Nivetha Subramanian, MD, MS

All Publications

• Early treatment with rasburicase and risk of kidney replacement therapy and death in adults with tumour lysis syndrome: emulated target trial. BMJ (Clinical research ed.) Shenoy, T., Sanchez-Almanzar, D., Dias, J. A., Hayden, R., Shashaty, M. G., Aklilu, A. M., Patell, R., Anand, S., Renaghan, A., Bassil, C., Neyra, J. A., Bansal, A., Shah, C. V., Gupta, S., Sise, M. E., Seethapathy, R., Chase, S., Thompson, C., Radhakrishnan, R., Verma, E., Ni, J., Hoge, S. T., Lypka, V., Ali, R., Monson, A. E., Kaunfer, S., Angus, E., Griffiths, S., Walling, C., Al Haddad, N., Brotman, C. H., Miano, T., Shirali, A. C., Turco, D. J., Alleyne, S. A., Shelton, K., Shaefi, S., Garcia, D., Nasim, A., Jan, N., Nguyen, P. H., Ziolkowski, S., Subramanian, N., Subramanian, V., Debnath, N., Faldu, C. T., Wickramasinghe, K., Donahue, B. P., Shah, A., Shostak, J., Jayakumar, V., Nadayil, J., Baz, R., Takeuchi, T., Renzi, S., Rehman, A. U., Nombera-Aznaran, N., Charkviani, M., Kotzin, M., Kaiser, J., Edwards, M., Mathavan, A., Mathavan, A., Obimdike, F., Shah, N., LaCasce, A. S., Armand, P., Leaf, D. E. 2026; 394: e100040

  Abstract

  To examine the association between early rasburicase treatment and acute kidney injury requiring kidney replacement therapy or death among patients with tumour lysis syndrome (TLS).Emulated target trial.36 US hospitals.1276 adults (≥18 years) admitted to hospital between 2014 and 2023 with active haematological malignancy or solid tumour with metastases, high tumour burden, or laboratory findings and clinical features consistent with TLS.The primary outcome was a composite of acute kidney injury requiring kidney replacement therapy or death during the index hospital admission. A key secondary outcome was 90 day mortality. Outcomes were compared between patients who received rasburicase within 12 hours after TLS onset and those who did not, using logistic regression with inverse probability of treatment weighting to adjust for confounding.Among 1276 patients included in the analysis, 705 (55.3%) received rasburicase within 12 hours after TLS onset. Among patients treated within 12 hours of TLS onset, rasburicase was administered at a median of 5.0 hours (interquartile range 3.1-7.5 hours). Patients who received rasburicase had higher uric acid concentrations than those who did not (median 0.71 v 0.59 mmol/L (11.9 v 9.9 mg/dL)); however, severity of illness was well balanced after applying inverse probability of treatment weighting. Early rasburicase treatment was associated with a lower risk of acute kidney injury requiring kidney replacement therapy or death (32.7% v 42.0%; adjusted odds ratio 0.67, 95% confidence interval 0.52 to 0.88; P<0.001). Results were consistent across multiple sensitivity analyses and for 90 day mortality (adjusted odds ratio 0.71, 0.54 to 0.94).Among adults with TLS, early rasburicase treatment for TLS was associated with about one third lower risk of acute kidney injury requiring kidney replacement therapy or death compared with delayed or no rasburicase treatment.

  View details for DOI 10.1136/bmj-2026-100040

  View details for PubMedID 42492944

• Dialysis Facility Closures in the US From 2018 to 2024: A Serial Cross-Sectional Study. American journal of kidney diseases : the official journal of the National Kidney Foundation Varkila, M. R., Montez-Rath, M., Yu, X., Subramanian, N., Owens, D. K., Brady, B., Block, G. A., Parsonnet, J., Chertow, G. M., Anand, S. 2026

