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Haarhaus M, Bratescu LO, Pana N, Gemene EM, Silva EM, Santos Araujo CAR, Macario F. Early referral to nephrological care improves long-term survival and hospitalization after dialysis initiation, independent of optimal dialysis start - a call for harmonization of reimbursement policies. Ren Fail 2024; 46:2313170. [PMID: 38357766 PMCID: PMC10877651 DOI: 10.1080/0886022x.2024.2313170] [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: 09/11/2023] [Accepted: 01/28/2024] [Indexed: 02/16/2024] Open
Abstract
Early treatment of kidney disease can slow disease progression and reduce the increased risk of mortality associated with end-stage kidney disease. However, uncertainty exists whether early referral (ER) to nephrological care per se or an optimal dialysis start impacts patient outcome after dialysis initiation. We determined the effect of ER and suboptimal dialysis start on the 3-year mortality and hospitalizations after dialysis initiation. Between January 2015 and July 2018, 349 patients with ≥1 month of follow-up started dialysis at nine Romanian dialysis clinics. After excluding patients with COVID-19 during follow-up, 254 patients (97 ER and 157 late referral) were included in this retrospective study. The observational period was truncated at 3 years, death, or loss to follow-up. Clinical and laboratory data were retrieved from the quality database of the nephrological care providers. Patients were followed for a median (25-75%) of 36 (16-36) months. At dialysis start, ER patients had higher hemoglobin, phosphate, and albumin levels and started dialysis less often via a central dialysis catheter (p < 0.001 for each). Logistic regression analysis demonstrated an independent lower risk for frequent hospitalizations for ER patients (odds ratio 0.22 (95% confidence interval 0.1-0.485), p < 0.001), and Cox regression analysis revealed an improved survival (hazard ratio 0.540 (95% confidence interval 0.325-0.899), p = 0.02), both independent of optimal dialysis start. In conclusion, early referral to nephrological care was associated with improved survival and lower hospitalization rates during the three years after dialysis initiation, independent of optimal dialysis start. These results strongly support the reimbursement of nephrological care before dialysis initiation.
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Affiliation(s)
- Mathias Haarhaus
- Diaverum, Malmö, Sweden
- Karolinska Institutet, Institutionen for klinisk vetenskap intervention och teknik, Stockholm, Sweden
| | | | - Nicolae Pana
- Diaverum Romania, Bucharest, Romania
- Universitatea de Medicina si Farmacie Carol Davila, Bucuresti, Romania
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2
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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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3
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Iqbal J, Su C, Wang M, Abbas H, Baloch MYJ, Ghani J, Ullah Z, Huq ME. Groundwater fluoride and nitrate contamination and associated human health risk assessment in South Punjab, Pakistan. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2023; 30:61606-61625. [PMID: 36811779 DOI: 10.1007/s11356-023-25958-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/11/2023] [Indexed: 05/10/2023]
Abstract
Consumption of high fluoride (F-) and nitrate (NO3-) containing water may pose serious health hazards. One hundred sixty-one groundwater samples were collected from drinking wells in Khushab district, Punjab Province, Pakistan, to determine the causes of elevated F- and NO3- concentrations, and to estimate the human health risks posed by groundwater contamination. The results showed pH of the groundwater samples ranged from slightly neutral to alkaline, and Na+ and HCO3- ions dominated the groundwater. Piper diagram and bivariate plots indicated that the key factors regulating groundwater hydrochemistry were weathering of silicates, dissolution of evaporates, evaporation, cation exchange, and anthropogenic activities. The F- content of groundwater ranged from 0.06 to 7.9 mg/L, and 25.46% of groundwater samples contained high-level fluoride concentration (F- > 1.5 mg/L), which exceeds the (WHO Guidelines for drinking-water quality: incorporating the first and second addenda, WHO, Geneva, 2022) guidelines of drinking-water quality. Inverse geochemical modeling indicates that weathering and dissolution of fluoride-rich minerals were the primary causes of F- in groundwater. High F- can be attributed to low concentration of calcium-containing minerals along the flow path. The concentrations of NO3- in groundwater varied from 0.1 to 70 mg/L; some samples are slightly exceeding the (WHO Guidelines for drinking-water quality: incorporating the first and second addenda, WHO, Geneva, 2022) guidelines for drinking-water quality. Elevated NO3- content was attributed to the anthropogenic activities revealed by PCA analysis. The high levels of nitrates found in the study region are a result of various human-caused factors, including leaks from septic systems, the use of nitrogen-rich fertilizers, and waste from households, farming operations, and livestock. The hazard quotient (HQ) and total hazard index (THI) of F- and NO3- showed high non-carcinogenic risk (> 1) via groundwater consumption, demonstrating a high potential risk to the local population. This study is significant because it is the most comprehensive examination of water quality, groundwater hydrogeochemistry, and health risk assessment in the Khushab district to date, and it will serve as a baseline for future studies. Some sustainable measures are urgent to reduce the F- and NO3- content in the groundwater.
