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Mutatiri C, Ratsch A, McGrail M, Venuthurupalli SK, Chennakesavan SK. Primary and specialist care interaction and referral patterns for individuals with chronic kidney disease: a narrative review. BMC Nephrol 2024; 25:149. [PMID: 38689219 PMCID: PMC11061991 DOI: 10.1186/s12882-024-03585-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/23/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Timely referral of individuals with chronic kidney disease from primary care to secondary care is evidenced to improve patient outcomes, especially for those whose disease progresses to kidney failure requiring kidney replacement therapy. A shortage of specialist nephrology services plus no consistent criteria for referral and reporting leads to referral pattern variability in the management of individuals with chronic kidney disease. OBJECTIVE The objective of this review was to explore the referral patterns of individuals with chronic kidney disease from primary care to specialist nephrology services. It focused on the primary-specialist care interface, optimal timing of referral to nephrology services, adequacy of preparation for kidney replacement therapy, and the role of clinical criteria vs. risk-based prediction tools in guiding the referral process. METHODS A narrative review was utilised to summarise the literature, with the intent of providing a broad-based understanding of the referral patterns for patients with chronic kidney disease in order to guide clinical practice decisions. The review identified original English language qualitative, quantitative, or mixed methods publications as well as systematic reviews and meta-analyses available in PubMed and Google Scholar from their inception to 24 March 2023. RESULTS Thirteen papers met the criteria for detailed review. We grouped the findings into three main themes: (1) Outcomes of the timing of referral to nephrology services, (2) Adequacy of preparation for kidney replacement therapy, and (3) Comparison of clinical criteria vs. risk-based prediction tools. The review demonstrated that regardless of the time frame used to define early vs. late referral in relation to the start of kidney replacement therapy, better outcomes are evidenced in patients referred early. CONCLUSIONS This review informs the patterns and timing of referral for pre-dialysis specialist care to mitigate adverse outcomes for individuals with chronic kidney disease requiring dialysis. Enhancing current risk prediction equations will enable primary care clinicians to accurately predict the risk of clinically important outcomes and provide much-needed guidance on the timing of referral between primary care and specialist nephrology services.
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Affiliation(s)
- Clyson Mutatiri
- Renal Medicine, Wide Bay Hospital and Health Service, Bundaberg, QLD, Australia.
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Bundaberg, QLD, Australia.
| | - Angela Ratsch
- Research Services, Wide Bay Hospital and Health Service, Hervey Bay, QLD, Australia
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Hervey Bay, QLD, Australia
| | - Matthew McGrail
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Rockhampton, QLD, Australia
| | - Sree Krishna Venuthurupalli
- Kidney Service, Department of Medicine, West Moreton Hospital and Health Service, Ipswich, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Gibyeli Genek D, Alp A, Uyar Gazezoğlu O, Huddam B. Vascular access route venture of the chronic hemodialysis patient: A prospective cohort study. Vascular 2024:17085381241244867. [PMID: 38569483 DOI: 10.1177/17085381241244867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVES This study aimed to collect evidence to improve the arteriovenous fistula practice by investigating vascular access routes and by identifying the factors influencing the preferred types of vascular access routes for the first-time hemodialysis in our center. METHODS We performed an epidemiological, prospective, cohort study. The study included 308 patients, who underwent hemodialysis for the first time between March 2023 and August 2023 in our hemodialysis center. We evaluated biochemical parameters, preferred vascular access routes for the first-time hemodialysis, planned/emergency hemodialysis status, the qualifications of the healthcare provider, who inserted the central venous catheter, if applicable, the presence of hypervolemia, anticoagulant use, nephrology follow-up findings, and in-hospital mortality in all patients and in those, who continued with chronic hemodialysis. RESULTS The number of patients, who continued with chronic hemodialysis, was 167 (54.2%) and a temporary internal jugular central venous catheter was the most commonly preferred vascular access route for the first-time hemodialysis (47.3%). A central venous catheter was most commonly inserted by a nephrologist (53.7%) in chronic hemodialysis patients. Of the patients continuing with chronic hemodialysis, 45.5% were followed up in the nephrology outpatient clinic, 9.6% initiated hemodialysis on a planned basis, and 8.4% initiated hemodialysis with an arteriovenous fistula. A temporary internal jugular central venous catheter was commonly preferred when patients were followed up in the nephrology clinic and when the insertion was performed by a nephrologist; a transient femoral central venous catheter was commonly preferred in case of hypervolemia (p < .001, p < .001, and p = .028, respectively). Age, gender, etiology, anticoagulant use, or biochemical test results did not act on the selection of the access site for the insertion of central venous catheter at the time of the first hemodialysis treatment. The access site for central venous catheter was not associated with in-hospital mortality (p = .644). In the overall patient group, the in-hospital mortality was significantly low in patients followed up in the nephrology clinic (p = .014). CONCLUSION The use of pre-emptive arteriovenous fistula for the first hemodialysis treatment occurs much less commonly than expected. Hemodialysis initiation rates with pre-emptive arteriovenous fistula lag behind nephrology outpatient follow-up rates.
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Affiliation(s)
- Dilek Gibyeli Genek
- School of Medicine, Department of Nephrology, Mugla Sitki Kocman University, Mugla, Turkey
| | - Alper Alp
- School of Medicine, Department of Nephrology, Mugla Sitki Kocman University, Mugla, Turkey
| | - Okşan Uyar Gazezoğlu
- Training and Research Hospital, Hemodialysis, Mugla Sitki Kocman University, Mugla, Turkey
| | - Bülent Huddam
- School of Medicine, Department of Nephrology, Mugla Sitki Kocman University, Mugla, Turkey
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Piveteau J, Raffray M, Couchoud C, Ayav C, Chatelet V, Vigneau C, Bayat S. Pre-dialysis care trajectory and post-dialysis survival and transplantation access in patients with end-stage kidney disease. J Nephrol 2023; 36:2057-2070. [PMID: 37505404 DOI: 10.1007/s40620-023-01711-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 06/18/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND The pre-dialysis care trajectory impact on post-dialysis outcomes is poorly known. This study assessed survival, access to kidney transplant waiting list and to transplantation after dialysis initiation by taking into account the patients' pre-dialysis care consumption (inpatient and outpatient) and the conditions of dialysis start: initiation context (emergency or planned) and vascular access type (catheter or fistula). METHODS Adults who started dialysis in France in 2015 were included. Clinical data came from the French REIN registry and data on the care trajectory from the French National Health Data system (SNDS). The Cox model was used to assess survival and access to kidney transplantation. RESULTS We included 8856 patients with a mean age of 68 years. Survival was shorter in patients with emergency or planned dialysis initiation with a catheter compared to patients with planned dialysis with a fistula. The risk of death was lower in patients who were seen by a nephrologist more than once in the 6 months before dialysis than in those who were seen only once. The rate of kidney transplant at 1 year post-dialysis was lower for patients with emergency or planned dialysis initiation with a catheter (respectively, HR = 0.5 [0.4; 0.8] and HR = 0.7 [0.5; 0.9]) compared to patients with planned dialysis start with a fistula. Patients who were seen by a nephrologist more than three times between 0 and 6 months before dialysis start were more likely to access the waiting list 1 and 3 years after dialysis start (respectively, HR = 1.3 [1.1; 1.5] and HR = 1.2 [1.1; 1.4]). CONCLUSIONS Nephrological follow-up in the year before dialysis initiation is associated with better survival and higher probability of access to kidney transplantation. These results emphasize the importance of early patient referral to nephrologists by general practitioners.
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Affiliation(s)
- Juliette Piveteau
- Univ Rennes, EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS - U1309, French School of Public Health, 15 Avenue du Professeur Léon Bernard, Rennes, France.
| | - Maxime Raffray
- Univ Rennes, EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS - U1309, French School of Public Health, 15 Avenue du Professeur Léon Bernard, Rennes, France
| | - Cécile Couchoud
- Renal Epidemiology and Information Network (REIN) Registry, Biomedecine Agency, Saint-Denis-La-Plaine, France
| | - Carole Ayav
- CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie Clinique, Nancy, France
| | - Valérie Chatelet
- Centre Universitaire des Maladies Rénales, CHU Caen, Caen, France
- U1086 Inserm, ANTICIPE, Centre de Lutte Contre le Cancer François Baclesse, Caen, France
| | - Cécile Vigneau
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France
| | - Sahar Bayat
- Univ Rennes, EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS - U1309, French School of Public Health, 15 Avenue du Professeur Léon Bernard, Rennes, France
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Cogley C, Carswell C, Bramham J, Bramham K, Smith A, Holian J, Conlon P, D’Alton P. Improving kidney care for people with severe mental health difficulties: a thematic analysis of twenty-two healthcare providers' perspectives. Front Public Health 2023; 11:1225102. [PMID: 37448661 PMCID: PMC10338099 DOI: 10.3389/fpubh.2023.1225102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/08/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction People with severe mental health difficulties (SMHDs) and concurrent kidney disease have less access to quality kidney care and worse clinical outcomes. Our research investigates the barriers and facilitators to effective kidney care for people with SMHDs, and how care might be improved for this underserved population. Methods We conducted semi-structured interviews with twenty-two physical (n = 14) and mental (n = 8) healthcare professionals with experience working with people with SMHDs and concurrent kidney disease. Interview data were analysed and interpreted using reflexive thematic analysis. Results Four themes were generated from the data: 1. "It's about understanding their limitations and challenges, without limiting their rights" describes how some people with SMHDs need additional support when accessing kidney care due to challenges with their mental state, motivation, cognitive difficulties, or mistrust of the healthcare system. 2. "There are people falling through the cracks" describes how the separation of physical and mental healthcare, combined with under-resourcing and understaffing, results in poorer outcomes for people with SMHDs. 3. "Psychiatry is a black spot in our continuing medical education" describes how many renal healthcare providers have limited confidence in their understanding of mental health and their ability to provide care for people with SMHDs. 4. "When they present to a busy emergency department with a problem, the staff tend to go '…psych patient"" describes how stigma towards people with SMHDs can negatively impact quality of care. Conclusion Healthcare professionals accounts' describe how people with SMHDs and kidney disease can have favourable outcomes if they have appropriate hospital, community and social supports. Findings indicate that effective management of kidney disease for people with SMHDs requires integrated physical and mental health care, which takes an individualised "whole person" approach to addressing the interaction between kidney disease and mental health.
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Affiliation(s)
- Clodagh Cogley
- School of Psychology, University College Dublin, Dublin, Ireland
| | - Claire Carswell
- Department of Health Sciences, University of York, York, United Kingdom
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Jessica Bramham
- School of Psychology, University College Dublin, Dublin, Ireland
| | | | | | - John Holian
- St Vincent’s University Hospital, Dublin, Ireland
| | | | - Paul D’Alton
- School of Psychology, University College Dublin, Dublin, Ireland
- St Vincent’s University Hospital, Dublin, Ireland
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Torreggiani M, Piccoli GB, Moio MR, Conte F, Magagnoli L, Ciceri P, Cozzolino M. Choice of the Dialysis Modality: Practical Considerations. J Clin Med 2023; 12:jcm12093328. [PMID: 37176768 PMCID: PMC10179541 DOI: 10.3390/jcm12093328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/02/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
Chronic kidney disease and the need for kidney replacement therapy have increased dramatically in recent decades. Forecasts for the coming years predict an even greater increase, especially in low- and middle-income countries, due to the rise in metabolic and cardiovascular diseases and the aging population. Access to kidney replacement treatments may not be available to all patients, making it especially strategic to set up therapy programs that can ensure the best possible treatment for the greatest number of patients. The choice of the "ideal" kidney replacement therapy often conflicts with medical availability and the patient's tolerance. This paper discusses the pros and cons of various kidney replacement therapy options and their real-world applicability limits.
