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Berkhout-Byrne NC, Voorend CGN, Meuleman Y, Mooijaart SP, Brunsveld-Reinders AH, Bos WJW, Van Buren M. Nephrology-tailored geriatric assessment as decision-making tool in kidney failure. J Ren Care 2024; 50:112-127. [PMID: 37031361 DOI: 10.1111/jorc.12466] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 01/26/2023] [Accepted: 03/16/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Dialysis might not benefit all older patients with kidney failure, particularly those with multimorbid conditions and frailty. Patients' and healthcare professionals' awareness of the presence of geriatric impairments could improve outcomes by tailoring treatment plans and decisions for individual patients. OBJECTIVE We aimed to explore the perspectives of patients and healthcare professionals on nephrology-tailored geriatric assessment to fuel decision-making for treatment choices in older patients with kidney failure. DESIGN In an exploratory qualitative study using focus groups, participants discussed perspectives on the use and value of nephrology-tailored geriatric assessment for the decision-making process to start or forego dialysis. PARTICIPANTS AND MEASUREMENTS Patients (n = 18) with kidney failure, caregivers (n = 4), and professionals (n = 25) were purposively sampled from 10 hospitals. Interviews were audio-recorded, transcribed verbatim and inductively analysed using thematic analysis. RESULTS Three main themes emerged that supported or impeded decision-making in kidney failure: (1) patient psycho-social situation; (2) patient-related factors on modality choice; (3) organisation of health care. Patients reported feeling vulnerable due to multiple chronic conditions, old age, experienced losses in life and their willingness to trade longevity for quality of life. Professionals recognised the added value of nephrology-tailored geriatric assessment in three major themes: (i) facilitating continual holistic assessment, (ii) filling the knowledge gap, and (iii) uncovering important patient characteristics. CONCLUSIONS nephrology-tailored geriatric assessment was perceived as a valuable tool to identify geriatric impairments in older patients with kidney failure. Integration of its outcomes can facilitate a more holistic approach to inform choices and decisions about kidney replacement therapy.
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Affiliation(s)
- Noeleen C Berkhout-Byrne
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Carlijn G N Voorend
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Yvette Meuleman
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Willem Jan W Bos
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marjolijn Van Buren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Haga Hospital, The Hague, The Netherlands
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Voorend CG, Berkhout-Byrne NC, van Bodegom-Vos L, Diepenbroek A, Franssen CF, Joosten H, Mooijaart SP, Bos WJW, van Buren M. Geriatric Assessment in CKD Care: An Implementation Study. Kidney Med 2024; 6:100809. [PMID: 38660344 PMCID: PMC11039322 DOI: 10.1016/j.xkme.2024.100809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Rationale & Objective Older people with progressive chronic kidney disease (CKD) have complex health care needs. Geriatric evaluation preceding decision making for kidney replacement is recommended in guidelines, but implementation is lacking in routine care. We aimed to evaluate implementation of geriatric assessment in CKD care. Study Design Mixed methods implementation study. Setting & Participants Dutch nephrology centers were approached for implementation of geriatric assessment in patients aged ≥70 years and with an estimated glomerular filtration rate of ≤20 mL/min/1.73 m2. Quality Improvement Activities/Exposure We implemented a consensus-based nephrology-tailored geriatric assessment: a patient questionnaire and professionally administered test set comprising 16 instruments covering functional, cognitive, psychosocial, and somatic domains and patient-reported outcome measures. Outcomes We aimed for implementation in 10 centers and 200 patients. Implementation was evaluated by (i) perceived enablers and barriers of implementation, including integration in work routines (Normalization Measure Development Tool) and (ii) relevance of the instruments to routine care for the target population. Analytical Approach Variations in implementation practices were described based on field notes. The postimplementation survey among health care professionals was analyzed descriptively, using an explanatory qualitative approach for open-ended questions. Results Geriatric assessment was implemented in 10 centers among 191 patients. Survey respondents (n = 71, 88% response rate) identified determinants that facilitated implementation, ie, multidisciplinary collaboration (with geriatricians) -meetings and reports and execution of assessments by nurses. Barriers to implementation were patient illiteracy or language barrier, time constraints, and patient burden. Professionals considered geriatric assessment sufficiently integrated into work routines (mean, 6.7/10 ± 2.0 [SD]) but also subject to improvement. Likewise, the relevance of geriatric assessment for routine care was scored as 7.8/10 ± 1.2. The Clinical Frailty Score and Montreal Cognitive Assessment were perceived as the most relevant instruments. Limitations Selection bias of interventions' early adopters may limit generalizability. Conclusions Geriatric assessment could successfully be integrated in CKD care and was perceived relevant to health care professionals.