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Affiliation(s)
- Javed Iqbal
- School of Environmental Studies, China University of Geosciences, Wuhan, 430074, China
- State Environmental Protection Key Laboratory of Source Apportionment and Control of Aquatic Pollution, China University of Geosciences, Wuhan, 430074, China
| | - Chunli Su
- School of Environmental Studies, China University of Geosciences, Wuhan, 430074, China.
- State Environmental Protection Key Laboratory of Source Apportionment and Control of Aquatic Pollution, China University of Geosciences, Wuhan, 430074, China.
| | - Mengzhu Wang
- School of Environmental Studies, China University of Geosciences, Wuhan, 430074, China
- State Environmental Protection Key Laboratory of Source Apportionment and Control of Aquatic Pollution, China University of Geosciences, Wuhan, 430074, China
| | - Hasnain Abbas
- School of Environmental Studies, China University of Geosciences, Wuhan, 430074, China
| | | | - Junaid Ghani
- Department of Biological, Geological, and Environmental Sciences, Alma Mater Studiorum University of Bologna, 40126, Bologna, Italy
| | - Zahid Ullah
- School of Environmental Studies, China University of Geosciences, Wuhan, 430074, China
| | - Md Enamul Huq
- College of Environment, Hohai University, Nanjing, China
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4
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Kaufman HW, Wang C, Wang Y, Han H, Chaudhuri S, Usvyat L, Hahn Contino C, Kossmann R, Kraus MA. Machine Learning Case Study: Patterns of Kidney Function Decline and Their Association With Clinical Outcomes Within 90 Days After the Initiation of Renal Dialysis. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:33-39. [PMID: 36723279 DOI: 10.1053/j.akdh.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 10/28/2022] [Accepted: 11/16/2022] [Indexed: 01/20/2023]
Abstract
A case study explores patterns of kidney function decline using unsupervised learning methods first and then associating patterns with clinical outcomes using supervised learning methods. Predicting short-term risk of hospitalization and death prior to renal dialysis initiation may help target high-risk patients for more aggressive management. This study combined clinical data from patients presenting for renal dialysis at Fresenius Medical Care with laboratory data from Quest Diagnostics to identify disease trajectory patterns associated with the 90-day risk of hospitalization and death after beginning renal dialysis. Patients were clustered into 4 groups with varying rates of estimated glomerular filtration rate (eGFR) decline during the 2-year period prior to dialysis. Overall rates of hospitalization and death were 24.9% (582/2341) and 4.6% (108/2341), respectively. Groups with the steepest declines had the highest rates of hospitalization and death within 90 days of dialysis initiation. The rate of eGFR decline is a valuable and readily available tool to stratify short-term (90 days) risk of hospitalization and death after the initiation of renal dialysis. More intense approaches are needed that apply models that identify high risks to potentially avert or reduce short-term hospitalization and death of patients with a severe and rapidly progressive chronic kidney disease.
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Affiliation(s)
| | - Catherine Wang
- Statistics and Data Science, Dietrich College of Humanities and Social Sciences, Carnegie Mellon University, Pittsburgh, PA
| | - Yuedong Wang
- Department of Statistics and Applied Probability, College of Letters and Science, University of California - Santa Barbara, Santa Barbara, CA
| | - Hao Han
- Fresenius Medical Care, Waltham, MA
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5
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Oliva-Damaso N, Delanaye P, Oliva-Damaso E, Payan J, Glassock RJ. Risk-based versus GFR threshold criteria for nephrology referral in chronic kidney disease. Clin Kidney J 2022; 15:1996-2005. [PMID: 36325015 PMCID: PMC9613424 DOI: 10.1093/ckj/sfac104] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Indexed: 02/22/2024] Open
Abstract
Chronic kidney disease (CKD) and kidney failure are global health problems associated with morbidity, mortality and healthcare costs, with unequal access to kidney replacement therapy between countries. The diversity of guidelines concerning referral from primary care to a specialist nephrologist determines different outcomes around the world among patients with CKD where several guidelines recommend referral when the glomerular filtration rate (GFR) is <30 mL/min/1.73 m2 regardless of age. Additionally, fixed non-age-adapted diagnostic criteria for CKD that do not distinguish correctly between normal kidney senescence and true kidney disease can lead to overdiagnosis of CKD in the elderly and underdiagnosis of CKD in young patients and contributes to the unfair referral of CKD patients to a kidney specialist. Non-age-adapted recommendations contribute to unnecessary referral in the very elderly with a mild disease where the risk of death consistently exceeds the risk of progression to kidney failure and ignore the possibility of effective interventions of a young patient with long life expectancy. The opportunity of mitigating CKD progression and cardiovascular complications in young patients with early stages of CKD is a task entrusted to primary care providers who are possibly unable to optimally accomplish guideline-directed medical therapy for this purpose. The shortage in the nephrology workforce has classically led to focused referral on advanced CKD stages preparing for kidney replacement, but the need for hasty referral to a nephrologist because of the urgent requirement for kidney replacement therapy in advanced CKD is still observed and changes are required to move toward reducing the kidney failure burden. The Kidney Failure Risk Equation (KFRE) is a novel tool that can guide wiser nephrology referrals and impact patients.