  Abstract

  Between 2006-2016, the number of US dialysis facilities experienced steady annual growth. Recent data suggest a reversal in this trend. We examined trends in US dialysis facility closures and associated facility- and neighborhood-level characteristics.Serial cross-sectional study of dialysis facilities from 2018 through 2024.Dialysis facilities in the United States.Calendar year; census region; census tract social vulnerability index; rural or urban area designation; racial and ethnic composition; coronavirus-19 mortality; dialysis facility payer mix, size, and profit status.Number of dialysis facility closures; temporal change in number of facilities by census tract.Dialysis facilities listed in the Provider of Services data from Centers for Medicare and Medicaid Services were used to determine openings and closures by quarter. Geocoded dialysis facility data were linked to the American Community Survey, rural urban commuting area codes, and the United States Renal Data System to describe associated facility- and neighborhood-level characteristics of closed facilities, and of census tracts without any remaining dialysis facilities.8343 unique dialysis facilities were identified across 7222 census tracts from 2018 through 2024. Annual opening-to-closure ratios were 8.9 (2018: 401 openings, 45 closures), 2.7 (2019: 293 openings, 105 closures), 4.3 (2020: 218 openings, 51 closures), 1.5 (2021: 171 openings, 111 closures), 0.6 (2022: 123 openings, 210 closures), 0.5 (2023: 94 openings, 207 closures), and 0.8 (2024: 56 openings,74 closures). Closures exceeded openings between fourth quarter, 2021 and first quarter, 2024 (n=500, 62.2% of all closures during study period). Closed facilities were smaller than facilities that remained open (median size 58 [25th, 75th percentile 34, 96] for closed versus 112 [66, 165] for open facilities). Closures were observed more frequently in rural versus urban areas (11.2% versus 9.3%, respectively), and among facilities located in the Midwest versus the West (10.8% versus 7.7%, respectively). Closed facilities had a modestly higher proportion of patients eligible for both Medicaid and Medicare-dual eligibility, a marker of economic disadvantage-than facilities that remained open (mean proportion of census dual eligible 36.1% versus 34.6%).Lack of data on patient outcomes.Nationwide, an increasing number of US dialysis facilities closed between 2018 and 2024, with smaller facilities, and rural and Midwest communities disproportionately affected. The patient-level implications of this trend require further study.Until recently, the number of dialysis facilities in the US was increasing, but this trend may have reversed in 2022. This study assessed whether dialysis facility closures were relatively more common in rural or socially vulnerable areas. It found a drastic increase in numbers of closures and a decrease in number of openings across the US starting in late 2021, with closures disproportionately affecting smaller facilities, rural areas, and the midwest. Closures may reflect a change in demand for dialysis, but since prior data indicate dialysis facility closures disrupt patient care, this trend and its effect on persons with complex medical needs requires attention by nephrologists and policymakers.

  View details for DOI 10.1053/j.ajkd.2025.12.003

  View details for PubMedID 41866018

• Vaccines as a Core Conversation in Nephrology AMERICAN JOURNAL OF KIDNEY DISEASES Subramanian, N., Anand, S. 2025; 86 (6): 724-726

  View details for Web of Science ID 001627329800001

  View details for PubMedID 41139327

• Community-Specific Differences in Kidney Function in Rural and Urban India. Kidney international reports Subramanian, N., Anand, S., Yu, X., Montez-Rath, M. E., Jarhyan, P., Rajan, S., Venkateshmurthy, N. S., Levin, A., Prabhakaran, D., Craig, P., Prabhakaran, P., Mohan, S., Jaacks, L. 2025; 10 (6): 2035-2040

  View details for DOI 10.1016/j.ekir.2025.04.006

  View details for PubMedID 40630315

  View details for PubMedCentralID PMC12231007

• Vaccination Strategies in Patients Receiving Dialysis: Should We Watch the Clock? Subramanian, N., Yu Xue, Varkila, M., Block, G. A., Parsonnet, J., Chertow, G. M., Anand, S., Montez-Rath, M. E. AMER SOC NEPHROLOGY. 2024

  View details for DOI 10.1681/ASN.2024swtrr2jc

  View details for Web of Science ID 001405917807040

• Trends in Dialysis Facility Access in the United States from 2018-2023 and Association with Area Socioeconomic Disadvantage Varkila, M., Montez-Rath, M. E., Yu Xue, Subramanian, N., Chertow, G. M., Parsonnet, J., Anand, S. AMER SOC NEPHROLOGY. 2024

  View details for DOI 10.1681/ASN.2024ak9m2bac

  View details for Web of Science ID 001405917806176

• Acceptance of SARS-CoV-2 Surveillance Testing Among Patients Receiving Dialysis: A Cluster Randomized Trial. JAMA network open Montez-Rath, M., Varkila, M., Yu, X., Brillhart, S., Morgan, C., Leppink, A., Block, M. S., Mehta, S., Hunsader, P., Fountaine, A., Subramanian, N., Dittrich, M., Owens, D. K., Chertow, G. M., Parsonnet, J., Anand, S., Block, G. A. 2024; 7 (9): e2434159