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Affiliation(s)
- Massimo Torreggiani
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France
| | | | - Maria Rita Moio
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France
| | - Ferruccio Conte
- Renal Division, Department of Health Sciences, Uiniversity of Milan, San Paolo Hospital, 20142 Milan, Italy
| | - Lorenza Magagnoli
- Renal Division, Department of Health Sciences, Uiniversity of Milan, San Paolo Hospital, 20142 Milan, Italy
| | - Paola Ciceri
- Renal Division, Department of Health Sciences, Uiniversity of Milan, San Paolo Hospital, 20142 Milan, Italy
| | - Mario Cozzolino
- Renal Division, Department of Health Sciences, Uiniversity of Milan, San Paolo Hospital, 20142 Milan, Italy
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Piccoli GB, Cederholm T, Avesani CM, Bakker SJL, Bellizzi V, Cuerda C, Cupisti A, Sabatino A, Schneider S, Torreggiani M, Fouque D, Carrero JJ, Barazzoni R. Nutritional status and the risk of malnutrition in older adults with chronic kidney disease - implications for low protein intake and nutritional care: A critical review endorsed by ERN-ERA and ESPEN. Clin Nutr 2023; 42:443-457. [PMID: 36857954 DOI: 10.1016/j.clnu.2023.01.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023]
Abstract
Increased life expectancy is posing unprecedented challenges to healthcare systems worldwide. These include a sharp increase in the prevalence of chronic kidney disease (CKD) and of impaired nutritional status with malnutrition-protein-energy wasting (PEW) that portends worse clinical outcomes, including reduced survival. In older adults with CKD, a nutritional dilemma occurs when indications from geriatric nutritional guidelines to maintain the protein intake above 1.0 g/kg/day to prevent malnutrition need to be adapted to the indications from nephrology guidelines, to reduce protein intake in order to prevent or slow CKD progression and improve metabolic abnormalities. To address these issues, the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Renal Nutrition group of the European Renal Association (ERN-ERA) have prepared this conjoint critical review paper, whose objective is to summarize key concepts related to prevention and treatment of both CKD progression and impaired nutritional status using dietary approaches, and to provide guidance on how to define optimal protein and energy intake in older adults with differing severity of CKD. Overall, the authors support careful assessment to identify the most urgent clinical challenge and the consequent treatment priority. The presence of malnutrition-protein-energy wasting (PEW) suggests the need to avoid or postpone protein restriction, particularly in the presence of stable kidney function and considering the patient's preferences and quality of life. CKD progression and advanced CKD stage support prioritization of protein restriction in the presence of a good nutritional status. Individual risk-benefit assessment and appropriate nutritional monitoring should guide the decision-making process. Higher awareness of the challenges of nutritional care in older adult patients with CKD is needed to improve care and outcomes. Research is advocated to support evidence-based recommendations, which we still lack for this increasingly large patient subgroup.
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Affiliation(s)
| | - Tommy Cederholm
- Department of Public Health and Caring Sciences, Uppsala University. Theme Inflammation & Aging, Karolinska University Hospital, Stockholm, Sweden
| | - Carla Maria Avesani
- Department of Clinical Science, Technology and Intervention, Division of Renal Medicine and Baxter Novum, Karolinska Institute, Stockholm, Sweden
| | - Stephan J L Bakker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Vincenzo Bellizzi
- Nephrology and Dialysis Division - Department of Medical Sciences, Hospital "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Cristina Cuerda
- Departamento de Medicina, Universidad Complutense de Madrid, Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Alice Sabatino
- UO Nefrologia, Azienda Ospedaliera- Universitaria Parma, Parma, Italy
| | - Stephane Schneider
- Gastroenterology and Nutrition, Nice University Hospital, Université Côte d'Azur, Nice, France
| | - Massimo Torreggiani
- Néphrologie et dialyse, Centre Hospitalier Le Mans, Avenue Rubillard, 72037, Le Mans, France
| | - Denis Fouque
- Renal Department, Lyon SUD Hospital, Hospices Civils de Lyon, Université de Lyon, Pierre Benite, France
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden; Division of Nephrology, Department of Clinical Sciences, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.
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Referral pattern to nephrologist and prognosis in diabetic kidney disease patients: Single center retrospective cohort study. PLoS One 2023; 18:e0282163. [PMID: 36827357 PMCID: PMC9956043 DOI: 10.1371/journal.pone.0282163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 02/09/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Management of diabetic kidney disease (DKD) to prevent end-stage kidney disease (ESKD) has become a major challenge for health care professionals. This study aims to investigate the characteristics of patients with DKD when they are first referred to a nephrologist and the subsequent prognoses. METHODS A total of 307 patients who were referred to our department from October 2010 to September 2014 at Osaka General Medical Center were analyzed. Independent risk factors associated with renal replacement therapy (RRT) and cardiovascular composite events (CVE) following their nephrology referral were later identified using Cox proportional hazards analysis. RESULTS Of 307 patients, 26 (8.5%), 67 (21.8%), 134 (43.6%), and 80 (26.1%) patients were categorized as having chronic kidney disease (CKD) stages 3a, 3b, 4, and 5, respectively. The median estimated glomerular filtration rate (eGFR) and urinary protein levels were 22.3 mL/min/1.73 m2 and 2.83 g/gCr, respectively, at the time of the nephrology referral. During the follow-up period (median, 30 months), 121 patients required RRT, and more than half of the patients with CKD stages 5 and 4 reached ESKD within 60 months following their nephrology referral; 30% and <10% of the patients with CKD stages 3b and 3a, respectively, required RRT within 60 months following their nephrology referral. CONCLUSION Patients with DKD were referred to nephrologist at CKD stage 4. Although almost half of the patients with CKD stage 5 at the time of nephrology referral required RRT within one-and-a-half years after the referral, kidney function of patients who were referred to nephrologist at CKD stage 3 and 4 were well preserved.
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Lee J, Kim SG, Yun D, Kang MW, Kim YC, Kim DK, Oh KH, Joo KW, Kim YS, Han SS. Consulting to nephrologist when starting continuous renal replacement therapy for acute kidney injury is associated with a survival benefit. PLoS One 2023; 18:e0281831. [PMID: 36791117 PMCID: PMC9931119 DOI: 10.1371/journal.pone.0281831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 02/02/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Several studies suggest improved outcomes for patients with kidney disease who consult a nephrologist. However, it remains undetermined whether a consultation with a nephrologist is related to a survival benefit after starting continuous renal replacement therapy (CRRT) due to acute kidney injury (AKI). METHODS Data from 2,397 patients who started CRRT due to severe AKI at Seoul National University Hospital, Korea between 2010 and 2020 were retrospectively collected. The patients were divided into two groups according to whether they underwent a nephrology consultation regarding the initiation and maintenance of CRRT. The Cox proportional hazards model was used to calculate the hazard ratio (HR) of mortality during admission to the intensive care unit after adjusting for multiple variables. RESULTS A total of 2,153 patients (89.8%) were referred to nephrologists when starting CRRT. The patients who underwent a nephrology consultation had a lower mortality rate than those who did not have a consultation (HR = 0.47 [0.40-0.56]; P < 0.001). Subsequently, patients who had nephrology consultations were divided into two groups (i.e., early and late) according to the timing of the consultation. Both patients with early and late consultation had lower mortality rates than patients without consultations, with HRs of 0.45 (0.37-0.54) and 0.51 (0.42-0.61), respectively. CONCLUSIONS Consultation with a nephrologist may contribute to a survival benefit after starting CRRT for AKI.
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Affiliation(s)
- Jinwoo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Seong Geun Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Donghwan Yun
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Min Woo Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- * E-mail:
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Che M, Iliescu E, Thanabalasingam S, Day AG, White CA. Death and Dialysis Following Discharge From Chronic Kidney Disease Clinic: A Retrospective Cohort Study. Can J Kidney Health Dis 2022; 9:20543581221118434. [PMID: 35992302 PMCID: PMC9386872 DOI: 10.1177/20543581221118434] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Multidisciplinary care is recommended for patients with advanced chronic kidney disease (CKD). A formalized, risk-based approach to CKD management is being adopted in some jurisdictions. In Ontario, Canada, the eligibility criteria for multidisciplinary CKD care funding were revised between 2016 and 2018 to a 2 year risk of kidney replacement therapy (KRT) greater than 10% calculated by the 4-variable Kidney Failure Risk Equation (KFRE). Implementation of the risk-based approach has led to the discharge of prevalent CKD patients. Objective: The primary objective of this study was to determine the frequency of occurrence of death and KRT initiation in patients discharged from CKD clinic. Design: Retrospective cohort study Setting: Single center multidisciplinary CKD clinic in Ontario, Canada Patients: Four hundred and twenty five patients seen at least once in 2013 at the multidisciplinary CKD clinic Measurements: Outcomes included discharge status, death, re-referral and KRT initiation. Reasons for discharge were recorded. Methods: Outcomes were extracted from available electronic medical records and the provincial death registry between the patient’s initial clinic visit in 2013 and January 1, 2020. KFRE-2 scores were calculated using the 4-variable KFRE equation. The hazard rates of death and KRT after discharge due to stable eGFR/low KFRE were compared to patients who remained in the clinic. Results: Of the 425 CKD patients, 69 (16%) and 19 (4%) were discharged to primary care and general nephrology, respectively. Of those discharged, 7 (8%) were re-referred to nephrology or CKD clinic, while only 2 (2%) discharged patients required subsequent KRT. The hazard of mortality was reduced after discharge from the clinic due to stable eGFR/low KFRE (adjusted HR = 0.45 [95% CI, 0.25-0.78, P = .005]). Limitations: Single center, observational retrospective study design and unknown kidney function over time post discharge for most patients Conclusions: Discharge of low risk patients from multidisciplinary CKD clinic appears feasible and safe, with fewer than 1 in 40 discharged patients subsequently initiated on KRT over the following 7 years.
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Affiliation(s)
- Michael Che
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Eduard Iliescu
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Susan Thanabalasingam
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Andrew G Day
- Kingston General Health Research Institute, Kingston Health Sciences Center, Kingston, ON, Canada
| | - Christine A White
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
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Ghimire A, Ye F, Hemmelgarn B, Zaidi D, Jindal KK, Tonelli MA, Cooper M, James MT, Khan M, Tinwala MM, Sultana N, Ronksley PE, Muneer S, Klarenbach S, Okpechi IG, Bello AK. Trends in nephrology referral patterns for patients with chronic kidney disease: Retrospective cohort study. PLoS One 2022; 17:e0272689. [PMID: 35951609 PMCID: PMC9371302 DOI: 10.1371/journal.pone.0272689] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/25/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Information on early, guideline discordant referrals in nephrology is limited. Our objective was to investigate trends in referral patterns to nephrology for patients with chronic kidney disease (CKD). Methods Retrospective cohort study of adults with ≥1 visits to a nephrologist from primary care with ≥1 serum creatinine and/or urine protein measurement <180 days before index nephrology visit, from 2006 and 2019 in Alberta, Canada. Guideline discordant referrals were those that did not meet ≥1 of: Estimated glomerular filtration rate (eGFR) ˂ 30 mL/min/1.73m2, persistent albuminuria (ACR ≥ 300 mg/g, PCR ≥ 500 mg/g, or Udip ≥ 2+), or progressive and persistent decline in eGFR until index nephrology visit (≥ 5 mL/min/1.73m2). Results Of 69,372 patients with CKD, 28,518 (41%) were referred in a guideline concordant manner. The overall rate of first outpatient visits to nephrology increased from 2006 to 2019, although guideline discordant referrals showed a greater increase (trend 21.9 per million population/year, 95% confidence interval 4.3, 39.4) versus guideline concordant referrals (trend 12.4 per million population/year, 95% confidence interval 5.7, 19.0). The guideline concordant cohort were more likely to be on renin-angiotensin system blockers or beta blockers (hazard ratio 1.14, 95% confidence interval 1.12, 1.16), and had a higher risk of CKD progression (hazard ratio 1.09, 95% confidence interval 1.06, 1.13), kidney failure (hazard ratio 7.65, 95% confidence interval 6.83, 8.56), cardiovascular event (hazard ratio 1.40, 95% confidence interval 1.35,1.45) and mortality (hazard ratio 1.58, 95% confidence interval 1.52, 1.63). Conclusions A significant proportion nephrology referrals from primary care were not consistent with current guideline-recommended criteria for referral. Further work is needed to identify quality improvement initiatives aimed at enhancing referral patterns of patients with CKD.