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Affiliation(s)
- Nestor Oliva-Damaso
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liege, Centre Hospitalier Universitaire Sart Tilman, ULgCHU, Liege, Belgium
- Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nîmes, France
| | - Elena Oliva-Damaso
- Department of Medicine, Division of Nephrology, Hospital Universitario Doctor Negrin, Las Palmas de Gran Canaria, Spain
| | - Juan Payan
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
| | - Richard J Glassock
- Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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6
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Wang KM, Mendu ML. Unmasking Disparities in Kidney Replacement Therapy Among Young Patients-A Call to Action. Am J Kidney Dis 2022; 80:1-3. [PMID: 35490050 DOI: 10.1053/j.ajkd.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/05/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Katherine M Wang
- Division of Kidney Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts.
| | - Mallika L Mendu
- Division of Kidney Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
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7
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Drozdz M, Frazão J, Silva F, Das P, Kleophas W, Al Badr W, Brzosko S, Jacobson SH. Improvements in six aspects of quality of care of incident hemodialysis patients - a real-world experience. BMC Nephrol 2021; 22:333. [PMID: 34620096 PMCID: PMC8499463 DOI: 10.1186/s12882-021-02529-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/10/2021] [Indexed: 11/17/2022] Open
Abstract
Background The transition from chronic kidney disease stage 5 to initiation of hemodialysis has gained increased attention in recent years as this period is one of high risk for patients with an annual mortality rate exceeding 20%. Morbidity and mortality in incident hemodialysis patients are partially attributed to failure to attain guideline-based targets. This study focuses on improvements in six aspects of quality of dialysis care (adequacy, anemia, nutrition, chronic kidney disease-mineral bone disorder (CKD-MBD), blood pressure and vascular access) aligning with KDIGO guidelines, during the first 6 months of hemodialysis. Methods We analyzed patient demographics, practice patterns and laboratory data in all 3 462 patients (mean age 65.9 years, 41% females) on hemodialysis (incident <90 days on hemodialysis, n=603, prevalent ≥90 days on hemodialysis, mean 55 months, n=2 859) from all 56 DaVita centers in Poland (51 centers) and Portugal (5 centers). 80% of patients had hemodialysis and 20% hemodiafiltration. Statistical analyses included unpaired and paired Students t-test, Chi-2 analyses, McNemar test and logistic regression analysis. Results Incident patients had lower Kt/V (1.4 vs 1.7, p<0.001), lower serum albumin (37 vs 40 g/l, p=0.001), lower Hb (9.9 vs 11.0 g/dl, p<0.001), lower TSAT (26 vs 31%, p<0.001), lower iPTH (372 vs 496 pg/ml, p<0.001), more often a central venous catheter (68 vs 26%, p<0.001), less often an AV fistula (34 vs 70 %, p<0.001) compared with all prevalent patients. Significantly more prevalent patients achieved international treatment targets. Improvements in quality of care was also analyzed in a subgroup of 258 incident patients who were followed prospectively for 6 months. We observed significant improvements in Kt/V (p<0.001), albumin (p<0.001), Hb (p<0.001) transferrin saturation (TSAT, p<0.001), iPTH (p=0.005) and an increased use of AV fistula (p<0.001). Furthermore, logistic regression analyses identified treatment time and TSAT as major factors influencing the attainment of adequacy and anemia treatment targets. Conclusion This large real-world European multicenter analysis of representative incident hemodialysis patients indicates that the use of medical protocols and medical targets assures significant improvements in quality of care, which may correspond to better outcomes. A selection bias of survivors with less comorbidities in prevalent patients may have influenced the results.
