Path Analysis on Medical Expenditures of 855 Patients with Chronic Kidney Disease in a Hospital in Beijing

Background： Investigate into the medical expenditures of chronic kidney disease （CKD） patients through path analysis method of three consecutive years within a Grade-A tertiary hospital in Beijing to conduct the main influencing factors in diagnosis-related groups （DRGs） grouping of the diagnosis, and reassess the present grouping process to provide information and reference on cost control for hospitals and medical management departments. Methods： Eight hundred and fifty-five inpatient cases whose first diagnosis were defined as CKD in the year 2014-2016 within the hospital were selected as the sample of the study, multiple linear regression and path analysis method were adopted in DRGs grouping process to investigate the main influencing factors of total medical expenditures and DRGs grouping process. Results： The maximum proportion of the medical costs within CKD patients was the costs on treatment, with the highest of 35.3% on the year 2014, the second was the costs on drug, which accounted for 〈30% during consecutive years, and the third was the costs on examination, which accounted for about 20% on average. The main influencing factors of medical expenditures included the type of dialysis, length of hospitalization, the admission of Intensive Care Unit （ICU）, and so on. The coefficients toward the effect for total costs were 0.416, 0.376, and 0.094. respectively. Conclusions： It is suggested that the type of dialysis and the admission of ICU were the major influencing factors of inpatient medical expenditures on CKD patients, and should be taken into consideration into the reassessment of DRGs grouping process to realize the localization and generalization of prospective payment system based on DRGs within the regional area and promote the implementation of medical cost control measures to reduce the economic burdens among patients and the society.

The role of high mobility group box 1(HMGB1)in the pathogenesis of kidney diseases

High mobility group box 1(HMGB1) is a nuclear protein that can bind to DNA and act as a co-factor for gene transcription. When released into extracellular fluid, it plays a proinflammatory role by acting as a damage-associated molecular pattern molecule(DAMP)(also known as an alarmin) to initiate innate immune responses by activating multiple cell surface receptors such as the receptor for advanced glycation end-products(RAGE) and toll-like receptors(TLRs), TLR2, TLR4 or TLR9. This proinflammatory role is now considered to be important in the pathogenesis of a wide range of kidney diseases whether they result from hemodynamic changes, renal tubular epithelial cell apoptosis, kidney tissue fibrosis or inflammation. This review summarizes our current understanding of the role of HMGB1 in kidney diseases and how the HMGB1-mediated signaling pathway may constitute a new strategy for the treatment of kidney diseases.

Impact of creatinine methodology on glomerular filtration rate estimation in diabetes

AIM To evaluate the influence of creatinine methodology on the performance of chronic kidney disease(CKD)-Epidemiology Collaboration Group-calculated estimated glomerular filtration rate(CKD-EPI-eGFR) for CKD diagnosis/staging in a large cohort of diabetic patients. METHODS Fasting blood samples were taken from diabetic patients attending our clinic for their regular annual examination, including laboratory measurement of serum creatinine and eGFR.RESULTS Our results indicated an overall excellent agreement in CKD staging(kappa = 0.918) between the Jaffé serum creatinine-and enzymatic serum creatinine-based CKDEPI-eGFR, with 9% of discordant cases. As compared to the enzymatic creatinine, the majority of discordances(8%) were positive, i.e., associated with the more advanced CKD stage re-classification, whereas only 1% of cases were negatively discordant if Jaffé creatinine was used for eGFR calculation. A minor proportion of the discordant cases(3.5%) were re-classified into clinically relevant CKD stage indicating mildly to moderately decreased kidney function(< 60 m L/min per 1.73 m^2). Significant acute and chronic hyperglycaemia, assessedas plasma glucose and Hb A1 c levels far above the recommended glycaemic goals, was associated with positively discordant cases. Due to a very low frequency, positive discordance is not likely to present a great burden for the health-care providers, while intensified medical care may actually be beneficial for the small number of discordant patients. On the other hand, a very low proportion of negatively discordant cases(1%) at the 60 m L/min per 1.73 m^2 eGFR level indicate a negligible possibility to miss the CKD diagnosis, which could be the most prominent clinical problem affecting patient care, considering high risk of CKD for adverse patient outcomes. CONCLUSION This study indicate that compensated Jaffé creatinine procedure, in spite of the glucose-dependent bias, is not inferior to enzymatic creatinine in CKD diagnosis/staging and therefore may provide a reliable and cost-effective tool for the renal function assessment in diabetic patients.