Death and Dialysis Following Discharge From Chronic Kidney Disease Clinic: A Retrospective Cohort Study

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.

Effectiveness of Multidisciplinary Care for Chronic Kidney Disease: A Systematic Review

BACKGROUND

Chronic kidney disease (CKD) is a common chronic disease. As this disease is extremely complex, multidisciplinary care (MDC) is needed to provide complete and continuous care.

AIM

A systematic literature review was performed to examine the constituents of MDC, the content of MDC interventions, and the health outcomes in CKD patients receiving MDC.

METHODS

Searches of five Chinese and English databases for studies of CKD patients who had received MDC from 2007 to 2019 revealed 11 studies, which comprised 16,066 CKD patients. The Physiotherapy Evidence Database scale (Physiotherapy Evidence Database, 2017) was used to appraise study quality for randomized controlled trials, and the Joanna Briggs Institute Critical Appraisal tools (Joanna Briggs Institute, 2017) were for cohort studies.

RESULTS

The MDC teams that provided comprehensive medical care for these patients included nephrologists, nurses, surgeons, general practitioners, pharmacists, psychotherapists, social workers, nutritionists, and other specialists. The literature review revealed that MDC for CKD slows the decline in estimated glomerular filtration rate and decreases patient mortality, the risk of renal replacement therapy, the need for emergent dialysis, and annual medical costs. Analyses of biochemical markers in the CKD patients showed that MDC improves control of serum levels of calcium and phosphate, improves control of parathyroid hormone, and reduces proteinuria and fasting blood glucose values. However, further studies are needed to determine the effects of MDC on all-cause mortality, blood pressure control, hospitalization rate, hospitalization for cardiovascular or infection events, medications use, and other biochemical markers in CKD patients.

LINKING EVIDENCE TO ACTION

Cross-disciplinary collaboration of healthcare professionals is needed to ensure that patients undergo regular follow-up and periodic assessment of clinical status, in addition to ensuring that relevant resources and assistance are provided in a timely manner. A follow-up period of at least 2 years is also needed to ensure sufficient time to observe MDC results.

A RAND-Modified Delphi on Key Indicators to Measure the Efficiency of Living Kidney Donor Candidate Evaluations

BACKGROUND AND OBJECTIVES

Many patients, providers, and potential living donors perceive the living kidney donor evaluation process to be lengthy and difficult to navigate.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We sought consensus on key terms and process and outcome indicators that can be used to measure how efficiently a transplant center evaluates persons interested in becoming a living kidney donor. Using a RAND-modified Delphi method, 77 participants (kidney transplant recipients or recipient candidates, living kidney donors or donor candidates, health care providers, and health care administrators) completed an online survey to define the terms and indicators. The definitions were then further refined during an in-person meeting with ten stakeholders.

RESULTS

We identified 16 process indicators (e.g., average time to evaluate a donor candidate), eight outcome indicators (e.g., annual number of preemptive living kidney donor transplants), and two measures that can be considered both process and outcome indicators (e.g., average number of times a candidate visited the transplant center for the evaluation). Transplant centers wishing to implement this set of indicators will require 22 unique data elements, all of which are either readily available or easily collected prospectively.

CONCLUSIONS

We identified a set of indicators through a consensus-based approach that may be used to monitor and improve the performance of a transplant center in how efficiently it evaluates persons interested in becoming a living kidney donor.

Multidisciplinary Chronic Kidney Disease Clinic Practices: A Scoping Review

Background:

Multidisciplinary chronic kidney disease (CKD) clinics improve patient outcomes but their optimal design is unclear.

Objective:

To perform a scoping review to identify and describe current practices (structure, function) associated with multidisciplinary CKD clinics.

Design:

Scoping review.

Setting:

Databases included Medline, EMBASE, Cochrane, and CINAHL.

Patients:

Patients followed in multidisciplinary CKD clinics globally.

Measurements:

Multidisciplinary CKD clinic composition, entry criteria, follow-up, and outcomes.

Methods:

We systematically searched the literature to identify randomized controlled trials, non-randomized interventional studies, or observational studies of multidisciplinary CKD clinics defined by an outpatient setting where two or more allied health members (with or without a nephrologist) provided longitudinal care to 50 or more adult or pediatric patients with CKD. Included studies were from 2002 to present. Searches were completed on August 10, 2018. Title, abstracts, and full texts were screened independently by two reviewers with disagreements resolved by a third. We abstracted data from included studies to summarize multidisciplinary CKD clinic team composition, entry criteria, follow-up, and processes.

Results:

40 studies (8 randomized controlled trials and 32 non-randomized interventional studies or observational studies) involving 23 230 individuals receiving multidisciplinary CKD care in 12 countries were included. Thirty-eight focused on adults (27 with CKD, 10 incident dialysis patients, one conservative therapy) while two studies focused on adolescents or children with CKD. The multidisciplinary team included a mean of 4.6 (SD 1.5) members consisting of a nephrologist, nurse, dietician, social worker, and pharmacist in 97.4%, 86.8%, 84.2%, 57.9%, and 42.1% of studies respectively. Entry criteria to multidisciplinary CKD clinics ranged from glomerular filtration rates of 20 to 70 mL/min/1.73m² or CKD stages 1 to 5 without any proteinuria or risk equation-based criteria. Frequency of follow-up was variable by severity of kidney disease. Team member roles and standardized operating procedures were infrequently reported.