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Affiliation(s)
| | - João Frazão
- DaVita Portugal, Lisbon, Portugal.,Department of Nephrology, São João Hospital Center, Porto, Portugal.,School of Medicine, University of Porto, Porto, Portugal
| | | | - Partha Das
- DaVita International, London, UK.,King's College Hospital NHS Foundation Trust, London, UK
| | - Werner Kleophas
- DaVita Germany, Düsseldorf, Germany.,Clinic for Nephrology, Heinrich-Heine University, Düsseldorf, Germany
| | - Wisam Al Badr
- DaVita Kingdom of Saudi Arabia, Riyadh, Saudi Arabia
| | - Szymon Brzosko
- 1st Department of Nephrology and Transplantation, Medical University of Bialystok, Białystok, Poland.,DaVita Poland, Wroclaw, Poland
| | - Stefan H Jacobson
- Department of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden.
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8
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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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9
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Soohoo M, Moradi H, Obi Y, Rhee CM, Gosmanova EO, Molnar MZ, Kashyap ML, Gillen DL, Kovesdy CP, Kalantar-Zadeh K, Streja E. Statin Therapy Before Transition to End-Stage Renal Disease With Posttransition Outcomes. J Am Heart Assoc 2020; 8:e011869. [PMID: 30885048 PMCID: PMC6475049 DOI: 10.1161/jaha.118.011869] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Although studies have shown that statin therapy in patients with non-dialysis-dependent chronic kidney disease was associated with a lower risk of death, this was not observed in dialysis patients newly initiated on statins. It is unclear if statin therapy benefits administered during the predialysis period persist after transitioning to end-stage renal disease. Methods and Results In 47 720 veterans who transitioned to end-stage renal disease during 2007 to 2014, we examined the association of statin therapy use 1 year before transition with posttransition all-cause and cardiovascular mortality and hospitalization incidence rates over the first 12 months of follow-up. Associations were examined using multivariable adjusted Cox proportional hazard models and negative binomial regressions. Sensitivity analyses included propensity score and subgroup analyses. The cohort's mean± SD age was 71±11 years, and the cohort included 4% women, 23% blacks, and 66% diabetics. Over 12 months of follow-up, there were 13 411 deaths, with an incidence rate of 35.3 (95% CI , 34.7-35.8) deaths per 100 person-years. In adjusted models, statin therapy compared with no statin therapy was associated with lower risks of 12-month all-cause (hazard ratio [95% CI], 0.79 [0.76-0.82]) and cardiovascular (hazard ratio [95% CI ], 0.83 [0.78-0.88]) mortality, as well as with a lower rate of hospitalizations (incidence rate ratio [95% CI ], 0.89 [0.87-0.92]) after initiating dialysis. These lower outcome risks persisted across strata of clinical characteristics, and in propensity score analyses. Conclusions Among veterans with non-dialysis-dependent chronic kidney disease, treatment with statin therapy within the 1 year before transitioning to end-stage renal disease is associated with favorable early end-stage renal disease outcomes.
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Affiliation(s)
- Melissa Soohoo
- 1 Harold Simmons Center for Kidney Disease Research and Epidemiology Division of Nephrology and Hypertension University of California Irvine Medical Center Orange CA.,2 Nephrology Section Tibor Rubin Veterans Affairs Medical Center Long Beach CA
| | - Hamid Moradi
- 1 Harold Simmons Center for Kidney Disease Research and Epidemiology Division of Nephrology and Hypertension University of California Irvine Medical Center Orange CA.,2 Nephrology Section Tibor Rubin Veterans Affairs Medical Center Long Beach CA
| | - Yoshitsugu Obi
- 1 Harold Simmons Center for Kidney Disease Research and Epidemiology Division of Nephrology and Hypertension University of California Irvine Medical Center Orange CA
| | - Connie M Rhee
- 1 Harold Simmons Center for Kidney Disease Research and Epidemiology Division of Nephrology and Hypertension University of California Irvine Medical Center Orange CA
| | - Elvira O Gosmanova
- 3 Nephrology Section Stratton Veterans Affairs Medical Center Albany NY.,4 Division of Nephrology Department of Medicine Albany Medical College Albany NY
| | - Miklos Z Molnar
- 5 Division of Transplant Surgery Methodist University Hospital Transplant Institute Memphis TN.,6 Department of Surgery University of Tennessee Health Science Center Memphis TN.,7 Department of Medicine University of Tennessee Health Science Center Memphis TN.,8 Department of Transplantation and Surgery Semmelweis University Budapest Hungary
| | - Moti L Kashyap