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Affiliation(s)
- Anukul Ghimire
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Feng Ye
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Brenda Hemmelgarn
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Deenaz Zaidi
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Kailash K. Jindal
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Marcello A. Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Cooper
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew T. James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maryam Khan
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Mohammed M. Tinwala
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Naima Sultana
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Paul E. Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shezel Muneer
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Scott Klarenbach
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ikechi G. Okpechi
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Aminu K. Bello
- Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
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11
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Dhanorkar M, Prasad N, Kushwaha R, Behera M, Bhaduaria D, Yaccha M, Patel M, Kaul A. Impact of Early versus Late Referral to Nephrologists on Outcomes of Chronic Kidney Disease Patients in Northern India. Int J Nephrol 2022; 2022:4768540. [PMID: 35692284 PMCID: PMC9177347 DOI: 10.1155/2022/4768540] [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: 02/09/2022] [Revised: 04/12/2022] [Accepted: 04/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background CKD patients are often asymptomatic in the early stages and referred late to nephrologists. Late referred patients carry a poor prognosis. There is a lack of data on outcomes associated with referral patterns in CKD patients from northern India. Methods In this observational cohort study, all CKD patients who visited the nephrology OPD of the institute between Nov 1, 2018, and Dec 31, 2020, were classified as early referral (ER) if their first encounter with a nephrologist occurred more than one year before initiation of dialysis and education about dialysis (from a nurse or nephrologist). The remaining others were considered late referrals (LRs). The outcomes impact of early and late referrals was analyzed. Results A total of 992 (male 656) CKD patients (ER, n = 475 and LR, n = 517) were enrolled. Patients referred early were older and diabetic and had higher BMI, better education, occupation, and socioeconomic status as compared to those referred late. The mean eGFR at first contact with the nephrologist was (25.4 ± 11.5 ml/min) in ER and 9.6 ± 5.7 ml/min in the LR group and had a higher comorbidity score. The CKD-MBD parameters, hemoglobin, and nutritional parameters were worse in LR. Only a few patients had AVF, and the majority required emergency dialysis in the LR group. A total of 91 (9.2%) patients died, 17 (1.7% ER and 74 (7.5%) patients in the LR group patients. There was significantly lower survival at 6 months (ER 97.1% vs. LR 89.7%), 12 months (ER 96.4% vs. LR 85.7%), 18 months (ER 96.4% vs. LR 85.7%), and 24 months (ER 96.4% vs. LR 85.7%) in late referral group as compared to early referral group (P=0.005). Conclusions LR to nephrologists has the risk of the emergency start of dialysis with temporary vascular access and had a higher risk of mortality. The timely referral to the nephrologist in the predialysis stage is associated with better survival and reduced mortality.
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Affiliation(s)
- Manoj Dhanorkar
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ravi Kushwaha
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Manas Behera
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Dharmendra Bhaduaria
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Monika Yaccha
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Manas Patel
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anupama Kaul
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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12
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Martin KE, Thomas BS, Greenberg KI. The expanding role of primary care providers in care of individuals with kidney disease. J Natl Med Assoc 2022; 114:S10-S19. [DOI: 10.1016/j.jnma.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Ghimire A, Sultana N, Ye F, Hamonic LN, Grill AK, Singer A, Akbari A, Braam B, Collister D, Jindal K, Courtney M, Shah N, Ronksley PE, Shurraw S, Brimble KS, Klarenbach S, Chou S, Shojai S, Deved V, Wong A, Okpechi I, Bello AK. Impact of quality improvement initiatives to improve CKD referral patterns: a systematic review protocol. BMJ Open 2022; 12:e055456. [PMID: 35450902 PMCID: PMC9024271 DOI: 10.1136/bmjopen-2021-055456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) is a global-health problem. A significant proportion of referrals to nephrologists for CKD management are early and guideline-discordant, which may lead to an excess number of referrals and increased wait-times. Various initiatives have been tested to increase the proportion of guideline-concordant referrals and decrease wait times. This paper describes the protocol for a systematic review to study the impacts of quality improvement initiatives aimed at decreasing the number of non-guideline concordant referrals, increasing the number of guideline-concordant referrals and decreasing wait times for patients to access a nephrologist. METHODS AND ANALYSIS We developed this protocol by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols (2015). We will search the following empirical electronic databases: MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, PsycINFO and grey literature for studies designed to improve guideline-concordant referrals or to reduce unnecessary referrals of patients with CKD from primary care to nephrology. Our search will include all studies published from database inception to April 2021 with no language restrictions. The studies will be limited to referrals for adult patients to nephrologists. Referrals of patients with CKD from non-nephrology specialists (eg, general internal medicine) will be excluded. ETHICS AND DISSEMINATION Ethics approval will not be required, as we will analyse data from studies that have already been published and are publicly accessible. We will share our findings using traditional approaches, including scientific presentations, open access peer-reviewed platforms, and appropriate government and public health agencies. PROSPERO REGISTRATION NUMBER CRD42021247756.
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Affiliation(s)
- Anukul Ghimire
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Naima Sultana
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Feng Ye
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Laura N Hamonic
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Allan K Grill
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alexander Singer
- Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ayub Akbari
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Branko Braam
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David Collister
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kailash Jindal
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Mark Courtney
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nikhil Shah
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Paul E Ronksley
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sabin Shurraw
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Scott Klarenbach
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sophia Chou
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Soroush Shojai
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Vinay Deved
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew Wong
- Callingwood Medical Center, Edmonton, Alberta, Canada
| | - Ikechi Okpechi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - A K Bello
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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14
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Heaf J, Heiro M, Petersons A, Vernere B, Povlsen JV, Sørensen AB, Clyne N, Bumblyte I, Zilinskiene A, Randers E, Løkkegaard N, Ots-Rosenberg M, Kjellevold S, Kampmann JD, Rogland B, Lagreid I, Heimburger O, Lindholm B. Choice of dialysis modality among patients initiating dialysis: results of the Peridialysis study. Clin Kidney J 2021; 14:2064-2074. [PMID: 34476093 PMCID: PMC8406075 DOI: 10.1093/ckj/sfaa260] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/30/2020] [Indexed: 12/16/2022] Open
Abstract
Background In patients with end-stage kidney disease (ESKD), home dialysis offers socio-economic and health benefits compared with in-centre dialysis but is generally underutilized. We hypothesized that the pre-dialysis course and institutional factors affect the choice of dialysis modality after dialysis initiation (DI). Methods The Peridialysis study is a multinational, multicentre prospective observational study assessing the causes and timing of DI and consequences of suboptimal DI. Clinical and biochemical data, details of the pre-dialytic course, reasons for DI and causes of the choice of dialysis modality were registered. Results Among 1587 included patients, 516 (32.5%) were judged unsuitable for home dialysis due to contraindications [384 ( 24.2%)] or no assessment [106 (6.7%); mainly due to late referral and/or suboptimal DI] or death [26 (1.6%)]. Older age, comorbidity, late referral, suboptimal DI, acute illness and rapid loss of renal function associated with unsuitability. Of the remaining 1071 patients, 700 (65.4%) chose peritoneal dialysis (61.7%) or home haemodialysis (HD; 3.6%), while 371 (34.6%) chose in-centre HD. Somatic differences between patients choosing home dialysis and in-centre dialysis were minor; factors linked to the choice of in-centre dialysis were late referral, suboptimal DI, acute illness and absence of a ‘home dialysis first’ institutional policy. Conclusions Given a personal choice with shared decision making, 65.4% of ESKD patients choose home dialysis. Our data indicate that the incidence of home dialysis potentially could be further increased to reduce the incidence of late referral and unplanned DI and, in acutely ill patients, by implementing an educational programme after improvement of their clinical condition.
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Affiliation(s)
- James Heaf
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark.,Department of Nephrology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Maija Heiro
- Department of Medicine, Turku University Hospital, Turku, Finland
| | - Aivars Petersons
- Latvia Nephrology Department, P. Stradins University Hospital, Riga, Latvia
| | - Baiba Vernere
- Latvia Nephrology Department, P. Stradins University Hospital, Riga, Latvia
| | - Johan V Povlsen
- Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Naomi Clyne
- Department of Nephrology, Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Inge Bumblyte
- Nephrological Clinic, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Alanta Zilinskiene
- Nephrological Clinic, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Else Randers
- Department of Medicine, Viborg Regional Hospital, Viborg, Denmark
| | | | - Mai Ots-Rosenberg
- Department of Nephrology, University Hospital of Tartu, Tartu, Estonia
| | | | | | - Björn Rogland
- Department of Medicine, Kristianstad Hospital, Kristianstad, Sweden
| | - Inger Lagreid
- Department of Medicine, St Olav University Hospital, Trondheim, Norway
| | - Olof Heimburger
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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15
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Chen JHC, Brown MA, Jose M, Brennan F, Johnson DW, Roberts MA, Wong G, Cheikh Hassan H, Kennard A, Walker R, Davies CE, Boudville N, Borlace M, Hawley C, Lim WH. Temporal changes and risk factors of death from early withdrawal within 12 months of dialysis initiation - a cohort study. Nephrol Dial Transplant 2021; 37:760-769. [PMID: 34175956 PMCID: PMC8951200 DOI: 10.1093/ndt/gfab207] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Indexed: 11/16/2022] Open
Abstract
Background Mortality risk is high soon after dialysis initiation in patients with kidney failure, and dialysis withdrawal is a major cause of early mortality, attributed to psychosocial or medical reasons. The temporal trends and risk factors associated with cause-specific early dialysis withdrawal within 12 months of dialysis initiation remain uncertain. Methods Using data from the Australia and New Zealand Dialysis and Transplant Registry, we examined the temporal trends and risk factors associated with mortality attributed to early psychosocial and medical withdrawals in incident adult dialysis patients in Australia between 2005 and 2018 using adjusted competing risk analyses. Results Of 32 274 incident dialysis patients, 3390 (11%) experienced death within 12 months post-dialysis initiation. Of these, 1225 (36%) were attributed to dialysis withdrawal, with 484 (14%) psychosocial withdrawals and 741 (22%) medical withdrawals. These patterns remained unchanged over the past two decades. Factors associated with increased risk of death from early psychosocial and medical withdrawals were older age, dialysis via central venous catheter, late referral and the presence of cerebrovascular disease; obesity and Asian ethnicity were associated with decreased risk. Risk factors associated with early psychosocial withdrawals were underweight and higher socioeconomic status. Presence of peripheral vascular disease, chronic lung disease and cancers were associated with early medical withdrawals. Conclusions Death from dialysis withdrawal accounted for >30% of early deaths in kidney failure patients initiated on dialysis and remained unchanged over the past two decades. Several shared risk factors were observed between mortality attributed to early psychosocial and medical withdrawals.
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Affiliation(s)
- Jenny H C Chen
- School of Medicine, University of Wollongong, Wollongong, Australia
- Depatment of Renal Medicine, Wollongong Hospital, Wollongong, Australia
- Correspondence to: Jenny H.C. Chen; E-mail:
| | - Mark A Brown
- Department of Nephrology, St George Hospital, Sydney, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - Matthew Jose
- School of Medicine, The University of Tasmania, Hobart, Australia
- Department of Nephrology, Royal Hobart Hospital, Hobart, Australia
| | - Frank Brennan
- Department of Nephrology, St George Hospital, Sydney, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Centre for Health Services Research, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- Australasian Kidney Trials Network, Brisbane, Australia
| | - Matthew A Roberts
- School of Medicine, Monash University, Melbourne, Australia
- Renal Service, Eastern Health, Melbourne, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
| | - Hicham Cheikh Hassan
- School of Medicine, University of Wollongong, Wollongong, Australia
- Depatment of Renal Medicine, Wollongong Hospital, Wollongong, Australia
| | - Alice Kennard
- School of Medicine, Australian National University, Canberra, Australia
- Department of Nephrology, Canberra Hospital, Canberra, Australia
| | - Rachael Walker
- Sydney School of Public Health, University of Sydney, Sydney, Australia
- School of Nursing, Eastern Institute of Technology, Napier, New Zealand
| | - Christopher E Davies
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Neil Boudville
- Medical School, University of Western Australia, Perth, Australia
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Monique Borlace
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Carmel Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
- Centre for Health Services Research, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- Australasian Kidney Trials Network, Brisbane, Australia
| | - Wai H Lim
- Medical School, University of Western Australia, Perth, Australia
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
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16
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Li PKT, Chan GCK, Chen J, Chen HC, Cheng YL, Fan SLS, He JC, Hu W, Lim WH, Pei Y, Teo BW, Zhang P, Yu X, Liu ZH. Tackling Dialysis Burden around the World: A Global Challenge. KIDNEY DISEASES (BASEL, SWITZERLAND) 2021; 7:167-175. [PMID: 34179112 PMCID: PMC8215964 DOI: 10.1159/000515541] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/26/2021] [Indexed: 11/19/2022]
Abstract
CKD is a global problem that causes significant burden to the healthcare system and the economy in addition to its impact on morbidity and mortality of patients. Around the world, in both developing and developed economies, the nephrologists and governments face the challenges of the need to provide a quality and cost-effective kidney replacement therapy for CKD patients when their kidneys fail. In December 2019, the 3rd International Congress of Chinese Nephrologists was held in Nanjing, China, and in the meeting, a symposium and roundtable discussion on how to deal with this CKD burden was held with opinion leaders from countries and regions around the world, including Australia, Canada, China, Hong Kong, Singapore, Taiwan, the UK, and the USA. The participants concluded that an integrated approach with early detection of CKD, prompt treatment to slow down progression, promotion of home-based dialysis therapy like peritoneal dialysis and home HD, together with promotion of kidney transplantation, are possible effective ways to combat this ongoing worldwide challenge.