  Abstract

  Integrating routine SARS-CoV-2 testing in dialysis facilities may benefit patients receiving dialysis by mitigating risks of serious illness and reducing transmission. Patient acceptance of nonmandatory testing is unknown.To evaluate the acceptance of 2 SARS-CoV-2 testing strategies among patients in hemodialysis facilities nationwide.This nationwide cluster (dialysis facility-level) randomized trial investigated the acceptance of SARS-CoV-2 testing among patients receiving maintenance hemodialysis at facilities located in 22 states.Anterior nares real-time reverse transcriptase-polymerase chain reaction tests offered once every 2 weeks (static testing facilities) vs offered once a week, once every 2 weeks, or once a month depending on county COVID-19 infection prevalence (dynamic testing facilities). Facilities were randomized by county, and tests were offered for 3 months between February 4 and July 24, 2023.The primary outcome was test acceptance. Secondary outcomes included the proportion of patients who accepted at least 1 test.In total, 62 hemodialysis facilities were randomized and 57 participated. Among 2389 participating patients, the median age was 64 (IQR, 54-74) years, 1341 (56%) were male, 138 (6%) were categorized as American Indian, 60 (3%) Asian, 885 (37%) Black, 75 (3%) Native Hawaiian or Pacific Islander, 338 (14%) Hispanic, and 876 (37%) White; and 1603 (67%) had diabetes. A median of 6 (IQR, 6-6) tests were offered per patient in the static arm and 4 (3-6) tests in the dynamic arm. Test acceptance was low: 8% of offered tests were accepted in each of the test arms. Among 503 patients who accepted at least 1 test, the median percentage of offered tests that were accepted was 16% (IQR, 17%-42%) using the static testing strategy and 50% (IQR, 33%-75%) using the dynamic testing strategy (P < .001). Older patients (odds ratio [OR], 1.08 [95% CI, 1.01-1.16] per 5-year age increment), patients with (vs without) diabetes (OR, 1.59 [95% CI, 1.18-2.16]), and women compared with men (OR, 1.30 [95% CI, 0.98-1.73]) were more likely to accept multiple tests. Patients designated in the electronic health record as Hispanic were more likely than patients designated as White (OR, 1.78 [95% CI, 1.15-2.76]) to accept at least 1 test, whereas patients living in zip codes electing Republican representatives to Congress were less likely than patients living in zip codes electing Democratic representatives (OR, 0.34 [95% CI, 0.17-0.69]) to accept multiple tests.In this cluster randomized trial evaluating 2 SARS-CoV-2 testing strategies in dialysis facilities, test acceptance was low, and a dynamic testing strategy anchored to COVID-19 infection prevalence did not outperform a static testing strategy of every 2 weeks.ClinicalTrials.gov Identifier: NCT05225298.

  View details for DOI 10.1001/jamanetworkopen.2024.34159

  View details for PubMedID 39298171

  View details for PubMedCentralID PMC11413714

• Comparison of Pre-Amputation Evaluation in Patients with and without Chronic Kidney Disease. American journal of nephrology Subramanian, N., Han, J., Leeper, N. J., Ross, E. G., Montez-Rath, M. E., Chang, T. I. 2021: 1–8

  Abstract

  INTRODUCTION: Patients with chronic kidney disease (CKD) and peripheral artery disease (PAD) are more likely to undergo lower extremity amputation than patients with preserved kidney function. We sought to determine whether patients with CKD were less likely to receive pre-amputation care in the 1-year prior to lower extremity amputation compared to patients without CKD.METHODS: We conducted a retrospective observational study of patients with PAD-related lower extremity amputation between January 2014 and December 2017 using a large commercial insurance database. The primary exposure was CKD identified using billing codes and laboratory values. The primary outcomes were receipt of pre-amputation care, defined as diagnostic evaluation (ankle-brachial index, duplex ultrasound, and computed tomographic angiography), specialty care (vascular surgery, cardiology, orthopedic surgery, and podiatry), and lower extremity revascularization in the 1-year prior to amputation. We conducted separate logistic regression models to estimate the adjusted odds ratio (aOR) and 95% confidence intervals (CIs) among patients with and without CKD. We assessed for effect modification by age, sex, Black race, and diabetes status.RESULTS: We identified 8,554 patients with PAD-related amputation. In fully adjusted models, patients with CKD were more likely to receive diagnostic evaluation (aOR 1.30; 95% CI 1.17-1.44) and specialty care (aOR 1.45, 95% CI 1.27-1.64) in the 1-year prior to amputation. There was no difference in odds of revascularization by CKD status (aOR 1.03, 0.90-1.19). Age, sex, Black race, and diabetes status did not modify these associations.DISCUSSION/CONCLUSION: Patients with CKD had higher odds of receiving diagnostic testing and specialty care and similar odds of lower extremity revascularization in the 1-year prior to amputation than patients without CKD. Disparities in access to pre-amputation care do not appear to explain the higher amputation rates seen among patients with CKD.

  View details for DOI 10.1159/000516017

  View details for PubMedID 33957619