- 9 Atherosclerosis Research Center Gerontology Section, Geriatric, Rehabilitation Medicine and Extended Care Health Care Group Veterans Affairs Medical Center Long Beach CA
| | - Daniel L Gillen
- 10 Department of Medicine University of California Irvine CA
| | - Csaba P Kovesdy
- 11 Nephrology Section Memphis Veterans Affairs Medical Center Memphis TN.,12 Division of Nephrology University of Tennessee Health Science Center Memphis TN
| | - Kamyar Kalantar-Zadeh
- 1 Harold Simmons Center for Kidney Disease Research and Epidemiology Division of Nephrology and Hypertension University of California Irvine Medical Center Orange CA.,2 Nephrology Section Tibor Rubin Veterans Affairs Medical Center Long Beach CA
| | - Elani Streja
- 1 Harold Simmons Center for Kidney Disease Research and Epidemiology Division of Nephrology and Hypertension University of California Irvine Medical Center Orange CA.,2 Nephrology Section Tibor Rubin Veterans Affairs Medical Center Long Beach CA
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10
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Lazareva NV, Oshchepkova EV, Orlovsky AA, Tereschenko SN. [Clinical characteristics and quality assessment of the treatment of patients with chronic heart failure with diabetes mellitus]. TERAPEVT ARKH 2020; 92:37-44. [PMID: 32598696 DOI: 10.26442/00403660.2020.04.000474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Indexed: 01/10/2023]
Abstract
AIM A study of the clinical and instrumental characteristics and quality of treatment of patients with chronic heart failure (CHF) with diabetes mellitus. MATERIALS AND METHODS The study was conducted by using the CHF register method, which is a computer program with remote access, which allows on-line data collection on patients who have been examined and treated in primary care and in hospitals. The study included 8272 patients with CHF IIIV FC (functional class) (New York Heart Association NYHA); among them 62% of patients were treated in hospital. RESULTS The study showed that the frequency of diabetes was 21%. The main causes of CHF in diabetic patients are coronary artery disease, myocardial infarction (in anamnesis) and hypertension. These patients are more often diagnosed with III and IV CHF FC according to (NYHA) and retained LV (left ventricular) ejection fraction. The reduced ejection fraction was observed in 6.8% of cases, and the frequency of the intermediate LV was significantly higher than among patients with CHF and with diabetes and accounted for 18.9%. At patients with CHF with diabetes in comparison with patients with CHF without diabetes, atherosclerosis of the peripheral arteries, stroke (in anamnesis) and chronic kidney disease of stage III and IV were significantly more common. CONCLUSION Under the treatment, patients with CHF with diabetes have higher levels of SBP (systolic blood pressure), lipids and glucose in the blood plasma, indicating a lack of quality of treatment and, accordingly, the doctors are not optimally performing the clinical guidelines on treating this category of patients.
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11
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Infection in Advanced Chronic Kidney Disease and Subsequent Adverse Outcomes after Dialysis Initiation: A Nationwide Cohort Study. Sci Rep 2020; 10:2938. [PMID: 32076027 PMCID: PMC7031239 DOI: 10.1038/s41598-020-59794-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 02/03/2020] [Indexed: 11/21/2022] Open
Abstract
It remains unclear whether infection events before entering end stage renal disease (ESRD) have a long-term negative impact on patients with advanced chronic kidney disease (CKD) who survive to permanent dialysis. We enrolled 62,872 patients with advanced CKD who transitioned to maintenance dialysis between January 1, 2004 and December 31, 2013. We used multivariable Cox as well as Fine and Gray models to determine the association of pre-dialysis infection exposure with all-cause mortality after starting dialysis. Compared with no infection during advanced CKD, the presence of infection exposure during that period was independently associated with a higher risk of all-cause mortality in the first year of dialysis (hazard ratio [HR] 1.34, 95% confidence interval [CI] 1.27–1.42) and also during the entire follow-up period (HR 1.19, 95% CI 1.16–1.22). The increased risks of all-cause mortality increased incrementally with higher annual number of infections during advanced CKD. Similar results were found for all other adverse outcomes, e.g. post-ESRD infection-related hospitalization and major cardiac and cerebrovascular events. In conclusion, infection events during advanced CKD was associated with increased risks of adverse outcomes after dialysis has been started. Timely interventions in such a vulnerable group may help attenuate these risks.