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Affiliation(s)
- Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Carol and Richard Yu Peritoneal Dialysis Research Centre, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Gordon Chun-Kau Chan
- Department of Medicine and Therapeutics, Carol and Richard Yu Peritoneal Dialysis Research Centre, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Jianghua Chen
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hung-Chun Chen
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yuk-Lun Cheng
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong, China
| | - Stanley L.-S. Fan
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, United Kingdom
| | - John Cijiang He
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Weixin Hu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Wai-Hon Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Washington, Australia
| | - York Pei
- Department of Medicine, University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Boon Wee Teo
- Division of Nephrology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ping Zhang
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xueqing Yu
- Department of Nephrology, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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17
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Abstract
Kidney transplantation is the ideal treatment option for patients with end-stage kidney disease (ESKD). Since there is clear mortality benefit to receiving a transplant regardless of comorbidities and age, the gold standard of care should focus on attaining kidney transplantation and minimizing, or better yet eliminating, time on dialysis. Unfortunately, only a small percentage of patients with ESKD receive a kidney transplant. Several barriers to kidney transplantation have been identified. Barriers can largely be grouped into three categories: patient-related, physician/provider-related, and system-related. Several barriers fall into multiple categories and play a role at various levels within the healthcare system. Acknowledging and understanding these barriers will allow transplant centers and dialysis facilities to make the necessary interventions to mitigate these disparities, optimize the transplant evaluation process, and improve patient outcomes. This review will discuss these barriers and potential interventions to increase access to kidney transplantation.
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18
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Xiang J, Morgenstern H, Li Y, Steffick D, Bragg-Gresham J, Panapasa S, Raphael KL, Robinson BM, Herman WH, Saran R. Incidence of ESKD Among Native Hawaiians and Pacific Islanders Living in the 50 US States and Pacific Island Territories. Am J Kidney Dis 2020; 76:340-349.e1. [DOI: 10.1053/j.ajkd.2020.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 01/12/2020] [Indexed: 11/11/2022]
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19
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Duration of predialysis nephrological care and mortality after dialysis initiation. Clin Exp Nephrol 2020; 24:705-714. [DOI: 10.1007/s10157-020-01889-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 02/28/2020] [Indexed: 11/26/2022]
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20
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Hicks CW, Wang P, Kernodle A, Lum YW, Black JH, Makary MA. Assessment of Use of Arteriovenous Graft vs Arteriovenous Fistula for First-time Permanent Hemodialysis Access. JAMA Surg 2020; 154:844-851. [PMID: 31188411 DOI: 10.1001/jamasurg.2019.1736] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Importance Initial hemodialysis access with arteriovenous fistula (AVF) is associated with superior clinical outcomes compared with arteriovenous graft (AVG) and should be the procedure of choice whenever possible. To address the national underuse of AVF in the United States, the Centers for Medicare & Medicaid has established an AVF goal of 66% or greater in 2009. Objective To explore contemporary practice patterns and physician characteristics associated with high AVG use compared with AVF use. Design, Setting, and Participants This review of 100% Medicare Carrier claims between January 1, 2016, and December 31, 2017, includes both inpatient and outpatient Medicare claims data. All patients undergoing initial permanent hemodialysis access placement with an AVF or AVG were included. All surgeons performing more than 10 hemodialysis access procedures during the study period were analyzed. Exposures Placement of an AVF or AVG for initial permanent hemodialysis access. Main Outcomes and Measures A surgeon-level AVG (vs AVF) use rate was calculated for all included surgeons. Hierarchical logistic regression modeling was used to identify patient-level and surgeon-level factors associated with AVG use. Results A total of 85 320 patients (median age, 70 [range, 18-103] years; 47 370 men [55.5%]) underwent first-time hemodialysis access placement, of whom 66 489 (77.9%) had an AVF and 18 831 (22.1%) had an AVG. Among the 2397 surgeons who performed more than 10 procedures per year, the median surgeon level AVG use rate was 18.2% (range, 0.0%-96.4%). However, 498 surgeons (20.8%) had an AVG use rate greater than 34%. After accounting for patient characteristics, surgeon factors that were independently associated with AVG use included more than 30 years of clinical practice (vs 21-30 years; odds ratio, 0.85 [95% CI, 0.75-0.96]), metropolitan setting (odds ratio, 1.25 [95% CI, 1.02-1.54]), and vascular surgery specialty (vs general surgery; odds ratio, 0.77 [95% CI, 0.69-0.86]). Surgeons in the Northeast region had the lowest rate of AVG use (vs the South; odds ratio, 0.83 [95% CI, 0.73-0.96]). First-time hemodialysis access benchmarking reports for individual surgeons were created for potential distribution. Conclusions and Relevance In this study, one-fifth of surgeons had an AVG use rate above the recommended best practices guideline of 34%. Although some of these differences may be explained by patient referral practices, sharing benchmarked performance data with surgeons could be an actionable step in achieving more high-value care in hemodialysis access surgery.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peiqi Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amber Kernodle
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ying W Lum
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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21
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Awan AA, Zhao B, Anumudu SJ, Winkelmayer WC, Ho V, Erickson KF. Pre-ESKD Nephrology Care and Employment at the Start of Dialysis. Kidney Int Rep 2020; 5:821-830. [PMID: 32518864 PMCID: PMC7270719 DOI: 10.1016/j.ekir.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/12/2020] [Accepted: 03/02/2020] [Indexed: 01/05/2023] Open
Abstract
Introduction Employment is associated with an improved sense of well-being and quality of life in patients with kidney disease. Earlier nephrology referral and longer duration of pre-end-stage kidney disease (ESKD) nephrology care are associated with improved health outcomes in patients with advanced kidney disease who initiate dialysis. It is unknown if pre-ESKD nephrology care helps patients stay employed leading up to dialysis initiation. Methods We used the US ESKD registry to identify adults aged 18-54 years who initiated dialysis between 2007 and 2014. Analyses were restricted to patients who reported being employed 6 months prior to ESKD. We used multivariable regression models with estimated average marginal effects to examine the independent association between ≥6 months of pre-ESKD nephrology care and employment at dialysis initiation. To reduce bias, we conducted an instrumental variable (IV) analysis based on geographic variation in pre-ESKD care. Results Of 75,700 patients included in study cohort, 49% reported receiving pre-ESKD nephrology care for ≥6 months, and 62% were employed at dialysis initiation. Although geographic variation in pre-ESKD nephrology care was strongly associated with the likelihood that working-aged patients in our analytic cohort received pre-ESKD care, the receipt of pre-ESKD nephrology care was not significantly associated with employment at dialysis initiation; estimated probability: 5%; 95% confidence interval (CI) -6% to 14%. Conclusions Pre-ESKD nephrology care 6 months prior to initiation of dialysis is not associated with the likelihood of remaining employed at the initiation of dialysis. Although nephrology care has potential to help patients remain employed, this benefit is not manifested in current practice.
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Affiliation(s)
- Ahmed A. Awan
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
- Correspondence: Ahmed A. Awan, Baylor College of Medicine, 7200 Cambridge Street, Suite 8B, MS: BCM902, Houston, Texas 77030, USA.
| | - Bo Zhao
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Samaya J. Anumudu
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Wolfgang C. Winkelmayer
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Vivian Ho
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston Texas, USA
- Baker Institute for Public Policy, Rice University, Houston, Texas, USA
| | - Kevin F. Erickson
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston Texas, USA
- Baker Institute for Public Policy, Rice University, Houston, Texas, USA
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22
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Marrón B, Ocaña JCM, Salgueira M, Barril G, Lamas JM, Martín M, Sierra T, Rodríguez–Carmona A, Soldevilla A, Martínez F, Castellano I, de Alcántara SP, González J, Jiménez JR, Moll R, Balius A, Coronel F, Herrero JA, Gago E, Arias R, Galindo P, Goyanes G, Ranero R, Gimeno I, Mardaras J, Ortega O, Munar MA, Solozabal C, Alonso JC, de Sequera P, Vega N, Sanz P, de Palma A, de la Macarena V. Analysis of Patient Flow into Dialysis: Role of Education in Choice of Dialysis Modality. Perit Dial Int 2020. [DOI: 10.1177/089686080502503s14] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
♦ Background Despite advances in predialysis care, morbidity and mortality remain high. ♦ Objectives To analyze end-stage renal disease (ESRD) patient demographics and clinical data on education on dialysis treatment options, type of chronic renal replacement therapy (RRT), and effects of planned versus non-planned dialysis start. ♦ Methods 621 patients, from 24 Spanish hospitals, who started RRT in 2002. Peritoneal or vascular access at dialysis initiation was considered “planned.” ♦ Results 304 (49%) patients were non-planned and half of them had prior nephrology follow-up. Of the patients with ≥3 months nephrology follow-up (76% of all), only half were educated on dialysis modalities. Dialysis education was associated with planned start in 73.4% versus 26% in non-educated patients ( p < 0.05), shorter follow-up (55 vs 65 months, p = 0.033), more medical visits in the prior year (6.5 vs 4.4, * p < 0.001), more patients starting peritoneal dialysis (31% vs 8.3%*), and more specific follow-up by ESRD unit versus general nephrology care (63% vs 26%*). Non-planned start was associated with older age (63 vs 60.6 years, p = 0.06), fewer medical visits (4.6 vs 6.4*), less education about modality options, and greater use of hemodialysis (92% vs 75%*). Planned patients had better biochemical parameters at start of dialysis. ♦ Conclusion Despite nephrology follow-up, half the patients did not have a planned dialysis start. Planned start was associated with better clinical status. More patients chose peritoneal dialysis when educated about dialysis modality options. ESRD-specific units were more likely to provide patient education.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Rosa Moll
- General de Valencia Hospital, Valencia
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23
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Shiao CC, Huang JW, Chien KL, Chuang HF, Chen YM, Wu KD. Early Initiation of Dialysis and Late Implantation of Catheters Adversely Affect Outcomes of Patients on Chronic Peritoneal Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686080802800113] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
ObjectivesPredialysis nephrology care is thought to affect morbidity and mortality in hemodialysis patients. This study evaluated the impact of different patterns of predialysis care on outcomes of patients undergoing chronic peritoneal dialysis (PD).DesignRetrospective cohort.Setting and Participants275 patients enrolled from January 1997 to March 2005 in a medical center in North Taiwan who recently initiated dialysis were classified according to early or late referral to nephrologists (≥ 6 or <6 months of dialysis), planned or late implantation of Tenckhoff catheters (absence or presence of preceding emergent hemodialysis), and early or late start of dialysis [glomerular filtration rate (GFR) ≥ 5 or <5 mL/minute/1.73 m2].Main Outcome MeasuresAll-cause mortality and hospitalization.ResultsDuring a median follow-up of 2.5 years, 41 deaths, 38 transfers to hemodialysis, and 26 renal transplantations occurred. Late start of dialysis was associated with a significant survival benefit (log rank, p = 0.012) and, along with planned implantation of catheters, exhibited a reduced risk for all-cause hospitalization (log rank, p = 0.025, 0.013). The predictors of overall mortality included baseline GFR [hazard ratio (HR) 1.18, p = 0.023], age (HR 1.07, p < 0.001), and diabetes (HR 3.64, p = 0.001); whereas the risk factors for all-cause hospitalization included age (HR 1.02, p = 0.012), late implantation of catheters (HR 1.78, p = 0.011), and diabetes (HR 1.92, p = 0.005). The timing of nephrology referral did not affect either death or hospitalization.ConclusionsOur data do not support earlier initiation of PD, but underscore the importance of planned implantation of catheters before commencement of chronic PD.
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Affiliation(s)
- Chih-Chung Shiao
- Renal Division, Department of Internal Medicine, St. Mary's Hospital, Lo Tung
| | - Jenq-Wen Huang
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University
| | - Kuo-Liong Chien
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University
| | - Hsueh-Fang Chuang
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Yung-Ming Chen
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University
| | - Kwan-Dun Wu
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University
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24
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Oreopoulos DG, Coleman S, Doyle E. Reversing the Decreasing Peritoneal Dialysis (PD) Trend in Ontario: A Government Initiative to Increase PD Use in Ontario to 30% by 2010. Perit Dial Int 2020. [DOI: 10.1177/089686080702700503] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In September 2005, the Ontario Ministry of Health and Long-Term Care established the Provincial PD Coordinating Committee to make recommendations to increase the use of PD among prevalent dialysis patients in Ontario from the present 18% to 30% by 2010. In the present paper, we describe the process through which the Committee produced its recommendations and we highlight the proposed implementation plan.