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Affiliation(s)
- Carlijn G.N. Voorend
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Noeleen C. Berkhout-Byrne
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Adry Diepenbroek
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Casper F.M. Franssen
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Hanneke Joosten
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Simon P. Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Jan W. Bos
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
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Voorend CGN, van Buren M, Berkhout-Byrne NC, Kerckhoffs APM, van Oevelen M, Gussekloo J, Richard E, Bos WJW, Mooijaart SP. Apathy Symptoms, Physical and Cognitive Function, Health-Related Quality of Life, and Mortality in Older Patients With CKD: A Longitudinal Observational Study. Am J Kidney Dis 2024; 83:162-172.e1. [PMID: 37741610 DOI: 10.1053/j.ajkd.2023.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 07/14/2023] [Accepted: 07/24/2023] [Indexed: 09/25/2023]
Abstract
RATIONALE & OBJECTIVE Apathy reflects diminished motivation, goal-directed behavior, and emotions, as well as less engagement in social interactions. Apathy overlaps with depression and is associated with cognitive decline. In the older individuals with chronic kidney disease (CKD), both depression and cognitive impairments are common, but apathy symptoms have been underreported. We investigated the occurrence of apathy symptoms and their associations with physical and cognitive functioning, health-related quality of life (HRQoL), and mortality in older patients with CKD. STUDY DESIGN Prospective observational cohort study. SETTING & PARTICIPANTS 180 outpatients aged≥65 years with estimated glomerular filtration rate≤20mL/min/1.73m2 from 5 Dutch nephrology centers. EXPOSURE Apathy symptoms at baseline were considered present when a Geriatric Depression Scale's 3-item apathy subscale score was≥2 points. OUTCOME Physical and cognitive functioning, HRQoL (assessed in annual geriatric assessments), and 4-year mortality. ANALYTICAL APPROACH Linear regression for cross-sectional associations, linear regression models for longitudinal associations, and Cox regression models for mortality over 4 years of observation. RESULTS Apathy symptoms were present in 64 patients (36%; 67% men; median age 75.5 years), of whom 32 (50%) had no depressive symptoms. At baseline, the presence of apathy symptoms was associated with significantly more frailty, more functional dependence, less physical capacity, lower visuoconstructive performance, worse delayed recall, and lower HRQoL scores. The presence of apathy symptoms at baseline was also associated with a higher mortality risk (hazard ratio, 2.3 [95% CI, 1.3-4.2], P=0.005 adjusted for age, sex, and high education level), but not with changes in physical and cognitive functioning or HRQoL during the follow-up period. LIMITATIONS Risk of selection bias and residual confounding. CONCLUSIONS Apathy symptoms were highly prevalent and associated with concurrent lower physical and cognitive status, lower HRQoL, and increased mortality. These findings highlight apathy as a potentially important clinical phenotype in older CKD patients. PLAIN-LANGUAGE SUMMARY We observed that older kidney patients often present apathy symptoms, such as less motivation, fewer goal-directed behaviors, fewer emotions, and less social engagement. Prior research has not extensively described apathy in kidney disease. We investigated the link between apathy symptoms and poor outcomes. We measured physical functioning, cognitive functioning, and quality of life. We learned that one-third of our older kidney patients showed symptoms of apathy, only half of whom had symptoms of depression. Patients with apathy symptoms showed lower quality of life and lower physical and cognitive performance. They also had a higher risk of death. These findings highlight the need for awareness of apathy symptoms in older kidney patients.