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12
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Lu JL, Molnar MZ, Sumida K, Diskin CD, Streja E, Siddiqui OA, Kalantar-Zadeh K, Kovesdy CP. Association of the frequency of pre-end-stage renal disease medical care with post-end-stage renal disease mortality and hospitalization. Nephrol Dial Transplant 2019; 33:789-795. [PMID: 29106625 DOI: 10.1093/ndt/gfx192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/23/2017] [Indexed: 11/12/2022] Open
Abstract
Background Previous studies have demonstrated that early pre-end-stage renal disease (ESRD) nephrology care could improve postdialysis prognosis. However, less is known about the specific types of interventions responsible for the improved outcomes. We hypothesized that more frequent predialysis laboratory testing is associated with better postdialysis outcomes in incident ESRD patients. Methods In all, 23 089 patients with available outpatient laboratory tests performed during the 2-year predialysis (i.e. prelude) period were identified from a total of 52 172 American veterans with chronic kidney disease (CKD) transitioning to dialysis between October 2007 and September 2011. The associations between the frequency of combined laboratory tests, including serum creatinine, serum potassium and hemoglobin (test trio), with postdialysis mortality and hospitalization were examined in multivariable adjusted Cox and logistic regression models. Results When entering the 2-year prelude period, the mean age (Standard Deviation) of the patients was 66.2 (SD 11.3) years and the mean estimated glomerular filtration rate was 46.8 (SD 23.9) mL/min/1.73 m2. In all, 14% of patients had the test trio performed less than twice in 24 months and 8.9% had the trio measured more often than every other month. Over a 2.5-year median postdialysis follow-up period, 15 303 (66.3%) patients died (mortality rate 260/1000 patient-years). The adjusted hazard ratio of all-cause mortality and adjusted odds ratio of the composite of hospitalization or death associated with lab testing done >12/24 months compared with 2-≤4/24 months were 0.68 [95% confidence interval (CI) 0.65-0.73] and 0.70 (95% CI 0.62-0.79), respectively. Conclusions More frequent laboratory testing in patients with advanced CKD is associated with better clinical outcomes after dialysis. Further examination in clinical trials is needed before the implementation of more frequent laboratory testing in clinical practice.
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Affiliation(s)
- Jun Ling Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan.,Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Charles D Diskin
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Omer A Siddiqui
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, CA, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA.,Nephrology Section, Memphis VA Medical Center, Memphis, TN, USA
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13
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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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14
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Oliva-Damaso N, Oliva-Damaso E, Rivas-Ruiz F, Lopez F, Castilla MDM, Baamonde-Laborda E, Rodriguez-Perez JC, Payan J. Impact of a phone app on nephrology referral. Clin Kidney J 2018; 12:427-432. [PMID: 31198544 PMCID: PMC6543955 DOI: 10.1093/ckj/sfy105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Indexed: 12/04/2022] Open
Abstract
Background Various factors can lead to inadequate nephrology referral decisions being taken by clinicians, but a major cause is unawareness of guidelines, recommendations and indications, or of appropriate timing. Today, tools such as smartphone applications (Apps) can make this knowledge more accessible to non-nephrologist clinicians. Our study aim is to determine the effectiveness of a purpose-built app in this respect. Methods In a retrospective study, nephrology referrals were compared before and after the introduction of the app in clinical practice. The initial study population consisted of first visits by patients referred to our department in 2015, before the introduction of the app. In 2016, the smartphone app NefroConsultor began to be implemented in our hospital. We compared the initial study population with the results obtained for patients referred in 2017, when the app was in use, taking into account clinical features considered, such as urinalysis, proteinuria or kidney ultrasound, to determine whether these patients met currently recommended criteria for referral. Results The total study population consisted of 628 patients, of whom 333 were examined before the introduction of the app (in 2015) and 295 when it was in use (in 2017). Among the first group, 132 (39.6%) met established KDIGO criteria for nephrology referral and were considered to be correctly referred. Among the second group, 200 (67.8%) met the criteria and were considered to be properly referred (P = 0.001). The increase in the rate of intervention success (before–after app) was 28.8% with a binomial effect size display (Cohen’s d effect size) of 0.751. Before the introduction of the app, data for albuminuria were included in 62.5% of nephrology referrals; in 2017, the corresponding value was 87.5% (P = 0.001). In the same line, referrals including urinalysis rose from 68.5% to 85.8% (P = 0.001). Multivariate regression analysis, using referrals meeting KDIGO criteria as the dependent variable and adjusting for age, sex and referring department, showed that the 2017 group (after the introduction of NefroConsultor) was associated with an odds ratio of 3.57 (95% confidence interval 2.52–5.05) for correct referrals, compared with the 2015 group (P = 0.001). References to proteinuria as the reason for nephrology referral also increased from 23.7% to 34.2% (P = 0.004). Conclusions Use of the app is associated with more frequent studies of albuminuria at the time of referral and a greater likelihood of proteinuria being cited as the reason for referral. The smartphone app considered can improve the accessibility of information concerning nephrology referrals and related studies.