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Affiliation(s)
| | | | - Ethel Doyle
- Priority Services Unit, Ministry of Health and Long-Term Care, Toronto, Ontario, Canada
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25
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Marie Patrice H, Joiven N, Hermine F, Jean Yves B, Folefack François K, Enow Gloria A. Factors associated with late presentation of patients with chronic kidney disease in nephrology consultation in Cameroon-a descriptive cross-sectional study. Ren Fail 2019; 41:384-392. [PMID: 31106687 PMCID: PMC6534206 DOI: 10.1080/0886022x.2019.1595644] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Late presentation (LP) of chronic kidney disease (CKD) patients to nephrologist is a serious problem worldwide with persistent high prevalence despite known benefits of early nephrology care. OBJECTIVE Determine the prevalence and factors associated with LP of CKD patients to nephrologists in Cameroon. METHODS A cross-sectional study from October 2015 to May 2016 at the nephrology units of the Douala General and Laquintinie hospitals, including all consenting incident CKD patients. Data collected were: socio-demographic, search of CKD diagnostic criteria during prior follow up, therapeutic itinerary, clinical and biological parameters at presentation, knowledge on CKD and attitude towards dialysis. LP was defined as eGFR < 30 ml/min/1.73 m2. It was physician-related whenever no CKD screening was done in the presence of risk factor or no referral to nephrologists at early stages; patient-related whenever patients did not have recourse to hospital care while symptomatic or disrespected a referral decision. p value <.05. RESULTS We included 130 patients, mean age 53.10 ± 14.66 years, 60.77% males, 58.70% were referred by internal medicine physicians and 10% had recourse to complementary and alternative medicine (CAM). At presentation, 70.80% were symptomatic, 53% had CKD stage five, 86.12% were poorly graded on knowledge and 49% had a negative attitude towards dialysis. The prevalence of LP was 73.90%, 50% was physician-related, 44.79% patient-related and 5.21% both. Being accompanied (p = .038), a low level of education (p = .025) and recourse to CAM (p = .008) were associated with LP. CONCLUSION LP is high in Cameroon, attributed to physician's practical attitudes and patient's socio-cultural behaviors and economic conditions.
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Affiliation(s)
- Halle Marie Patrice
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
- Department of Internal Medicine, Douala General Hospital, Douala, Cameroon
| | - Nyongbella Joiven
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | - Fouda Hermine
- Department of Internal Medicine, Douala General Hospital, Douala, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Douala, Cameroon
| | - Balepna Jean Yves
- Department of Internal Medicine, Douala Laquintinie Hospital, Douala, Cameroon
| | | | - Ashuntantang Enow Gloria
- Faculty of Medicine and Biomedical sciences, Yaoundé General Hospital Cameroon, Douala, Cameroon
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26
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Lim WH, Johnson DW, McDonald SP, Hawley C, Clayton PA, Jose MD, Wong G. Impending challenges of the burden of end-stage kidney disease in Australia. Med J Aust 2019; 211:374-380.e3. [PMID: 31595516 DOI: 10.5694/mja2.50354] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Sex and age-specific incidence rates of patients with treated end-stage kidney disease (ESKD) in Australia are comparable to those in European countries, but substantially lower compared with those in the United States, Canada and many Asian countries. The incidence rates of treated ESKD in Australia increase with advancing age; however, the incidence of ESKD is likely to be underestimated because a proportion of patients with ESKD (about 50%) remain untreated. Late referral to nephrologists has reduced over the past decade, temporally associated with improved ESKD recognition. However, late referral still occurs in one in five Australians with ESKD. One in two Australians with ESKD has diabetes, with up to 35% of cases directly attributed to diabetes. Mortality rates for patients with ESKD remain substantially higher compared with the age-matched general population, although there has been a significant improvement in survival over time. Cardiovascular disease and cancer are the two most common causes of death in patients with ESKD.
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Affiliation(s)
- Wai H Lim
- Sir Charles Gairdner Hospital, Perth, WA
| | - David W Johnson
- Princess Alexandra Hospital, Brisbane, QLD.,Centre for Health Services Research, University of Queensland, Brisbane, QLD
| | - Stephen P McDonald
- South Australian Health and Medical Research Institute, ANZDATA Registry, Adelaide, SA.,University of Adelaide, Adelaide, SA
| | - Carmel Hawley
- Princess Alexandra Hospital, Brisbane, QLD.,Centre for Health Services Research, University of Queensland, Brisbane, QLD
| | - Philip A Clayton
- South Australian Health and Medical Research Institute, ANZDATA Registry, Adelaide, SA
| | - Matthew D Jose
- University of Tasmania, Hobart, TAS.,Royal Hobart Hospital, Hobart, TAS
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27
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Huml AM, Sehgal AR. Hemodialysis Quality Metrics in the First Year Following a Failed Kidney Transplant. Am J Nephrol 2019; 50:161-167. [PMID: 31311008 DOI: 10.1159/000501605] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/17/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Failure of a previously transplanted kidney is a common cause of end-stage renal disease (ESRD) and represents 5% of incident dialysis patients in the United States. Patients with native kidney failure ESRD (Nat-ESRD) who receive predialysis care from a nephrologist have better outcomes in the first 12 months on dialysis than those who don't. Because many patients with a failed kidney transplant ESRD (Tx-ESRD) receive care from nephrologists, they would also be expected to have good dialysis outcomes. We sought to compare the quality metrics of Tx-ESRD patients and Nat-ESRD patients during the first 12 months of hemodialysis. METHODS We used data from the United States Renal Data System to identify hemodialysis patients who began treatment between May 2012 and December 2013 and who received nephrology care prior to starting hemodialysis. Quality metrics by quarter for the first 12 months of treatment were dichotomized according to practice guidelines to determine the percentage of patients in each quarter who met quality of care goals. RESULTS Compared to Nat-ESRD (n = 96,063) patients, Tx-ESRD (n = 5,528) patients had 10-19% lower rates of at goal hemoglobin levels, 6-12% lower rates of at goal serum phosphorus, and 3-11% lower rates of at goal albumin levels. Compared to Nat-ESRD patients, -Tx-ESRD patients had a 6% higher rate of fistula use in the first quarter but a 3-7% lower rate in subsequent quarters. CONCLUSIONS Tx-ESRD patients have worse quality metrics related to anemia, phosphorus, albumin, and vascular access compared to Nat-ESRD patients. Nephrology care for patients with Tx-ESRD should be improved to address these quality metrics gaps.
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Affiliation(s)
- Anne M Huml
- Center for Reducing Health Disparities, Case Western Reserve University, Cleveland, Ohio, USA,
- Division of Nephrology, Department of Medicine, Metro Health Medical Center, Cleveland, Ohio, USA,
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA,
| | - Ashwini R Sehgal
- Center for Reducing Health Disparities, Case Western Reserve University, Cleveland, Ohio, USA
- Division of Nephrology, Department of Medicine, Metro Health Medical Center, Cleveland, Ohio, USA
- Department of Epidemiology and Biostatistics, Case Western Reserve University Cleveland, Cleveland, Ohio, USA
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28
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Chen YY, Chen L, Huang JW, Yang JY. Effects of Early Frequent Nephrology Care on Emergency Department Visits among Patients with End-stage Renal Disease. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E1158. [PMID: 30935119 PMCID: PMC6479768 DOI: 10.3390/ijerph16071158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 03/27/2019] [Accepted: 03/28/2019] [Indexed: 11/16/2022]
Abstract
In this retrospective cohort study, we examined the association between predialysis nephrology care status and emergency department (ED) events among patients with end-stage renal disease. Data pertaining to 76,702 patients who began dialysis treatment between 1999 and 2010 were obtained from the National Health Insurance Research Database of Taiwan (NHIRD). The patients were divided into three groups based on the timing of the first nephrology care visit prior to the initiation of maintenance dialysis, and the frequency of nephrologist visits (i.e., early referral/frequent consultation, early referral/infrequent consultation, late referral). At 1-year post-dialysis initiation, a large number of the patients had experienced at least one all-cause ED visit (58%), infection-related ED visit (17%), or potentially avoidable ED visit (7%). Cox proportional hazard models revealed that patients who received early frequent care faced an 8% lower risk of all-cause ED visit (HR: 0.92; 95% CI: 0.90⁻0.94), a 24% lower risk of infection-related ED visit (HR: 0.76; 95% CI: 0.73⁻0.79), and a 24% lower risk of avoidable ED visit (HR: 0.76; 95% CI: 0.71⁻0.81), compared with patients in the late referral group. With regard to the patients undergoing early infrequent consultations, the only marginally significant association was for infection-related ED visits. Recurrent event analysis revealed generally consistent results. Overall, these findings indicate that continuous nephrology care from early in the predialysis period could reduce the risk of ED utilization in the first year of dialysis treatment.
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Affiliation(s)
- Yun-Yi Chen
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei 100, Taiwan.
| | - Likwang Chen
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan 350, Taiwan.
| | - Jenq-Wen Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan.
| | - Ju-Yeh Yang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei 100, Taiwan.
- Division of Nephrology, Far Eastern Memorial Hospital, New Taipei City 220, Taiwan.
- Department of Quality Management Center, Far Eastern Memorial Hospital, New Taipei City 220, Taiwan.
- Lee-Ming Institute of Technology, New Taipei City 243, Taiwan.
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29
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Abstract
In the statistical analysis of observational data, propensity score is a technique that attempts to estimate the effect of a treatment (exposure) by accounting for the covariates that predict receiving the treatment (exposure). The aim of this paper is to provide a brief guide for clinicians and researchers who are applying propensity score analysis as a tool for analyzing observational data. We reviewed literature about how, when and why propensity score is used and then we discussed some important practical issues in using propensity score in observational studies. Appling propensity score as a method for analyzing observational studies is very useful but, we should know when and how we can use this method. Moreover, new methods of propensity score analysis such as Bayesian and doubly robust approaches were established in recent years, and these methods could be more useful for researchers in estimating causal effect from observational studies.
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30
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Bello BT, Ojo OE, Oguntunde OF, Adegboye AA. Chronic kidney disease in the emergency centre: A prospective observational study. Afr J Emerg Med 2018; 8:134-139. [PMID: 30534516 PMCID: PMC6277533 DOI: 10.1016/j.afjem.2018.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 11/19/2017] [Accepted: 05/10/2018] [Indexed: 12/02/2022] Open
Abstract
Introduction Late presentation, usually to the emergency centre (EC), is frequently reported among patients with chronic kidney disease (CKD) in resource-limited settings, and is known to be associated with poor outcomes. This study aims to describe the pattern of EC presentation of adults with CKD in Southwest Nigeria. Methods This was a prospective observational study of 158 consecutively presenting CKD patients at the EC of two tertiary hospitals in Southwest Nigeria. Patients 18 years of age or older who were admitted into the EC at either study site with an admitting diagnosis of CKD and who consented to participate in the study were recruited. Socio-demographic characteristics, primary reason(s) for admission into the EC, requirement for dialysis, as well as the indication for dialysis were documented. The patients were followed-up for the duration of their stay in the EC and the outcome of EC admission documented. Results Overall, 54 (34.2%) were females, median age was 49 years and 74.1% were not known to have CKD prior to EC admission. The commonest indications for admission into the EC were uraemia, sepsis and hypertensive crisis, with 73.4% of the patients having at least one indication for dialysis at EC admission. The commonest indications for dialysis were uraemia, marked azotaemia and acute pulmonary oedema. The median time to first session of dialysis was 48 h and 24.1% of patients who required dialysis were not dialysed. Death during the period of EC admission occurred in 14 (8.9%) patients all of whom were not previously known to have CKD. Discussion There is a large pool of undiagnosed CKD among the general population. In many of these, the diagnosis will likely be made only when they present to the EC with complications. Late diagnosis is associated with worse outcomes.