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Affiliation(s)
- Carlijn G N Voorend
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands.
| | - Marjolijn van Buren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands; Department of Internal Medicine, Haga Hospital, The Hague, the Netherlands
| | - Noeleen C Berkhout-Byrne
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands
| | - Angèle P M Kerckhoffs
- Department of Internal Medicine and Geriatrics, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Mathijs van Oevelen
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands
| | - Jacobijn Gussekloo
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands; Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
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Ferrara F, Zovi A, Nava E, Langella R, Vitiello A. Great Sustainability Results From Appropriate Antihypertensive Therapy. Curr Probl Cardiol 2023; 48:101857. [PMID: 37301491 DOI: 10.1016/j.cpcardiol.2023.101857] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023]
Abstract
Cardiovascular diseases are emerging as a major cause of death and hospitalization in the Western world. For many years, a number of medicines have been placed on the market, in well-established and safe use for antihypertensive therapy. The various classes of antihypertensives in established use include, ACE inhibitors, as monotherapy or in combination with diuretics or calcium antagonists, sartans, calcium antagonists, beta blockers, and diuretics. Among these medicines classes there are differences in mechanism of action, efficacy in reducing blood pression, tolerability, and cost. In fact, there are wide differences in the monthly cost of therapy within each class and among the classes themselves. In this analysis we describe an example about the prescribing trends of antihypertensive drugs at a European sample represented by an Italian health care company of about 1 million inhabitants. Aspects of pharmacoeconomics, pharmacoutilization, and pharmacological differences are described.
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Affiliation(s)
- Francesco Ferrara
- Pharmaceutical Department, Hospital Pharmacist Manager, ASL Napoli 3 Sud, Naples, Italy.
| | - Andrea Zovi
- Pharmaceutical Department, Hospital Pharmacist, Ministry of Health, Rome, Italy
| | - Eduardo Nava
- Pharmaceutical Department, Director Pharmaceutical, Coordination Area, ASL Napoli 3 Sud, Naples, Italy
| | - Roberto Langella
- Pharmaceutical Department, Italian Society of Hospital Pharmacy (SIFO), SIFO Secretariat of the Lombardy Region, Milan, Italy
| | - Antonio Vitiello
- Pharmaceutical Department, Clinical Pharmacologist, Ministry of Health, Rome, Italy
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Zhao Q, Nooren SJL, Zijlstra LE, Westenberg JJM, Kroft LJM, Jukema JW, Berkhout-Byrne NC, Rabelink TJ, van Zonneveld AJ, van Buren M, Mooijaart SP, Bijkerk R. Circulating miRNAs and Vascular Injury Markers Associate with Cardiovascular Function in Older Patients Reaching End-Stage Kidney Disease. Noncoding RNA 2022; 8:ncrna8010002. [PMID: 35076541 PMCID: PMC8788543 DOI: 10.3390/ncrna8010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/16/2022] Open
Abstract
The prevalence of end-stage kidney disease (ESKD) is rapidly increasing and mostly occurring in patients aged 65 years or older. The main cause of death in these patients is cardiovascular disease (CVD). Novel markers of vascular integrity may thus be of clinical value for identifying patients at high risk for CVD. Here we associated the levels of selected circulating angiogenic miRNAs, angiopoietin-2 (Ang-2) and asymmetric dimethylarginine (ADMA) with cardiovascular structure and function (as determined by cardiovascular MRI) in 67 older patients reaching ESKD that were included from ‘The Cognitive decline in Older Patients with End stage renal disease’ (COPE) prospective, multicentered cohort study. We first determined the association between the vascular injury markers and specific heart conditions and observed that ESKD patients with coronary heart disease have significantly higher levels of circulating ADMA and miR-27a. Moreover, circulating levels of miR-27a were higher in patients with atrial fibrillation. In addition, the circulating levels of the vascular injury markers were associated with measures of cardiovascular structure and function obtained from cardiovascular MRI: pulse wave velocity (PWV), ejection fraction (EF) and cardiac index (CI). We found Ang-2 and miR-27a to be strongly correlated to the PWV, while Ang-2 also associated with ejection fraction. Finally, we observed that in contrast to miR-27a, Ang-2 was not associated with a vascular cause of the primary kidney disease, suggesting Ang-2 may be an ESKD-specific marker of vascular injury. Taken together, among older patients with ESKD, aberrant levels of vascular injury markers (miR-27a, Ang-2 and ADMA) associated with impaired cardiovascular function. These markers may serve to identify individuals at higher risk of CVD, as well as give insight into the underlying (vascular) pathophysiology.