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Affiliation(s)
- Nestor Oliva-Damaso
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
| | - Elena Oliva-Damaso
- Department of Medicine, Division of Nephrology, Hospital Doctor Negrin, Las Palmas de Gran Canaria, Spain
| | - Francisco Rivas-Ruiz
- Department of Research Unit, Hospital Costa del Sol, Malaga, Spain.,Research Network in Health Services in Chronic Diseases (REDISSEC), Madrid, Spain
| | - Francisca Lopez
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
| | - Maria Del Mar Castilla
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
| | - Eduardo Baamonde-Laborda
- Department of Medicine, Division of Nephrology, Hospital Doctor Negrin, Las Palmas de Gran Canaria, Spain
| | | | - Juan Payan
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
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15
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Affiliation(s)
- James Gilbert
- National Guideline Centre, Royal College of Physicians, London, UK
| | - Kate Lovibond
- National Guideline Centre, Royal College of Physicians, London, UK
| | - Andrew Mooney
- Leeds Teaching Hospitals NHS Trust and Honorary Clinical Associate Professor, University of Leeds
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16
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Sharief S, Hsu CY. The Transition From the Pre-ESRD to ESRD Phase of CKD: Much Remains to Be Learned. Am J Kidney Dis 2018; 69:8-10. [PMID: 28007193 DOI: 10.1053/j.ajkd.2016.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 10/05/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Shimi Sharief
- University of California, San Francisco, San Francisco, California
| | - Chi-Yuan Hsu
- University of California, San Francisco, San Francisco, California.
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17
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Kovesdy CP, Naseer A, Sumida K, Molnar MZ, Potukuchi PK, Thomas F, Streja E, Heung M, Abbott KC, Saran R, Kalantar-Zadeh K. Abrupt Decline in Kidney Function Precipitating Initiation of Chronic Renal Replacement Therapy. Kidney Int Rep 2018; 3:602-609. [PMID: 29854967 PMCID: PMC5976817 DOI: 10.1016/j.ekir.2017.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 12/12/2017] [Accepted: 12/18/2017] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Abrupt declines in kidney function often occur in patients with advanced chronic kidney disease and may exacerbate the need to initiate dialysis treatment. It is unclear how frequently such events occur in patients transitioning to chronic dialysis therapy, and what outcomes they are associated with. METHODS We examined a national cohort of 23,349 US veterans with incident end-stage renal disease (ESRD) and with available pre-ESRD estimated glomerular filtration rate (eGFR) to identify abrupt declines in kidney function, defined as an unexpected >50% decrease in eGFR at the time of chronic dialysis transition. Associations with all-cause mortality and with renal recovery were examined in Cox proportional hazard and competing risk regression models. RESULTS A total of 4804 (21%) patients experienced an abrupt decline in kidney function at dialysis transition. Renal recovery occurred in 586 (12.2%) and 297 (1.6%) patients with and without an abrupt decline, respectively (adjusted subhazard ratio: 4.42; 95% confidence interval [CI]: 3.72-5.27; P < 0.001). In the first 6 months after dialysis transition 1178 patients (24.5%) with abrupt decline died (annualized mortality rate 574/1000 patient-years), compared with 2354 deaths (12.7%) in patients without abrupt decline (274 deaths/1000 patient-years). An abrupt decline was associated with 45% higher mortality after multivariable adjustments (hazard ratio: 1.45; 95% CI: 1.33-1.57). CONCLUSION Abrupt declines in kidney function are common in patients transitioning to chronic dialysis, and are associated with higher mortality. Patients with abrupt declines also experience a higher rate of renal recovery; hence, careful attention to residual kidney function is warranted in these patients.
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Affiliation(s)
- Csaba P. Kovesdy
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Adnan Naseer
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Miklos Z. Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, Tennessee, USA
- Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Praveen K. Potukuchi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Fridtjof Thomas
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
| | - Michael Heung
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Rajiv Saran
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, California, USA
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18
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Abstract
Confronted with the decision to initiate dialysis, patients and caregivers often seek information about how expected survival chances evolve, both initially and afterward, providing the patient survives beyond arbitrary periods of time. Large registry data, used to examine these issues, may be subject to early ascertainment bias, such as those accruing from nonregistration of with end-stage kidney disease who die shortly after dialysis initiation and inclusion of patients with acute kidney injury with slower than typical recovery rates. Despite these caveats, available studies have suggested that mortality hazards are much higher in the first 3 months of renal replacement therapy. Prominent modifiable associations of early mortality include late referral to nephrology services, initial dialysis with vascular catheters, and, most problematically, higher glomerular filtration rates at initiation of renal replacement therapy. Despite their imperfections, currently available information is relatively user-unfriendly and could be better leveraged to help patients and treatment teams make better decisions.