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31
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Hsiao LL. Raising awareness, screening and prevention of chronic kidney disease: It takes more than a village. Nephrology (Carlton) 2018; 23 Suppl 4:107-111. [DOI: 10.1111/nep.13459] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Li-Li Hsiao
- Renal Division, Brigham and Women’s Hospital; Harvard Medical School; Boston Massachusetts USA
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32
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Bowman B, Zheng S, Yang A, Schiller B, Morfín JA, Seek M, Lockridge RS. Improving Incident ESRD Care Via a Transitional Care Unit. Am J Kidney Dis 2018; 72:278-283. [DOI: 10.1053/j.ajkd.2018.01.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 01/07/2018] [Indexed: 11/11/2022]
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33
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Liu P, Quinn RR, Oliver MJ, Ronksley PE, Hemmelgarn BR, Quan H, Hiremath S, Bello AK, Blake PG, Garg AX, Johnson J, Verrelli M, Zacharias JM, Abd ElHafeez S, Tonelli M, Ravani P. Association between Duration of Predialysis Care and Mortality after Dialysis Start. Clin J Am Soc Nephrol 2018; 13:893-899. [PMID: 29507006 PMCID: PMC5989670 DOI: 10.2215/cjn.11951017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/27/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Early nephrology referral is recommended for people with CKD on the basis of observational studies showing that longer nephrology care before dialysis start (predialysis care) is associated with lower mortality after dialysis start. This association may be observed because predialysis care truly reduces mortality or because healthier people with an uncomplicated course of disease will have both longer predialysis care and lower risk for death. We examined whether the survival benefit of longer predialysis care exists after accounting for the potential confounding effect of disease course that may also be affected by predialysis care. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a retrospective cohort study and used data from 3152 adults with end stage kidney failure starting dialysis between 2004 and 2014 in five Canadian dialysis programs. We obtained duration of predialysis care from the earliest nephrology outpatient visit to dialysis start; markers of disease course, including inpatient or outpatient dialysis start and residual kidney function around dialysis start; and all-cause mortality after dialysis start. RESULTS The percentages of participants with 0, 1-119, 120-364, and ≥365 days of predialysis care were 23%, 8%, 10%, and 59%, respectively. When we ignored markers of disease course as in previous studies, longer predialysis care was associated with lower mortality (hazard ratio120-364 versus 0-119 days, 0.60; 95% confidence interval, 0.46 to 0.78]; hazard ratio≥365 versus 0-119 days, 0.60; 95% confidence interval, 0.51 to 0.71; standard Cox model adjusted for demographics and laboratory and clinical characteristics). When we additionally accounted for markers of disease course using the inverse probability of treatment weighted Cox model, this association was weaker and no longer significant (hazard ratio120-364 versus 0-119 days, 0.84; 95% confidence interval, 0.60 to 1.18; hazard ratio≥365 versus 0-119 days, 0.88; 95% confidence interval, 0.69 to 1.13). CONCLUSIONS The association between longer predialysis care and lower mortality after dialysis start is weaker and imprecise after accounting for patients' course of disease.
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Affiliation(s)
- Ping Liu
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Robert R. Quinn
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Matthew J. Oliver
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul E. Ronksley
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Hude Quan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Swapnil Hiremath
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Aminu K. Bello
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Peter G. Blake
- Division of Nephrology, Western University, London, Ontario, Canada
| | - Amit X. Garg
- Departments of Medicine, Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - John Johnson
- London Health Sciences Centre, London, Ontario, Canada
| | - Mauro Verrelli
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James M. Zacharias
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Samar Abd ElHafeez
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Epidemiology Department, High Institute of Public Health, Alexandria University, Egypt
| | - Marcello Tonelli
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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34
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Tangri N, Ferguson T, Komenda P. Pro: Risk scores for chronic kidney disease progression are robust, powerful and ready for implementation. Nephrol Dial Transplant 2018; 32:748-751. [PMID: 28499025 DOI: 10.1093/ndt/gfx067] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 03/21/2017] [Indexed: 12/28/2022] Open
Abstract
Accurate risk prediction for chronic kidney disease (CKD) progression can inform the patient-provider dialogue, and provide actionable thresholds for key clinical decisions. In 2011, we developed the kidney failure risk equations (KFREs) to predict the risk of kidney failure requiring dialysis or transplant in patients with CKD. Subsequently, the KFREs have been extensively validated, and have now been proven accurate in multiple continents, ethnicities and disease-specific subpopulations. They can discriminate progressors from non-progressors, and are well calibrated and easy to use. We believe that current and future studies should now focus on clinical implementation of the KFREs, through quality improvement initiatives and cluster randomized trials. A risk-based care paradigm for CKD care can be achieved through knowledge translation and implementation research.
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Affiliation(s)
- Navdeep Tangri
- Department of Medicine and Community Health Sciences, University of Manitoba, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Thomas Ferguson
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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35
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Pillado E, Korn A, De Virgilio C, Bowens N. The Burden of Tunneled Central Venous Catheters for Hemodialysis in a County Hospital. Am Surg 2017. [DOI: 10.1177/000313481708301016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Prolonged use of central venous catheters (CVCs) for hemodialysis (HD) is associated with greater morbidity and mortality when compared with autogenous arteriovenous fistulas (AVF). The objective was to assess compliance with CVC guidelines in adults referred for hemoaccess at a county teaching hospital. Out of 256 patients, 172 (67.2%) were male, with a mean age of 50.0 ± 12.4 years. Overall 62.5 per cent initiated dialysis via CVC. Patients were divided into two groups (those with CVC (62.5%) and those without (37.5%)). Male gender was associated with initiation of dialysis via CVC versus no CVC (72.5 vs 58.3%, P = 0.02), as was a history of prior vascular access (P < 0.01). There were no significant differences between the groups regarding age, diabetes, smoking, ambulatory status, or insurance status. There were no differences in gender, age, insurance status, or prior vascular access between prolonged CVC use (≥90 days) and short-term CVC use (<90 days). We conclude that most patients initiated HD with CVC and exceed the recommended CVC duration. Men are more likely to initiate HD via CVC. Insurance status was not associated with CVC use. Multidisciplinary action may address barriers to reducing CVC duration.
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Affiliation(s)
- Eric Pillado
- David Geffen School of Medicine at UCLA Dean's Leadership in Health and Science Scholarship, Torrance, California
| | - Abraham Korn
- Division of Vascular Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Christian De Virgilio
- Division of Vascular Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
- Division of Vascular Surgery, Department of Surgery, Los Angeles Biomedical Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Nina Bowens
- Division of Vascular Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
- Division of Vascular Surgery, Department of Surgery, Los Angeles Biomedical Institute at Harbor-UCLA Medical Center, Torrance, California
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Nee R, Fisher E, Yuan CM, Agodoa LY, Abbott KC. Pre-End-Stage Renal Disease Care and Early Survival among Incident Dialysis Patients in the US Military Health System. Am J Nephrol 2017; 45:464-472. [PMID: 28501861 DOI: 10.1159/000475767] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 03/12/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Previous reports showed an increased early mortality after chronic dialysis initiation among the end-stage renal disease (ESRD) population. We hypothesized that ESRD patients in the Military Health System (MHS) would have greater access to pre-ESRD care and hence better survival rates during this early high-risk period. METHODS In this retrospective cohort study, using the US Renal Data System database, we identified 1,256,640 patients initiated on chronic dialysis from January 2, 2004 through December 31, 2014, from which a bootstrap sample of 3,984 non-MHS incident dialysis patients were compared with 996 MHS patients. We assessed care by a nephrologist and dietitian, erythropoietin administration, and vascular access use at dialysis initiation as well as all-cause mortality as outcome variables. RESULTS MHS patients were significantly more likely to have had pre-ESRD nephrology care (adjusted OR [aOR] 2.9; 95% CI 2.3-3.7) and arteriovenous fistula used at dialysis initiation (aOR 2.2; 95% CI 1.7-2.7). Crude mortality rates peaked between the 4th and the 8th week for both cohorts but were reduced among MHS patients. The baseline adjusted Cox model showed significantly lower death rates among MHS vs. non-MHS patients at 6, 9, and 12 months. This survival advantage among MHS patients was attenuated after further adjustment for pre-ESRD nephrology care and dialysis vascular access. CONCLUSIONS MHS patients had improved survival within the first 12 months compared to the general ESRD population, which may be explained in part by differences in pre-ESRD nephrology care and vascular access types.
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Affiliation(s)
- Robert Nee
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA
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Nee R, Yuan CM, Hurst FP, Jindal RM, Agodoa LY, Abbott KC. Impact of poverty and race on pre-end-stage renal disease care among dialysis patients in the United States. Clin Kidney J 2016. [PMID: 28638604 PMCID: PMC5469551 DOI: 10.1093/ckj/sfw098] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Access to nephrology care prior to end-stage renal disease (ESRD) is significantly associated with lower rates of morbidity and mortality. We assessed the association of area-level and individual-level indicators of poverty and race/ethnicity on pre-ESRD care provided by nephrologists. Methods In this retrospective cohort study using the US Renal Data System database, we identified 739 537 patients initiated on maintenance dialysis from 1 January 2007 through 31 December 2012. We assessed the Medicare–Medicaid dual eligibility status as an indicator of individual-level poverty and ZIP code–level median household income (MHI) data obtained from the 2010 US census. We conducted multivariable logistic regression of pre-ESRD nephrology care as the outcome variable. Results Among patients in the lowest area-level MHI quintile, 61.28% received pre-ESRD nephrology care versus 67.68% among those in higher quintiles (P < 0.001). Similarly, the proportions of dual-eligible and nondual-eligible patients who had pre-ESRD nephrology care were 61.49 and 69.84%, respectively (P < 0.001). Patients in the lowest area-level MHI quintile were associated with significantly lower likelihood of pre-ESRD nephrology care (adjusted odds ratio [aOR] 0.86 [95% confidence interval (CI) 0.85–0.87]) compared with those in higher quintiles. Both African American (AA) and Hispanic patients were significantly less likely to have received pre-ESRD nephrology care [aOR 0.85 (95% CI 0.84–0.86) and aOR 0.72 (95% CI 0.71–0.74), respectively]. Conclusions Individual- and area-level measures of poverty, AA race and Hispanic ethnicity were independently associated with a lower likelihood of pre-ESRD nephrology care. Efforts to improve pre-ESRD nephrology care may require focusing on the poor and minority groups.
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Affiliation(s)
- Robert Nee
- Department of Nephrology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Christina M Yuan
- Department of Nephrology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Frank P Hurst
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Rahul M Jindal
- USU-Walter Reed Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Lawrence Y Agodoa
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Kevin C Abbott
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
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Norton JM, Moxey-Mims MM, Eggers PW, Narva AS, Star RA, Kimmel PL, Rodgers GP. Social Determinants of Racial Disparities in CKD. J Am Soc Nephrol 2016; 27:2576-95. [PMID: 27178804 PMCID: PMC5004663 DOI: 10.1681/asn.2016010027] [Citation(s) in RCA: 182] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Significant disparities in CKD rates and outcomes exist between black and white Americans. Health disparities are defined as health differences that adversely affect disadvantaged populations, on the basis of one or more health outcomes. CKD is the complex result of genetic and environmental factors, reflecting the balance of nature and nurture. Social determinants of health have an important role as environmental components, especially for black populations, who are disproportionately disadvantaged. Understanding the social determinants of health and appreciating the underlying differences associated with meaningful clinical outcomes may help nephrologists treat all their patients with CKD in an optimal manner. Altering the social determinants of health, although difficult, may embody important policy and research efforts, with the ultimate goal of improving outcomes for patients with kidney diseases, and minimizing the disparities between groups.
