaining productivity and quality control. The Japanese paradigm thus has a built-in mechanism for self-improvement and competitiveness enhancement.

The continued strife in Detroit suggests that the older American paradigm must be restructured; its top-down way of conducting business must allow labor to become a genuine partner with management instead of an adversary. The Japanese immigrant plants in the United States clearly show the way to do this. While such restructuring is frequently time-consuming, the period available for reform dwindles as the Asians keep strengthening their U.S. operations.     

The Quest for Relevance: Roles for Academia and Industry in Japan and the U.S.

While U.S. industry is making headway in worldwide markets, much remains to be done. Some have proposed that improving the relevance of engineering education can have a marked influence on the future success of U.S. manufacturing. Some in academia have heard industries' cries for help to improve relevancy in engineering education and have responded with various solutions. Is this the situation in Japan? What is the state of engineering education in Japan? Where is it headed and how does the U.S. compare? We found that industry-academia relationships like those being strengthened in the U.S. are minimal in Japan. Surprisingly, Japanese industry and academia appear not to be headed in a collaborative direction and are even more detached from one another than in the United States. This paper presents some differences in the way Japan and the U.S. view their roles for academia and industry and their interrelationships. Our objective is to further motivate U.S. educators to collaborate with industry and continue to integrate greater relevancy into engineering education.     

Short and long nightly hemodialysis in the United States

When hemodialysis first started in the United States in the 1960s, a large percentage of patients performed their treatments at home. However, because of reimbursement issues, home hemodialysis (HHD) gradually succumbed to an in-center approach and eventually a mindset. Since the introduction of nightly HHD by Uldall and Pierratos in 1993, there has been a resurgence of interest in HHD. This paper describes the different types of home hemodialysis being performed as of December 31, 2007 in this country. Because neither the United States Renal Data System (USRDS) nor the End Stage Renal Disease (ESRD) Networks break down home dialysis into the different modalities, a provider questionnaire was sent out to 2 major providers, a number of mid-level providers and other providers known to do HHD. In addition, a questionnaire was sent out to 3 machine providers to obtain the number of patients using their machine for HHD as of December 31, 2007. The results showed that 91.7% of patients are dialyzing in-center, 7.3% are doing peritoneal dialysis, and 0.7% are doing HHD. Currently about 1% of ESRD patients in the United States are doing home hemodialysis. NxStage, however, has started 1000 patients in the past year on short-daily home hemodialysis. Patients are beginning to understand that there are better options than 3 times a week in-center dialysis. And as a result of the "HEMO Study," nephrologists now believe that longer and more frequent dialysis is a better therapy for ESRD patients. Therefore, promotion of HHD should become a priority for the renal community in the future.     

Optimal timing of initiation of chronic hemodialysis?

Despite the availability of clinical guidelines for the timing of dialysis initiation in both the United States and Canada, patients continue to start dialysis at very low levels of predicted glomerular filtration rate (GFR). A cross-sectional study was performed to determine the demographic and clinical characteristics of patients who started hemodialysis, their level of GFR, and mortality at 1 and 2 years following the initiation of dialysis. Retrospective data were collected on all eligible patients who commenced chronic hemodialysis in 1 tertiary care center in Canada from March 2001 to February 2005. Only those patients who had been followed by a nephrologist in the chronic kidney disease clinic before dialysis initiation were included (n=271). Seventeen percent of patients started hemodialysis late (GFR<5 mL/min/1.73 m(2)). Compared with the group of patients who started dialysis earlier, the late start group were significantly younger (p=0.008), had more females (p=0.013), more employed (p=0.051), less cardiac (p<0.001), and peripheral vascular disease (p=0.031), and were taking medication for hypertension (p=0.041). Serum albumin was lower in the late start group (p=0.023). At year 1, there was no difference in mortality rate while at year 2, the earlier the dialysis, the greater the mortality rate (p=0.022). After adjustment for demographic variables and comorbidities, only antihypertensive use had an independent but weak association with the 2 year mortality. Adjustment for all these variables eliminated the significant association noted for the 2 year mortality in the early versus late dialysis start. The survival benefit for late versus early dialysis start appears to be multifactorial and relates to a preponderance of clinical and demographic factors favoring a lengthened survival occurring in the late dialysis group. Our survival benefit findings suggest the premorbid health condition is a more important determinant of 2 year survival than the timing of dialysis initiation.     