Limitations:

Unstandardized definition of multidisciplinary CKD care, studies limited to CKD defined by glomerular filtration rate, and lack of representation from countries other than Canada, Taiwan, the United States, and the United Kingdom.

Conclusions:

There is heterogeneity in multidisciplinary CKD team composition, entry criteria, follow-up, and processes with inadequate reporting of this complex intervention. Additional research is needed to determine the best model for multidisciplinary CKD clinics.

Trial registration:

Not applicable.

Multidisciplinary Cleft Palate Program at BC Children's Hospital: Are We Meeting the Standards of Care?

Objective

To characterize current Cleft Palate Program (CPP) practices and evaluate the timeliness of appointments with respect to patient age and diagnosis based on American Cleft Palate-Craniofacial Association (ACPA) population guidelines and CPP patient-specific recommendations.

Design

A retrospective review of CPP patient appointments from November 6, 2012, to March 31, 2015, was done. Data were analyzed using descriptive and inferential statistics.

Setting

The study was conducted using data from the CPP at BC Children's Hospital.

Patients

A total of 1214 appointments were considered in the analysis, including syndromic and nonsyndromic patients of 0 to 27 years of age.

Main Outcome Measures

Percentage of patients meeting follow-up targets by ACPA standards and CPP team recommendations.

Results

Our results showed patients 5 years and younger or nonsyndromic were more likely to be seen on time (P < .001). No relationship between the timeliness of an appointment and specific patient diagnoses or distance to clinic was found. With the exception of nursing (97% of appointments were on time), all disciplines had less than 45% of appointments on time with 51% of appointments meeting ACPA guidelines for timeliness and 32% of all appointments meeting CPP recommendations.

Conclusion

Timely care for the cleft/craniofacial patient populations represents a challenge for the CPP. Although half of patients may meet the general ACPA guidelines, only 32% of patients are meeting the CPP patient-specific recommendations. To provide better patient care, future adjustments are needed, which may include improved resource allotment and program support.

Pro: Risk scores for chronic kidney disease progression are robust, powerful and ready for implementation

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.

Risk Prediction Models in CKD

Chronic kidney disease (CKD) currently affects 20 million Americans and is associated with increased morbidity and mortality. Resource-efficient and appropriate treatment of CKD benefits the patient and provides improved resource allocation for the health care system. Prediction models can be useful in efficiently allocating resources, and currently are being used at the bedside for several important clinical decisions. There is a paucity of prediction models in use in nephrology, but one such model, the Kidney Failure Risk Equation, uses routinely collected laboratory values and can inform clinical decisions related to the following: (1) triage of nephrology referrals, (2) evaluating the need for more intensive interdisciplinary clinic care, (3) determining the timing of modality education, and (4) dialysis access planning. The development of new models that predict survival and quality of life on dialysis, success on home modalities, failure of arteriovenous fistulas, and risk of cardiovascular disease in patients with CKD is needed.

Risk Prediction in CKD: The Rational Alignment of Health Care Resources in CKD 4/5 Care

CKD is a well-recognized global epidemic with consequences on patient morbidity, mortality, and health care resources. In the United States and Canada, a financial premium is often paid to programs and providers for caring for patients with Stage 4 to 5 CKD (not on dialysis) and is justified by the intensive care required by these patients, particularly in preparation for dialysis. About half of all patients with CKD Stages 3 and 4 never progress to kidney failure, and more than a quarter of them have stable kidney function for years. Among patients with Stage 3 CKD, even fewer progresses to kidney failure but small subpopulations with certain characteristics (eg, younger age, higher levels of proteinuria) have a more predictable trajectory. Clearly, a more robust method of screening patients for nephrology referral and subsequent enrollment into multidisciplinary clinics is needed to provide better efficiency within the health care system. The Kidney Failure Risk Equation is a generalizable CKD risk prediction model that has been externally validated and allows for the efficient risk-based triaging of nephrology referrals with a significant benefit to decreasing wait times. It is also efficiently used in a multidisciplinary kidney disease clinic with aiding timing in modality planning and frequency of follow-ups. The overall potential benefit of this system should allow for appropriate allocation of human resources to those at highest risk to yield optimal care in the most cost-effective manner to the health care system.

Perspectives on optimizing care of patients in multidisciplinary chronic kidney disease clinics

Purpose of review

To summarize a jointly held symposium by the Canadian Society of Nephrology (CSN), the Canadian Association of Nephrology Administrators (CANA), and the Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) entitled “Perspectives on Optimizing Care of Patients in Multidisciplinary Chronic Kidney Disease (CKD) Clinics” that was held on April 24, 2015, in Montreal, Quebec.