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Affiliation(s)
- Qiao Zhao
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Sabine J. L. Nooren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Laurien E. Zijlstra
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (L.E.Z.); (J.W.J.)
| | - Jos J. M. Westenberg
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (J.J.M.W.); (L.J.M.K.)
| | - Lucia J. M. Kroft
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (J.J.M.W.); (L.J.M.K.)
| | - J. Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (L.E.Z.); (J.W.J.)
- Netherlands Heart Institute, Moreelsepark 1, 3511 EP Utrecht, The Netherlands
| | - Noeleen C. Berkhout-Byrne
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
| | - Ton J. Rabelink
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Anton Jan van Zonneveld
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
- Department of Nephrology, HAGA Hospital, 2545 AA The Hague, The Netherlands
| | - Simon P. Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, 2300 RC Leiden, The Netherlands;
| | - Roel Bijkerk
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (Q.Z.); (S.J.L.N.); (N.C.B.-B.); (T.J.R.); (A.J.v.Z.); (M.v.B.)
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Correspondence: ; Tel.: +31-(0)71-526-8138; Fax: +31-(0)71-526-6868
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Voorend CGN, Joosten H, Berkhout-Byrne NC, Diepenbroek A, Franssen CFM, Bos WJW, Van Buren M, Mooijaart SP. Design of a consensus-based geriatric assessment tailored for older chronic kidney disease patients: results of a pragmatic approach. Eur Geriatr Med 2021; 12:931-942. [PMID: 33871790 PMCID: PMC8463384 DOI: 10.1007/s41999-021-00498-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/08/2021] [Indexed: 12/15/2022]
Abstract
Aim To propose a consensus-based geriatric assessment for optimizing both routine care and research in older patients with advanced chronic kidney disease. Findings Using a pragmatic approach, we reached consensus on a suitable nephrology-tailored geriatric assessment to routinely identify major geriatric impairments in older patients with advanced chronic kidney disease. This geriatric assessment contains instruments in functional, cognitive, psychological, somatic, patient preferences, nutritional status, and social domains, and can be administered with patient questionnaires and professional-administered instruments by nurse (practitioners) in approximately 20 and 40 minutes, respectively. Message We propose a consensus test set for standardized nephrology-tailored geriatric assessment, which is currently being implemented in multiple hospitals and studies, to benefit clinical care for older patients with advanced chronic kidney disease and enhance research comparability. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00498-0. Purpose Unidentified cognitive decline and other geriatric impairments are prevalent in older patients with advanced chronic kidney disease (CKD). Despite guideline recommendation of geriatric evaluation, routine geriatric assessment is not common in these patients. While high burden of vascular disease and existing pre-dialysis care pathways mandate a tailored geriatric assessment, no consensus exists on which instruments are most suitable in this population to identify geriatric impairments. Therefore, the aim of this study was to propose a geriatric assessment, based on multidisciplinary consensus, to routinely identify major geriatric impairments in older people with advanced CKD. Methods A pragmatic approach was chosen, which included focus groups, literature review, inventory of current practices, an expert consensus meeting, and pilot testing. In preparation of the consensus meeting, we composed a project team and an expert panel (n = 33), drafted selection criteria for the selection of instruments, and assessed potential instruments for the geriatric assessment. Results Selection criteria related to general geriatric domains, clinical relevance, feasibility, and duration of the assessment. The consensus-assessment contains instruments in functional, cognitive, psychological, somatic, patient preferences, nutritional status, and social domains. Administration of (seven) patient questionnaires and (ten) professional-administered instruments, by nurse (practitioners), takes estimated 20 and 40 min, respectively. Results are discussed in a multidisciplinary meeting including at least nephrology and geriatric expertise, informing nephrology treatment decisions, and follow-up interventions among which comprehensive geriatric assessment. Conclusion This first multidisciplinary consensus on nephrology-tailored geriatric assessment intent to benefit clinical care and enhance research comparability for older patients with advanced CKD. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00498-0.