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Affiliation(s)
- Jenna M Norton
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Marva M Moxey-Mims
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Paul W Eggers
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Andrew S Narva
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Robert A Star
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Paul L Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Griffin P Rodgers
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland Office of the Director and
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Lee J, Lee JP, An JN, Kim SG, Kim YL, Yang CW, Kang SW, Kim NH, Kim YS, Oh YK, Lim CS. Factors Affecting the Referral Time to Nephrologists in Patients With Chronic Kidney Disease: A Prospective Cohort Study in Korea. Medicine (Baltimore) 2016; 95:e3648. [PMID: 27175688 PMCID: PMC4902530 DOI: 10.1097/md.0000000000003648] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Timely referral to nephrologists is important for improving clinical outcomes and reducing costs during transition periods. We evaluated the impact of patients' demographic, clinical, and social health characteristics on referral time.A total of 1744 CKD patients who started maintaining dialysis were enrolled in a Korean prospective cohort. The early referral (ER) and late referral group (LR) were defined as patients who were referred to a nephrologist more than or less than 1 year prior to dialysis initiation, respectively.A total of 1088 patients (62.3%) were in the ER, and 656 patients (37.6%) were in the LR. Among the patients in the LR, 398 patients (60.7%) were referred within the 3 months prior to the start of dialysis (ultralate referral group [ULR]). The ER was younger at the time of referral than the LR; however, the ER was older at the start of dialysis. Patients with diabetes or hypertension as the cause of kidney disease were more common in the LR, whereas patients with glomerulonephritis, females, and nonsmokers were more common in the ER. The ER had more well-controlled blood pressure, lower phosphorus levels, and higher hemoglobin levels at the start of dialysis. Congestive heart failure (CHF) was more common in the LR. In the multivariate analysis, male sex (odds ratio [OR] 1.465, 95% confidence interval [CI] 1.034-2.076), underlying kidney disease (diabetes mellitus [OR 1.507, 95% CI 1.057-2.148] and hypertension [OR 1.995, 95% CI 1.305-3.051]), occupation (mechanician [OR 2.975, 95% CI 1.445-6.125], laborer [OR 3.209, 95% CI 1.405-7.327], and farmer [OR 5.147, 95% CI 2.217-11.953]), CHF (OR 2.152, 95% CI 1.543-3.000), and ambulatory status (assisted-walks, OR 2.072, 95% CI 1.381-3.111) were proved as the independent risk factor for late referral.Patients with hypertensive or diabetic kidney disease are referred later than those with glomerulonephritis. Male patients with physically active occupations exhibiting CHF and restricted ambulation were associated with a late referral. Considering the various factors associated with late referral, efforts to increase early referrals should be emphasized, particularly in patients with hypertension, diabetes, or congestive heart failure.
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Affiliation(s)
- Jeonghwan Lee
- From the Department of Internal Medicine (JL), Hallym University Hangang Sacred Heart Hospital; Department of Internal Medicine (JPL, JNA, YKO, CSL), Seoul National University Boramae Medical Center, Seoul; Department of Internal Medicine (SGK), Hallym University Sacred Heart Hospital, Anyang; Department of Internal Medicine (Y-LK), Kyungpook National University School of Medicine, Daegu; Department of Internal Medicine (CWY), Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea; Department of Internal Medicine (S-WK), Yonsei University College of Medicine, Seoul; Department of Internal Medicine (N-HK), Chonnam National University Medical School, Gwangju; Department of Internal Medicine (YSK), Seoul National University College of Medicine, Seoul; and Clinical Research Center for End Stage Renal Disease (CRC for ESRD), Daegu (JL; JPL; JNA; SGK; Y-LK; CWY; S-WK; N-HK; YSK; YKO; CSL), Republic of Korea
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Buttigieg J, Mercieca L, Saliba A, Aquilina S, Farrugia E, Fava S. Chronic kidney disease referral practices among non-nephrology specialists: A single-centre experience. Eur J Intern Med 2016; 29:93-7. [PMID: 26809863 DOI: 10.1016/j.ejim.2016.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 12/22/2015] [Accepted: 01/10/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Early referral of CKD patients to nephrology teams (NT) is vital to identify patients most likely to progress, delay decline of excretory function, and provide planned RRT. Unfortunately, many are still being referred late. METHODS We conducted a retrospective analysis to investigate referral rates, predictors of non-referral, and performed urine investigations in hospitalised CKD patients. RESULTS Out of 388 patients studied, 5.6%, 11.4%, and 16.4% in CKD3A, 3B, and 4+5, respectively, were referred to an NT upon discharge (CKD3A vs. CKD4+5, p=0.016). For every additional year of age, the odds of being referred decreased by 5% (OR: 0.95, CI: 0.92-0.98, p=0.003). Patients were more likely to be referred to an NT if they were males (OR: 2.31, CI: 1.09-4.90, p=0.029) and having reached CKD 4+5 (OR: 3.99, CI: 1.58-10.10, p=0.003). Only 28.8%, 43.9%, and 50.7% of patients with CKD3A, 3B, and 4+5 were followed up with urine investigations after discharge (p=0.001). CKD stage 3B (OR: 3.54, CI: 1.23-10.19, p=0.019), CKD stage 4+5 (OR: 6.06, CI: 1.69-21.67, p=0.006), DM (OR: 6.28, CI: 2.38-16.58, p<0.0001), and having been referred to a NT (OR: 20.95, CI: 3.54-123.92, p=0.001) were independent predictors for having urine investigations. CONCLUSION The highest rate of referral was achieved in males, younger age group, and those who have reached CKD stage 4+5. Urine tests remain largely underutilised and only a minority (16.4%) of patients with an eGFR <30mL/min/1.73m(2) were referred to a NT.
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Affiliation(s)
| | - Liam Mercieca
- Department of Medicine, Mater Dei Hospital, Msida, Malta.
| | - Arielle Saliba
- Department of Medicine, Mater Dei Hospital, Msida, Malta.
| | - Simon Aquilina
- Department of Medicine, Mater Dei Hospital, Msida, Malta.
| | | | - Stephen Fava
- Diabetes and Endocrine Department, Mater Dei Hospital, Msida, Malta.
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Watanabe Y, Yamagata K, Nishi S, Hirakata H, Hanafusa N, Saito C, Hattori M, Itami N, Komatsu Y, Kawaguchi Y, Tsuruya K, Tsubakihara Y, Suzuki K, Sakai K, Kawanishi H, Inaguma D, Yamamoto H, Takemoto Y, Mori N, Okada K, Hataya H, Akiba T, Iseki K, Tomo T, Masakane I, Akizawa T, Minakuchi J. Japanese society for dialysis therapy clinical guideline for "hemodialysis initiation for maintenance hemodialysis". Ther Apher Dial 2015; 19 Suppl 1:93-107. [PMID: 25817934 DOI: 10.1111/1744-9987.12293] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Arora P, Elkin PL, Eberle J, Bono JJ, Argauer L, Murray BM, Ram R, Venuto RC. An observational study of the quality of care for chronic kidney disease: a Buffalo and Albany, New York metropolitan area study. BMC Nephrol 2015; 16:199. [PMID: 26634443 PMCID: PMC4669622 DOI: 10.1186/s12882-015-0194-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 11/24/2015] [Indexed: 11/30/2022] Open
Abstract
Background The database of a major regional health insurer was employed to identify the number and frequency of covered patients with chronic kidney disease (CKD). We then examined the characteristics of their care as defined, in part, by the frequency of physician visits and specialty referral, the characteristics of laboratory testing and total costs as indices of the quality of care of the subject population. Methods This retrospective, cross-sectional study analyzed insurance claims, laboratory results and medication prescription data. Patients with two estimated glomerular filtration rate readings below 60 ml/min/1.73 m2 (n = 20,388) were identified and classified by CKD stage. Results The prevalence of CKD stages 3a and above was 12 %. Vascular comorbidities were common with prevalence increasing steadily from stage 3a through stage 5. Only 55.6 % of stage 4 CKD patients had claims for nephrology visits within one year of their index date. Fifty-nine percent of patients had claims for renin-angiotensin system (RAS) blockers. Twenty-five percent of patients in stage 3a CKD filled a prescription for non-steroidal anti-inflammatory drugs. Fifty-two percent of patients who developed end-stage renal disease received their first dialysis treatment as inpatients. Conclusions The pattern of medical practice observed highlights apparent deficiencies in the care of CKD patients including inappropriate medication use, delayed nephrology referral, and a lack of preparation for dialysis. This study shows the potential value of using large patient databases available through insurers to assess and likely improve regional CKD care.
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Affiliation(s)
- Pradeep Arora
- State University of New York at Buffalo, School of Medicine and Biosciences, Buffalo, NY, 14215, USA.
| | - Peter L Elkin
- State University of New York at Buffalo, School of Medicine and Biosciences, Buffalo, NY, 14215, USA.
| | - Joseph Eberle
- Computer Task Group, Inc, 800 Delaware Avenue, Buffalo, NY, 14209, USA.
| | - J James Bono
- Computer Task Group, Inc, 800 Delaware Avenue, Buffalo, NY, 14209, USA.
| | - Laura Argauer
- Computer Task Group, Inc, 800 Delaware Avenue, Buffalo, NY, 14209, USA.
| | - Brian M Murray
- State University of New York at Buffalo, School of Medicine and Biosciences, Buffalo, NY, 14215, USA.
| | - Raghu Ram
- HealthNow New York, 257 West Genesee Street, Buffalo, NY, 14202, USA.
| | - Rocco C Venuto
- State University of New York at Buffalo, School of Medicine and Biosciences, Buffalo, NY, 14215, USA. .,Nephrology Department, 462 Grider Street, Buffalo, NY, 14215, USA.
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Abstract
Chronic kidney disease (CKD) is defined by reduced estimated glomerular filtration rate, increased proteinuria, or both. CKD affects more than 10% of US adults, or 20 million people, and the numbers are rising as the population ages. However, CKD remains underdiagnosed. Diabetes and hypertension are the most common causes of CKD. Although end-stage renal disease is a feared complication of CKD, patients with CKD have a much greater risk of dying of cardiovascular (CV) disease than progressing to kidney failure. Special effort should be made to address modifiable CV risk factors in patients with CKD.
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Affiliation(s)
- Meghan M Kiefer
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Michael J Ryan
- Division of Nephrology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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Duong CM, Olszyna DP, Nguyen PD, McLaws ML. Challenges of hemodialysis in Vietnam: experience from the first standardized district dialysis unit in Ho Chi Minh City. BMC Nephrol 2015; 16:122. [PMID: 26231882 PMCID: PMC4522093 DOI: 10.1186/s12882-015-0117-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 07/20/2015] [Indexed: 11/10/2022] Open
Abstract
Background Hemodialysis is an increasingly common treatment in Vietnam as the diagnosis of end stage renal disease continues to rise. To provide appropriate hemodialysis treatment for end-stage renal disease patients, we conducted a 1-year cross-sectional study to measure the prevalence of bloodborne infection and factors associated with non-compliant behaviors in hemodialysis patients. Methods One hundred forty-two patients were tested for hepatitis B virus (HBV) surface antigen and hepatitis C virus (HCV) core antigen. They provided demographic, medical and dialysis information. Non-compliant behaviors were obtained from their medical records. Results Overall, 99 % of patients reused their dialyzers and 46 % had arteriovenous fistula on admission. Both HBV and HCV equally accounted for 8 % of patients and concurrent infection accounted for 1 %. Non-compliance rates of dietary and medication were 39 and 27 % respectively. 42 % of patients missed hemodialysis session, 8 % were verbally or physically abusive and 9 % were non-cooperative. Of the 54 % catheterized patients, 7 % improperly cared for their dialysis access. Dietary non-adherence was associated with male patients (p = 0.03) and medication non-adherence was associated with younger age (p = 0.05). Duration between diagnosis of chronic kidney disease and initiation of hemodialysis was associated with improper care of dialysis access (p = 0.04). Time on hemodialysis was associated with missed hemodialysis session (p = 0.007) and verbal or physical abuse (p = 0.01). Conclusion Health services need to provide safe practice for dialyzer reuse given the endemicity of hepatitis. We believe a national survey similar to ours about seroprevalence and infection control challenges would prepare Vietnam for providing safer satellite treatment units. Safe hemodialysis services should also comprise patient preparedness, education and counseling.
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Affiliation(s)
- Cuong Minh Duong
- School of Public Health and Community Medicine, UNSW Medicine, UNSW Australia, Level 3 Samuels Building, Sydney, 2052, NSW, Australia.
| | - Dariusz Piotr Olszyna
- Division of Infectious Diseases, University Medicine Cluster, National University Health System, Singapore, Singapore.
| | - Phong Duy Nguyen
- Training Center for Family Physicians, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.
| | - Mary-Louise McLaws
- School of Public Health and Community Medicine, UNSW Medicine, UNSW Australia, Level 3 Samuels Building, Sydney, 2052, NSW, Australia.