Younger black patients have a higher risk of infection mortality that is mostly non‐dialysis related: A national study of cause‐specific mortality among U.S. maintenance dialysis patients

Introduction: While it has been well documented that in the U.S., black and Hispanic dialysis patients have overall lower risks of death than white dialysis patients, little is known whether their lower risks are observed in cause‐specific deaths. Additionally, recent research reported that younger black patients have a higher risk of death, but the source is unclear. Therefore, this study examined cause‐specific deaths among US dialysis patients by race/ethnicity and age. Methods: This national study included 1,255,640 incident dialysis patients between 1995 and 2010 in the United States Renal Data System. Five cause‐specific mortality rates, including cardiovascular (CVD), infection, malignancy, other known causes (miscellaneous), and unknown, were compared across blacks, Hispanics, and whites overall and stratified by age groups. Findings: After multiple adjustments, Hispanic patients had the lowest risk of mortality for every major cause in almost all ages. Compared with whites, blacks had a lower risk of death from CVD, malignancy and miscellaneous causes in most age groups, but not from infection. In fact, blacks had a higher risk of infection death than whites in ages 18–30 years (HR [95% CI] 1.94 [1.69–2.23]; P < 0.001), 31–40 years (HR 1.51 [1.40–1.63]; P < 0.001) and 41–50 years (HR 1.07 [1.02–1.12]; P = 0.009), which were partially attributed to their higher prevalence of AIDS nephropathy. For each race/ethnicity, more than two‐thirds of infection deaths were due to non‐dialysis related infections. Discussion: Hispanics had the lowest risk for each major cause of death. Blacks were less likely to die than whites from most causes, except infection. The previously reported higher overall mortality rate for younger blacks is attributed to their two‐fold higher infection mortality, which is mostly non‐dialysis related, suggesting a new direction to improve their overall health status. Research is greatly needed to determine social and biological factors that account for the survival gap in dialysis among different racial/ethnic groups.     

Gender,low Kt/V,and mortality in Japanese hemodialysis patients: Opportunities for improvement through modifiable practices

Guidelines have recommended single pool Kt/V > 1.2 as the minimum dose for chronic hemodialysis (HD) patients on thrice weekly HD. The Dialysis Outcomes and Practice Patterns Study (DOPPS) has shown that “low Kt/V” (<1.2) is more prevalent in Japan than many other countries, though survival is longer in Japan. We examined trends in low Kt/V, dialysis practices associated with low Kt/V, and associations between Kt/V and mortality overall and by gender in Japanese dialysis patients. We analyzed 5784 HD patients from Japan DOPPS (1999–2011), restricted to patients dialyzing for >1 year and receiving thrice weekly dialysis. Logistic regression models estimated the relationships of patient characteristics with Kt/V. Logistic models also were used to estimate the proportion of low Kt/V cases attributable to various treatment practices. Multivariable Cox regression was used to estimate the associations of low Kt/V, blood flow rate (BFR), and treatment time (TT), with all‐cause mortality. From 1999 to 2009, the prevalence of low Kt/V declined in men (37–27%) and women (15–10%). BFR <200 mL/min, TT <240 minutes, and dialyzate flow rate (DFR) < 500 mL/min were common (35, 13, and 19% of patients, respectively) and strongly associated with low Kt/V. Fifteen percent of low Kt/V cases were attributable to BFR <200 and 13% to TT <240, compared to only 3% for DFR <500. Lower Kt/V was associated with elevated mortality, more so among women (hazard ratio [HR] = 1.13 per 0.1 lower Kt/V, 95% CI: 1.07–1.20) than among men (HR = 1.06 per 0.1 lower Kt/V, 95% CI: 1.00–1.12). The relatively large proportion of low Kt/V cases in Japanese facilities may potentially be reduced 30% by increasing BFR to 200 mL/min and TT to 4 hours thrice weekly in HD patients. Associations of low Kt/V with elevated mortality suggest that modification of these practices may further improve survival for Japanese HD patients.     