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Affiliation(s)
- Carlijn G N Voorend
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands.
| | - Hanneke Joosten
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Noeleen C Berkhout-Byrne
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Adry Diepenbroek
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Casper F M Franssen
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St. Antonius hospital, Nieuwegein, The Netherlands
| | - Marjolijn Van Buren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Haga Hospital, The Hague, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
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Perspectives and experiences of patients and healthcare professionals with geriatric assessment in chronic kidney disease: a qualitative study. BMC Nephrol 2021; 22:9. [PMID: 33407240 PMCID: PMC7789317 DOI: 10.1186/s12882-020-02206-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/10/2020] [Indexed: 12/24/2022] Open
Abstract
Background Older patients with end-stage kidney disease (ESKD) often live with unidentified frailty and multimorbidity. Despite guideline recommendations, geriatric assessment is not part of standard clinical care, resulting in a missed opportunity to enhance (clinical) outcomes including quality of life in these patients. To develop routine geriatric assessment programs for patients approaching ESKD, it is crucial to understand patients’ and professionals’ experiences with and perspectives about the benefits, facilitators and barriers for geriatric assessment. Methods In this qualitative study, semi-structured focus group discussions were conducted with ESKD patients, caregivers and professionals. Participants were purposively sampled from three Dutch hospital-based study- and routine care initiatives involving geriatric assessment for (pre-)ESKD care. Transcripts were analysed inductively using thematic analysis. Results In six focus-groups, participants (n = 47) demonstrated four major themes: (1) Perceived characteristics of the older (pre)ESKD patient group. Patients and professionals recognized increased vulnerability and (cognitive) comorbidity, which is often unrelated to calendar age. Both believed that often patients are in need of additional support in various geriatric domains. (2) Experiences with geriatric assessment. Patients regarded the content and the time spent on the geriatric assessment predominantly positive. Professionals emphasized that assessment creates awareness among the whole treatment team for cognitive and social problems, shifting the focus from mainly somatic to multidimensional problems. Outcomes of geriatric assessment were observed to enhance a dialogue on suitability of treatment options, (re)adjust treatment and provide/seek additional (social) support. (3) Barriers and facilitators for implementation of geriatric assessment in routine care. Discussed barriers included lack of communication about goals and interpretation of geriatric assessment, burden for patients, illiteracy, and organizational aspects. Major facilitators are good multidisciplinary cooperation, involvement of geriatrics and multidisciplinary team meetings. (4) Desired characteristics of a suitable geriatric assessment concerned the scope and use of tests and timing of assessment. Conclusions Patients and professionals were positive about using geriatric assessment in routine nephrology care. Implementation seems achievable, once barriers are overcome and facilitators are endorsed. Geriatric assessment in routine care appears promising to improve (clinical) outcomes in patients approaching ESKD. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-020-02206-9.
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Bijkerk R, Kallenberg MH, Zijlstra LE, van den Berg BM, de Bresser J, Hammer S, Bron EE, Achterberg H, van Buchem MA, Berkhout-Byrne NC, Bos WJW, van Heemst D, Rabelink TJ, van Zonneveld AJ, van Buren M, Mooijaart S. Circulating angiopoietin-2 and angiogenic microRNAs associate with cerebral small vessel disease and cognitive decline in older patients reaching end stage renal disease. Nephrol Dial Transplant 2020; 37:498-506. [PMID: 33355649 DOI: 10.1093/ndt/gfaa370] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The prevalence of end-stage renal disease (ESRD) is increasing worldwide, with the majority of new ESRD cases diagnosed in patients aged >60 years. These older patients are at increased risk for impaired cognitive functioning, potentially through cerebral small vessel disease (SVD). Novel markers of vascular integrity may be of clinical value for identifying patients at high risk for cognitive impairment. METHODS We aimed to associate the levels of Angiopoietin-2 (Ang-2), asymmetric dimethylarginine (ADMA), and a selection of eight circulating angiogenic miRNAs with SVD and cognitive impairment in older patients reaching ESRD that did not initiate renal replacement therapy yet (n = 129; mean age 75.3 years; mean eGFR 16.4 mL/min). We assessed brain MRI changes of SVD (white matter hyperintensity volume, microbleeds and presence of lacunes) and measures of cognition in domains of memory, psychomotor speed and executive function, comprised in a neuropsychological test battery. RESULTS Older patients reaching ESRD showed an unfavorable angiogenic profile, as indicated by aberrant levels of Ang-2 and five angiogenic miRNAs (miR-27a, miR-126, miR-132, miR-223, miR-326), compared to healthy persons and patients with diabetic nephropathy. Moreover, Ang-2 associated with SVD and with the domains of psychomotor speed and executive function, while miR-223 and miR-29a associated with memory function. CONCLUSIONS Taken together, these novel angiogenic markers might serve to identify older patients with ESRD at risk of cognitive decline, as well as give insight into the underlying (vascular) pathophysiology.