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Baek SH, Ahn SY, Lee SW, Park YS, Kim S, Na KY, Chae DW, Kim S, Chin HJ. Outcomes of predialysis nephrology care in elderly patients beginning to undergo dialysis. PLoS One 2015; 10:e0128715. [PMID: 26030256 PMCID: PMC4451015 DOI: 10.1371/journal.pone.0128715] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 04/29/2015] [Indexed: 12/21/2022] Open
Abstract
Background The proportion of elderly patients beginning to undergo dialysis is increasing globally. Whether early referral (ER) of elderly patients is associated with favorable outcomes remains under debate. We investigated the influence of referral timing on the mortality of elderly patients. Methods We retrospectively assessed mortality in 820 patients aged ≥70 years with end-stage renal disease (ESRD) who initiated hemodialysis at a tertiary university hospital between 2000 and 2010. Mortality data was obtained from the time of dialysis initiation until December 2010. We assigned patients to one of two groups according to the time of their first encounters with nephrologists: ER (≥ 3 months) and late referral (LR; < 3 months). Results During a mean follow-up period of 25.1 months, the ER group showed a 24% reduced risk of long-term mortality relative to the LR group (HR = 0.760, P = 0.009). Rate of reduction in 90-day mortality for ER patients was 58% (HR = 0.422, P=0.012). However, the statistical significance of the difference in mortality rates between ER and LR group was not observed across age groups after 90 days. Old age, LR, central venous catheter, high white blood cell count and corrected Ca level, and lower levels of albumin, creatinine, hemoglobin, and sodium were significantly associated with increased risk of mortality. Conclusions Timely referral was also associated with reduced mortality in elderly ESRD patients who initiated hemodialysis. In particular, the initial 90-day mortality reduction in ER patients contributed to mortality differences during the follow-up period.
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Affiliation(s)
- Seon Ha Baek
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Shin young Ahn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Sung Woo Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Youn Su Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ki Young Na
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Wan Chae
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Suhnggwon Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- * E-mail:
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Abstract
This issue provides a clinical overview of chronic kidney disease, focusing on prevention, diagnosis, treatment, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.
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Plantinga LC, Drenkard C, Patzer RE, Klein M, Kramer MR, Pastan S, Lim SS, McClellan WM. Sociodemographic and geographic predictors of quality of care in United States patients with end-stage renal disease due to lupus nephritis. Arthritis Rheumatol 2015; 67:761-72. [PMID: 25692867 DOI: 10.1002/art.38983] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 12/02/2014] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To describe end-stage renal disease (ESRD) quality of care (receipt of pre-ESRD nephrology care, access to kidney transplantation, and placement of permanent vascular access for dialysis) in US patients with ESRD due to lupus nephritis (LN-ESRD) and to examine whether quality measures differ by patient sociodemographic characteristics or US region. METHODS National surveillance data on patients in the US in whom treatment for LN-ESRD was initiated between July 2005 and September 2011 (n = 6,594) were analyzed. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) were determined for each quality measure, according to sociodemographic factors and US region. RESULTS Overall, 71% of the patients received nephrology care prior to ESRD. Black and Hispanic patients were less likely than white patients to receive pre-ESRD care (OR 0.73 [95% CI 0.63-0.85] and OR 0.73 [95% CI 0.60-0.88], respectively) and to be placed on the kidney transplant waitlist within the first year after the start of ESRD (HR 0.78 [95% CI 0.68-0.91] and HR 0.82 [95% CI 0.68-0.98], respectively). Those with Medicaid (HR 0.51 [95% CI 0.44-0.58]) or no insurance (HR 0.36 [95% CI 0.29-0.44]) were less likely than those with private insurance to be placed on the waitlist. Only 24% had a permanent vascular access, and placement was even less likely among the uninsured (OR 0.62 [95% CI 0.49-0.79]). ESRD quality-of-care measures varied 2-3-fold across regions of the US, with patients in the Northeast and Northwest generally having higher probabilities of adequate care. CONCLUSION LN-ESRD patients have suboptimal ESRD care, particularly with regard to placement of dialysis vascular access. Minority race/ethnicity and lack of private insurance are associated with inadequate ESRD care. Further studies are warranted to examine multilevel barriers to, and develop targeted interventions to improve delivery of, care among patients with LN-ESRD.
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Salter ML, Kumar K, Law AH, Gupta N, Marks K, Balhara K, McAdams-DeMarco MA, Taylor LA, Segev DL. Perceptions about hemodialysis and transplantation among African American adults with end-stage renal disease: inferences from focus groups. BMC Nephrol 2015; 16:49. [PMID: 25881073 PMCID: PMC4395977 DOI: 10.1186/s12882-015-0045-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/31/2015] [Indexed: 12/22/2022] Open
Abstract
Background Disparities in access to kidney transplantation (KT) remain inadequately understood and addressed. Detailed descriptions of patient attitudes may provide insight into mechanisms of disparity. The aims of this study were to explore perceptions of dialysis and KT among African American adults undergoing hemodialysis, with particular attention to age- and sex-specific concerns. Methods Qualitative data on experiences with hemodialysis and views about KT were collected through four age- and sex-stratified (males <65, males ≥65, females <65, and females ≥65 years) focus group discussions with 36 African American adults recruited from seven urban dialysis centers in Baltimore, Maryland. Results Four themes emerged from thematic content analysis: 1) current health and perceptions of dialysis, 2) support while undergoing dialysis, 3) interactions with medical professionals, and 4) concerns about KT. Females and older males tended to be more positive about dialysis experiences. Younger males expressed a lack of support from friends and family. All participants shared feelings of being treated poorly by medical professionals and lacking information about renal disease and treatment options. Common concerns about pursuing KT were increased medication burden, fear of surgery, fear of organ rejection, and older age (among older participants). Conclusions These perceptions may contribute to disparities in access to KT, motivating granular studies based on the themes identified.
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Affiliation(s)
- Megan L Salter
- Center on Aging and Health, Johns Hopkins University, Baltimore, MD, USA. .,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA. .,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Johns Hopkins Medical Institutions, 720 Rutland Ave, Turner 034, Baltimore, MD, 21205, USA.
| | - Komal Kumar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Johns Hopkins Medical Institutions, 720 Rutland Ave, Turner 034, Baltimore, MD, 21205, USA.
| | - Andrew H Law
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Johns Hopkins Medical Institutions, 720 Rutland Ave, Turner 034, Baltimore, MD, 21205, USA.
| | - Natasha Gupta
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Johns Hopkins Medical Institutions, 720 Rutland Ave, Turner 034, Baltimore, MD, 21205, USA.
| | - Kathryn Marks
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Johns Hopkins Medical Institutions, 720 Rutland Ave, Turner 034, Baltimore, MD, 21205, USA.
| | - Kamna Balhara
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Johns Hopkins Medical Institutions, 720 Rutland Ave, Turner 034, Baltimore, MD, 21205, USA.
| | - Mara A McAdams-DeMarco
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA. .,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Johns Hopkins Medical Institutions, 720 Rutland Ave, Turner 034, Baltimore, MD, 21205, USA.
| | - Laura A Taylor
- Johns Hopkins University School of Nursing, Baltimore, MD, USA. .,Johns Hopkins Medical Institutions, 720 Rutland Ave, Turner 034, Baltimore, MD, 21205, USA.
| | - Dorry L Segev
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA. .,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Johns Hopkins Medical Institutions, 720 Rutland Ave, Turner 034, Baltimore, MD, 21205, USA.
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Plantinga LC, Patzer RE, Drenkard C, Pastan SO, Cobb J, McClellan W, Lim SS. Comparison of quality-of-care measures in U.S. patients with end-stage renal disease secondary to lupus nephritis vs. other causes. BMC Nephrol 2015; 16:39. [PMID: 25884409 PMCID: PMC4389993 DOI: 10.1186/s12882-015-0037-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 03/18/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) due to lupus nephritis (LN-ESRD) may be followed by multiple providers (nephrologists and rheumatologists) and have greater opportunities to receive recommended ESRD-related care. We aimed to examine whether LN-ESRD patients have better quality of ESRD care compared to other ESRD patients. METHODS Among incident patients (7/05-9/11) with ESRD due to LN (n = 6,594) vs. other causes (n = 617,758), identified using a national surveillance cohort (United States Renal Data System), we determined the association between attributed cause of ESRD and quality-of-care measures (pre-ESRD nephrology care, placement on the deceased donor kidney transplant waitlist, and placement of permanent vascular access). Multivariable logistic and Cox proportional hazards models were used to estimate adjusted odds ratios (ORs) and hazard ratios (HRs). RESULTS LN-ESRD patients were more likely than other ESRD patients to receive pre-ESRD care (71% vs. 66%; OR = 1.68, 95% CI 1.57-1.78) and be placed on the transplant waitlist in the first year (206 vs. 86 per 1000 patient-years; HR = 1.42, 95% CI 1.34-1.52). However, only 24% had a permanent vascular access (fistula or graft) in place at dialysis start (vs. 36%; OR = 0.63, 95% CI 0.59-0.67). CONCLUSIONS LN-ESRD patients are more likely to receive pre-ESRD care and have better access to transplant, but are less likely to have a permanent vascular access for dialysis, than other ESRD patients. Further studies are warranted to examine barriers to permanent vascular access placement, as well as morbidity and mortality associated with temporary access, in patients with LN-ESRD.
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Affiliation(s)
| | - Rachel E Patzer
- Department of Surgery, Emory University, Atlanta, Georgia, USA.
| | | | - Stephen O Pastan
- Department of Medicine, Emory University, Atlanta, Georgia, USA.
- Emory Transplant Center, Emory Healthcare, Atlanta, Georgia, USA.
| | - Jason Cobb
- Department of Medicine, Emory University, Atlanta, Georgia, USA.
| | - William McClellan
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA.
| | - Sung Sam Lim
- Department of Medicine, Emory University, Atlanta, Georgia, USA.
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de Moraes TP, Figueiredo AE, de Campos LG, Olandoski M, Barretti P, Pecoits-Filho R. Characterization of the BRAZPD II cohort and description of trends in peritoneal dialysis outcome across time periods. Perit Dial Int 2014; 34:714-23. [PMID: 25185014 DOI: 10.3747/pdi.2013.00282] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Observational studies from different regions of the world provide valuable information in patient selection, clinical practice, and their relationship to patient and technique outcome. The present study is the first large cohort providing patient characteristics, clinical practice, patterns and their relationship to outcomes in Latin America. The objective of the present study was to characterize the cohort and to describe the main determinants of patient and technique survival, including trends over time of peritoneal dialysis (PD) initiation and treatment. This was a nationwide cohort study in which all incident adult patients on PD from 122 centers were studied. Patient demographics, socioeconomic and laboratory values were followed from December 2004 to January 2011 and, for comparison purposes, divided into 3 groups according to the year of starting PD: 2005/06, 2007/08 and 2009/10. Patient survival and technique failure (TF) were analyzed using the competing risk model of Fine and Gray. All patients active at the end of follow-up were treated as censored. In contrast, all patients who dropped the study for any reason different from the primary event of interest were treated as competing risk. Significance was set to a p level of 0.05. A total of 9,905 patients comprised the adult database, 7,007 were incident and 5,707 remained at least 90 days in PD. The main cause of dropout was death (54%) and of TF was peritonitis (63%). Technique survival at 1, 2, 3, 4, and 5 years was 91%, 84%, 77%, 68%, and 58%, respectively. There was no change in TF during the study period but 3 independent risk factors were identified: lower center experience, lower age, and automated PD (APD) as initial therapy. Cardiovascular disease (36%) was the main cause of death and the overall patient survival was 85%, 74%, 64%, 54%, and 48% at 1, 2, 3, 4, and 5 years, respectively. Patient survival improved along all study periods: compared to 2005/2006, patients starting at 2007/2008 had a relative risk reduction (SHR) of 0.83 (95% confidence interval [CI] 0.72 - 0.95); and starting in 2009/2010 of 0.69 (95% CI 0.57 - 0.83). The independent risk factors for mortality were diabetes, age > 65 years, previous hemodialysis, starting PD modality, white race, low body mass index (BMI), low educational level, center experience, length of pre-dialysis care, and the year of starting PD. We observed an improvement in patient survival along the years. This finding was sustained even after correction for several confounders and using a competing risk approach. On the other hand, no changes in technique survival were found.
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Affiliation(s)
- Thyago Proença de Moraes
- School of Medicine, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil; Graduate Program in Medicine and Health Sciences, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; and School of Medicine, UNESP, Botucatu, Brazil
| | - Ana Elizabeth Figueiredo
- School of Medicine, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil; Graduate Program in Medicine and Health Sciences, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; and School of Medicine, UNESP, Botucatu, Brazil
| | - Ludimila Guedim de Campos
- School of Medicine, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil; Graduate Program in Medicine and Health Sciences, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; and School of Medicine, UNESP, Botucatu, Brazil
| | - Marcia Olandoski
- School of Medicine, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil; Graduate Program in Medicine and Health Sciences, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; and School of Medicine, UNESP, Botucatu, Brazil
| | - Pasqual Barretti
- School of Medicine, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil; Graduate Program in Medicine and Health Sciences, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; and School of Medicine, UNESP, Botucatu, Brazil
| | - Roberto Pecoits-Filho
- School of Medicine, Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil; Graduate Program in Medicine and Health Sciences, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; and School of Medicine, UNESP, Botucatu, Brazil
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