Recurrent Ochrobactrum anthropi and Shewanella putrefaciens bloodstream infection complicating hemodialysis

Bloodstream infections (BSIs) are common in hemodialysis, especially when the access is a catheter. These infections are more commonly gram-positive bacteria or gram-negative bacilli and on some occasions, fungi. Ochrobactrum anthropi and Shewanella putrefaciens are ubiquitous hydrophilic gram-negative bacilli. There have been three cases of O. anthropi BSI reported in hemodialysis patients (one from the United States and two from Vienna) and two cases of S. putrefaciens BSI in hemodialysis patients (one from the United States and the other from Japan). There have been few more cases reported of infections with these bacteria in peritoneal dialysis, especially outside the United States. We present a novel case of a patient with both recurrent O. anthropi and S. putrefaciens BSI complicating hemodialysis. There have been no reports in the literature of such a case. We also discuss the microbiology, clinical features, and the challenging aspects of treatment of such infections.     

Association of education level with dialysis outcome

The impact of education on health care outcome has been studied in the past, but its role in the dialysis population is unclear. In this report, we evaluated this association. We used the United States Renal Data System data of end-stage renal disease patients aged 18 years. Education level at the time of end-stage renal disease onset was the primary variable of interest. The outcome of the study was patient mortality. We used four categories of education level: 0 = less than 12 years of education; 1 = high school graduate; 2 = some college; 3 = college graduate. Subgroups based on age, race, sex, donor type, and diabetic status were also analyzed. After adjustments for covariates in the Cox model, using individuals with less than 12 years of education as a reference, patients with college education showed decreased mortality with hazard ratio of 0.81 (95% confidence interval 0.69–0.95), P = 0.010. In conclusion, we showed that higher education level is associated with improved survival of patients on dialysis.     

Associations with home hemodialysis modality failure and mortality

Background: Limited data exist on risk factors for home hemodialysis (HH) failure and mortality. We sought to determine whether age, helper status, or ethnicity was associated with home dialysis failure or mortality. Methods: We conducted a retrospective cohort study of all prevalent and incident patients from a regional dialysis unit who initiated HH training from December 2000 to September 2002. Baseline demographics, program entry and exit dates, and mortality were ascertained. Characteristics of those more likely to remain in the program were assessed using logistic regression; survival was determined using Cox proportional hazards models. Results: Of the 1117 patients enrolled for dialysis, 116 patients were trained in the HH program (6.8%). Of those, 45.7% remained in the program, 10.3% received a transplant, 10.3% returned to in‐center dialysis, 1.7% were lost to follow‐up, and 31.7% expired. Compared to patients who returned to center or received a transplant, patients who remained on HH were more likely to be older, to have been on dialysis longer, and to have diabetes as their primary renal disease. Ethnicity, sex, or type of helper did not affect home program status. Among those who remained in the HH program, those with hypertension or other renal diseases had better survival than those with diabetes, as did those who had related helpers compared to those with unrelated helpers. Conclusions: Older and younger ages, but not ethnicity, helper status, or sex, were associated with home dialysis failure. Diabetes remained an independent risk factor for increased mortality. HH remains a viable option for many patients.     