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Affiliation(s)
- Roel Bijkerk
- Department of Internal Medicine (Nephrology).,Einthoven Laboratory for Vascular and Regenerative Medicine
| | - Marije H Kallenberg
- Department of Internal Medicine (Nephrology).,Department of Internal Medicine (Gerontology and Geriatrics)
| | - Laurien E Zijlstra
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bernard M van den Berg
- Department of Internal Medicine (Nephrology).,Einthoven Laboratory for Vascular and Regenerative Medicine
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Esther E Bron
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Hakim Achterberg
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Willem Jan W Bos
- Department of Internal Medicine (Nephrology).,Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Ton J Rabelink
- Department of Internal Medicine (Nephrology).,Einthoven Laboratory for Vascular and Regenerative Medicine
| | - Anton Jan van Zonneveld
- Department of Internal Medicine (Nephrology).,Einthoven Laboratory for Vascular and Regenerative Medicine
| | - Marjolijn van Buren
- Department of Internal Medicine (Nephrology).,Department of Nephrology, HAGA Hospital, The Hague, The Netherlands
| | - Simon Mooijaart
- Department of Internal Medicine (Gerontology and Geriatrics).,Institute of Evidence-Based Medicine in Old Age, Leiden, The Netherlands
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9
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Chien CW, Lin YC, Huang SK, Chen PE, Tung TH. A population-based study of the association between hemodialysis and cognitive impairment. Asia Pac Psychiatry 2020; 12:e12404. [PMID: 32715665 DOI: 10.1111/appy.12404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 06/15/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION End-stage renal disease is a serious public health issue. The objective of this retrospective cohort study was to assess the association between hemodialysis and cognitive impairment, while controlling for age, sex, residence, and comorbidities. METHODS This study assesses the risk of cognitive impairment among a nationwide cohort of new hemodialysis patients derived from the NHIRD. RESULTS A total of 4330 patients were assigned to the dialysis group and 17 320 patients were assigned to the control group. A total of 2103 of the patients developed cognitive impairment within 2 years after the date of dialysis initiation. Patients who developed cognitive impairment were older (69.85 ± 11.56) than their counterparts who did not develop cognitive impairment (58.58 ± 14.77; P < .001). The log-rank test of Kaplan-Meier analysis revealed a higher risk of cognitive impairment in the hemodialysis group than in the non-hemodialysis group (P < .001). The interval between dialysis initiation and the onset of cognitive impairment was 98.66 ± 46.39 months among non-dialysis subjects and 53.45 ± 41.90 months among dialysis subjects, and the between-group difference was significant (P < .001). The Cox Proportional Hazard Model revealed that after controlling for gender, age, residence, and comorbidities, hemodialysis was shown to have a significant impact on cognitive impairment (Hazard Ratio [HR]: 1.44; 95% confidence interval [CI]: 1.29-1.60). Furthermore, the risk of developing cognitive impairment increased with age (HR: 1.07; 95% CI: 1.06-1.08). DISCUSSION Hemodialysis was associated with cognitive impairment. There was a significant association between age and cognitive impairment, regardless of the comorbidities prior to hemodialysis. There was no evidence of an association between comorbidities and cognitive impairment after beginning hemodialysis.