Sources of information

The panel consisted of a variety of members from across Canada including a multidisciplinary CKD clinic patient (Randall Russell), nephrology fellow (Dr. David Collister), geriatrician (Dr. Josee Verdon), and nephrologists (Dr. Monica Beaulieu, Dr. Adeera Levin).

Findings

The objectives of the symposium were (1) to gain an understanding of the goals of care for CKD patients, (2) to gain an appreciation of different perspectives regarding optimal care for patients with CKD, (3) to examine the components required for optimal care including education strategies, structures, and tools, and (4) to describe a framework and metrics for CKD care which respect patient and system needs. This article summarizes the key concepts discussed at the symposium from a patient and physician perspectives. Key messages include (1) understanding patient values and preferences is important as it provides a framework as to what to prioritize in multidisciplinary CKD clinic and provincial renal program models, (2) barriers to effective communication and education are common in the elderly, and adaptive strategies to limit their influence are critical to improve adherence and facilitate shared decision-making, (3) the use of standardized operating procedures (SOPs) improves efficiency and minimizes practice variability among health care practitioners, and (4) CKD scorecards with standardized system processes are useful in approaching variability as well as measuring and improving patient outcomes.

Limitations

The perspectives provided may not be applicable across centers given the differences in patient populations including age, ethnicity, culture, language, socioeconomic status, education, and multidisciplinary CKD clinic structure and function.

Implications

Knowledge transmission by collaborative interprovincial and interprofessional networks may play a role in facilitating optimal CKD care. Validation of system and clinic models that improve outcomes is needed prior to disseminating these best practices.

Optimizing care for Canadians with diabetic nephropathy in 2015

Diabetic chronic kidney disease (CKD) is the cause of kidney failure in approximately 35% of Canadian patients requiring dialysis. Traditionally, only a minority of patients with type 2 diabetes and CKD progress to kidney failure because they die of a cardiovascular event first. However, with contemporary therapies for diabetes and cardiovascular disease, this may no longer be true. The classic description of diabetic CKD is the development of albuminuria followed by progressive kidney dysfunction in a patient with longstanding diabetes. Many exciting candidate agents are under study to halt the progression of diabetic CKD; current therapies center on optimizing glycemic control, renin angiotensin system inhibition, blood pressure control and lipid management. Lifestyle modifications, such as salt and protein restriction as well as smoking cessation, may also be of benefit. Unfortunately, these accepted therapies do not entirely halt the progression of diabetic CKD. Also unfortunately, the presence of CKD in general is under-recognized by primary care providers, which can lead to late referral, missed opportunities for preventive care and inadvertent administration of potentially harmful interventions. Not all patients require referral to nephrology for diagnosis and management, but modern risk-prediction algorithms, such as the kidney failure risk equation, may help to guide referral appropriateness and dialysis modality planning in subspecialty nephrology multidisciplinary care clinics.

Multidisciplinary care for poor patients with chronic kidney disease in Mexico

Coordinated multidisciplinary care (MDC) could improve management and outcomes of patients with chronic kidney disease (CKD). We opened a nurse-led, MDC CKD clinic in Guadalajara, Mexico. We report the clinic's results between March 2008 and July 2011. The records of 353 patients with CKD stage 3 and 4 were reviewed. Data were collected prospectively. Mean age was 59.1±15.5 years; 54.4% were female and 63.7% were diabetic. We observed significant changes in the quality of care between baseline and follow-up. Compliance with practice guidelines for angiotensin II receptor blockers (ARB) and beta blockers increased from 30.6% to 46.6%, and from 11% to 19%, respectively; for statins from 41.4% to 80.3% for erythropoietin and calcium binders from 10.5% to 23.4%, and from 41.9 to 82.6%, respectively. At last visit, 90% of patients were on ACE inhibitors/ARB. Blood pressure <130/80 mm Hg increased from 23% to 38%. Serum glucose ⩽130 mg/dl increased from 54.4% to 67.7%. Serum cholesterol >160 mg/dl decreased from 64.8% to 60.3%. At last visit, 70% of the patients had a serum Hgb ⩾11.0 g/dl, and 80.1% and 65.1% had a normal serum calcium and serum phosphate, respectively. In conclusion, we observed a trend in the improvement of quality of care of CKD patients similar to those reported by other MDC programs in the developed world. Our study demonstrated that a nurse-led MDC program could be successfully implemented in developing countries.

Time to move away from damage control strategy in hemodialysis vascular access management: a view from Saudi Arabia

For the last 40 years, most of the research and publications on hemodialysis access, has focused on the management of its complications e.g. thrombosis, infection, aneurysms. In other words, a damage control strategy. While this is undoubtedly an important part of access management, it is a deficient reactive strategy that does not enhance a better quality of life for patients or help reduce the burden on health care resources. To achieve these objectives, efforts should be directed at ways which provide a longer access life with fewer complications. Such an approach would save costs and reduce the suffering of the patient. In this paper we will focus on hemodialysis management in Saudi Arabia, describe the reasons for the current unsatisfactory situation, and highlight possible remedies.