The emergence of a mass market for fax machines

The international diffusion of new technologies is strongly affected by the political, economic, and social dynamics of nations. Due to technological improvements and a shift to open standards facsimile (fax) machines were ready for a mass market as early as 1980. They were widely adopted in Japan during 1983, in the U.S.A. in 1987–1988, and in Western Europe only after 1992. Though barriers were about equally low in Japan and the U.S.A., Japan adopted the technology more quickly because transmitting written Japanese is much easier with a technology that scans pages rather than codes individual characters. Tariffs on imported machines, greater restrictions on connecting customer-owned equipment that could be connected to telephone lines, and higher charges for long distance calls were the principal reasons for the slower adoption of fax machines in Western Europe.     

Determinants of survival in patients receiving dialysis in Libya

Maintenance dialysis is associated with reduced survival when compared with the general population. In Libya, information about outcomes on dialysis is scarce. This study, therefore, aimed to provide the first comprehensive analysis of survival in Libyan dialysis patients. This prospective multicenter study included all patients in Libya who had been receiving dialysis for >90 days in June 2009. Sociodemographic and clinical data were collected upon enrolment and survival status after 1 year was determined. Two thousand two hundred seventy‐three patients in 38 dialysis centers were followed up for 1 year. The majority were receiving hemodialysis (98.8%). Sixty‐seven patients were censored due to renal transplantation, and 46 patients were lost to follow‐up. Thus, 2159 patients were followed up for 1 year. Four hundred fifty‐eight deaths occurred, (crude annual mortality rate of 21.2%). Of these, 31% were due to ischemic heart disease, 16% cerebrovascular accidents, and 16% due to infection. Annual mortality rate was 0% to 70% in different dialysis centers. Best survival was in age group 25 to 34 years. Binary logistic regression analysis identified age at onset of dialysis, physical dependency, diabetes, and predialysis urea as independent determinants of increased mortality. Patients receiving dialysis in Libya have a crude 1‐year mortality rate similar to most developed countries, but the mean age of the dialysis population is much lower, and this outcome is thus relatively poor. As in most countries, cardiovascular disease and infection were the most common causes of death. Variation in mortality rates between different centers suggests that survival could be improved by promoting standardization of best practice.     

Technical assistance versus cultural export: George Cressey and the U.S. Cultural Relations Program in wartime China, 1942–1946

After the outbreak of the Pacific War, the United States and the United Kingdom both set up cultural assistance programs to China in order to aid the fight against Japan in Asia and to shape the postwar world according to their interests. From 1942 to 1946, the United States sent 30 experts in science, technology, medicine, and public health to China. Among them was George Cressey, a geographer of international reputation deeply familiar with the cultural and physical geography of China, who travelled to China as a visiting professor of the Sino–U.S. Cultural Relations Program and a representative of the State Department. However, he was recalled earlier than expected, after only 7 months, because his remarks were thought to be damaging to Sino–U.S. relations. Examining his wartime visit to China within the context of Sino–U.S. relations, this paper uncovers Cressey's diplomatic mission. We illustrate how geography simultaneously became the object of Cressey's research, a tool for the promotion of Sino–U.S. cultural relations, and the theoretical basis for foreign policy proposals. Finally, through a comparison of Cressey's and Joseph Needham's experiences in wartime China, this paper illuminates their different understanding of Chinese culture (including China's society and concept of science and culture), which led to their different approaches to Chinese affairs. It also shows the tension between technical assistance and cultural export in diplomatic relations during wartime. This case demonstrates the expanding role of science and technology in diplomatic agendas and international relations as a new, distinctive feature of science and technology in the 20th century.     

The US-EU race for leadership of science and technology: Qualitative and quantitative indicators

Both the United States and the European Union have set goals for worldwide leadership of science and technology. While the U. S. leads in most input quantitative indicators, output indicators may be more specific for determining present leadership. They show that the EU has taken the lead in important metrics and is challenging the U. S. in others. Qualitative indicators of fields of research and development, based on expert review studies organized by the authors, confirm that many EU labs are equal or better than those in the U. S. This revised version was published online in June 2006 with corrections to the Cover Date.