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Affiliation(s)
- Ching-Wen Chien
- Institute for Hospital Management, Tsing Hua University, Shenzhen, China
| | - Ying Chi Lin
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Song-Kong Huang
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Pei-En Chen
- Taiwan Association of Health Industry Management and Development, Taipei, Taiwan, China
| | - Tao-Hsin Tung
- Department of Medical Research and Education, Cheng Hsin General Hospital, Taipei, Taiwan, China.,Maoming People's Hospital, Maoming, Guangdong, China
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10
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van Deudekom FJ, Kallenberg MH, Berkhout-Byrne NC, Blauw GJ, Boom H, de Bresser J, van Buchem MA, Gaasbeek A, Hammer S, Lagro J, van Osch MJP, Witjes-Ané MN, Rabelink TJ, van Buren M, Mooijaart SP. Patterns and characteristics of cognitive functioning in older patients approaching end stage kidney disease, the COPE-study. BMC Nephrol 2020; 21:126. [PMID: 32272897 PMCID: PMC7147053 DOI: 10.1186/s12882-020-01764-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 03/12/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The prevalence of impaired cognitive functioning in older patients with end stage kidney disease (ESKD) is high. We aim to describe patterns of memory, executive function or psychomotor speed and to identify nephrologic, geriatric and neuroradiologic characteristics associated with cognitive impairment in older patients approaching ESKD who have not yet started with renal replacement therapy (RRT). METHODS The COPE-study (Cognitive Decline in Older Patients with ESRD) is a prospective cohort study including 157 participants aged 65 years and older approaching ESKD (eGFR ≤20 ml/min/1.73 m2) prior to starting with RRT. In addition to routinely collected clinical parameters related to ESKD, such as vascular disease burden and parameters of metabolic disturbance, patients received a full geriatric assessment, including extensive neuropsychological testing. In a subgroup of patients (n = 93) a brain MRI was performed. RESULTS The median age was 75.3 years. Compared to the normative data of neuropsychological testing participants memory performance was in the 24th percentile, executive function in the 18th percentile and psychomotor speed in the 20th percentile. Independent associated characteristics of impairment in memory, executive and psychomotor speed were high age, low educational level and low functional status (all p-values < 0.003). A history of vascular disease (p = 0.007) and more white matter hyperintensities on brain MRI (p = 0.013) were associated with a lower psychomotor speed. CONCLUSION Older patients approaching ESKD have a high prevalence of impaired memory, executive function and psychomotor speed. The patterns of cognitive impairment and brain changes on MRI are suggestive of vascular cognitive impairment. These findings could be of potentially added value in the decision-making process concerning patients with ESKD.
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Affiliation(s)
- Floor J van Deudekom
- Department of Gerontology and Geriatrics C7-Q, Leiden University Medical Center, PO box 9600, 2300 RC, Leiden, The Netherlands.
| | - Marije H Kallenberg
- Department of Gerontology and Geriatrics C7-Q, Leiden University Medical Center, PO box 9600, 2300 RC, Leiden, The Netherlands.,Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Gerard J Blauw
- Department of Gerontology and Geriatrics C7-Q, Leiden University Medical Center, PO box 9600, 2300 RC, Leiden, The Netherlands.,Department of Geriatrics, Haaglanden Medical Center, The Hague, the Netherlands
| | - Henk Boom
- Department of Nephrology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - André Gaasbeek
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Joep Lagro
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | | | - Marie-Noëlle Witjes-Ané
- Department of Gerontology and Geriatrics C7-Q, Leiden University Medical Center, PO box 9600, 2300 RC, Leiden, The Netherlands.,Department of Geriatrics, Haaglanden Medical Center, The Hague, the Netherlands
| | - Ton J Rabelink
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marjolijn van Buren
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Nephrology, HAGA Hospital, The Hague, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics C7-Q, Leiden University Medical Center, PO box 9600, 2300 RC, Leiden, The Netherlands.,Institute of Evidence-Based Medicine in Old Age, Leiden, the Netherlands
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11
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Zijlstra LE, Trompet S, Mooijaart SP, van Buren M, Sattar N, Stott DJ, Jukema JW. The association of kidney function and cognitive decline in older patients at risk of cardiovascular disease: a longitudinal data analysis. BMC Nephrol 2020; 21:81. [PMID: 32138689 PMCID: PMC7059260 DOI: 10.1186/s12882-020-01745-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 02/27/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) has been identified as a significant direct marker for cognitive decline, but controversy exists regarding the magnitude of the association of kidney function with cognitive decline across the different CKD stages. Therefore, the aim of this study was to investigate the association of kidney function with cognitive decline in older patients at high risk of cardiovascular disease, using data from the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER). METHODS Data of 5796 patients of PROSPER were used. Strata were made according to clinical stages of CKD based on estimated glomerular filtration rate; < 30 ml/min/1.73m2 (stage 4), 30-45 ml/min/1.73m2 (stage 3b), 45-60 ml/min/1.73m2 (stage 3a) and ≥ 60 ml/min/1.73m2 (stage 1-2). Cognitive function and functional status was assessed at six different time points and means were compared at baseline and over time, adjusted for multiple prespecified variables. Stratified analyses for history of vascular disease were executed. RESULTS Mean age was 75.3 years and 48.3% participants were male. Mean follow-up was 3.2 years. For all cognitive function tests CKD stage 4 compared to the other stages had the worst outcome at baseline and a trend for faster cognitive decline over time. When comparing stage 4 versus stage 1-2 over time the estimates (95% CI) were 2.23 (0.60-3.85; p = 0.009) for the Stroop-Colour-Word test, - 0.33 (- 0.66-0.001; p = 0.051) for the Letter-Digit-Coding test, 0.08 (- 0.06-0.21; p = 0.275) for the Picture-Word-Learning test with immediate recall and - 0.07 (- 0.02-0.05; p = 0.509) for delayed recall. This association was most present in patients with a history of vascular disease. No differences were found in functional status. CONCLUSION In older people with vascular burden, only severe kidney disease (CKD stage 4), but not mild to modest kidney disease (CKD stage 3a and b), seem to be associated with cognitive impairment at baseline and cognitive decline over time. The association of severe kidney failure with cognitive impairment and decline over time was more outspoken in patients with a history of vascular disease, possibly due to a higher probability of polyvascular damage, in both kidney and brain, in patients with proven cardiovascular disease.
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Affiliation(s)
- Laurien E Zijlstra
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands.
| | - Stella Trompet
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands.,Department of Gerontology and Geriatrics, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Marjolijn van Buren
- Department of Nephrology, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands.,Department of Internal Medicine, HagaHospital, Els Borst-Eilersplein 275, 2545AA,, The Hague, The Netherlands
| | - Naveed Sattar
- BHF Glasgow Cardiovascular Research Centre, Faculty of Medicine, Glasgow, G12 8TD, UK
| | - David J Stott
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, 126 University Place, G12 8TA, Glasgow, UK
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
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12
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Association of cardiovascular structure and function with cerebrovascular changes and cognitive function in older patients with end-stage renal disease. Aging (Albany NY) 2020; 12:1496-1511. [PMID: 31907337 PMCID: PMC7053617 DOI: 10.18632/aging.102696] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 12/26/2019] [Indexed: 12/17/2022]
Abstract
The Dutch prospective multicenter cohort study COPE (Cognitive decline in Older Patients with End stage renal disease) aimed to investigate the association of cardiovascular structure and function with cerebrovascular changes and cognitive function in 85 older patients with chronic kidney disease stage 4 and 5, awaiting either dialysis or conservative care. MRI was performed measuring aortic stiffness (pulse wave velocity [PWV]) and cardiac systolic function (ejection fraction and cardiac index). Outcomes were MRI-derived cerebrovascular changes (microbleeds, lacunes and white matter hyperintensities) and cognitive function (memory, executive function and psychomotor speed). Mean age was 76 years and 66% were male. No statistically significant associations were observed between cardiovascular parameters and cerebrovascular changes. Cognitive function was worse in patients with high compared to low PWV in all three cognitive domains. Although there were clinically relevant associations of high PWV with poor cognition in all domains, after adjustment for age, sex and education only the Trail Making Test A remained statistically significant (p=0.030). In conclusion, this study suggests that a higher PWV might be associated with lower cognitive function, suggesting that arterial stiffness may be an underlying mechanism of development of cognitive impairment in older patients with ESRD. Larger studies should replicate and extend these findings.
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