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Affiliation(s)
- Robert N Foley
- Department of Medicine, University of Minnesota, Minneapolis, MN.
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19
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Long B, Koyfman A, Lee CM. Emergency medicine evaluation and management of the end stage renal disease patient. Am J Emerg Med 2017; 35:1946-1955. [PMID: 28893450 DOI: 10.1016/j.ajem.2017.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 09/02/2017] [Accepted: 09/03/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND End stage renal disease (ESRD) is increasing in the U.S., and these patients demonstrate greater all-cause mortality, cardiovascular events, and hospitalization rates when compared to those with normal renal function. These patients may experience significant complications associated with loss of renal function and dialysis. OBJECTIVE This review evaluates complications of ESRD including cardiopulmonary, neurologic, infectious disease, vascular, and access site complications, as well as medication use in this population. DISCUSSION ESRD incidence is rapidly increasing, and patients commonly require renal replacement therapy including hemodialysis (HDS) or peritoneal dialysis (PD), each type with specific features. These patients possess greater risk of neurologic complications, cardiopulmonary pathology, infection, and access site complications. Focused history and physical examination are essential. Neurologic issues include uremic encephalopathy, cerebrovascular pathology, and several others. Cardiopulmonary complications include pericarditis, pericardial effusion/tamponade, acute coronary syndrome, sudden cardiac death, electrolyte abnormalities, pulmonary edema, and air embolism. Infections are common, with patients more commonly presenting in atypical fashion. Access site infections and metastatic infections must be treated aggressively. Access site complications include bleeding, aneurysm/pseudoaneurysm, thrombosis/stenosis, and arterial steal syndrome. Specific medication considerations are required for analgesics, sedatives, neuromuscular blocking agents, antimicrobials, and anticoagulants. CONCLUSIONS Consideration of renal physiology with complications in ESRD can assist emergency providers in the evaluation and management of these patients. ESRD affects many organ systems, and specific pharmacologic considerations are required.
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Affiliation(s)
- Brit Long
- San Antonio Military Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Courtney M Lee
- Joint Base Elmendorf Richardson Medical Center, Department of Emergency Medicine, 5955 Zeamer Ave, JBER, AK, 99506, United States
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20
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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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21
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Abstract
The optimal timing of initiation of maintenance dialysis in patients with end-stage renal disease currently is unknown. This transition period is one of exceptionally high vulnerability for patients; annual mortality rates in stage 5 chronic kidney disease through the first year of maintenance dialysis exceed 20%. The results of the Initiating Dialysis Early and Late (IDEAL) study, a randomized trial that tested the impact of dialysis initiation at two different levels of kidney function on outcomes, showed no significant difference in survival or other patient-centered outcomes between treatment groups. These data have challenged the established paradigm of using estimates of glomerular filtration as the primary guide for initiation of maintenance dialysis and illustrate the compelling need for research to optimize the high-risk transition period from chronic kidney disease to end-stage renal disease. This article reviews the findings of the IDEAL study and summarizes the evolution of research findings, updated clinical practice guidelines, and trends in dialysis initiation practices in the United States in the 6 years since the publication of the results from IDEAL. Complementary strategies to the use of estimated glomerular filtration rate to optimally time the initiation of maintenance dialysis and potentially improve patient-centered outcomes also are considered.
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Affiliation(s)
- Matthew B Rivara
- Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, WA.
| | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, University of Washington, Seattle, WA
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22
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Caro Domínguez C, Garrido Pérez L, Sanz Turrado M. Influencia de la Consulta de Enfermedad Renal Crónica avanzada en la elección de modalidad de terapia renal sustitutiva. ENFERMERÍA NEFROLÓGICA 2016. [DOI: 10.4321/s2254-28842016000400003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introducción: La enfermedad renal crónica constituye un problema de salud pública por su elevada incidencia y prevalencia, importante morbimortalidad y coste asistencial. Un aspecto fundamental para el paciente es la elección de modalidad de terapia sustitutiva renal. En este sentido, la consulta de enfermedad renal crónica avanzada o prediálisis, puede jugar un papel fundamental. Objetivo: Conocer producción científica sobre la influencia de la consulta de enfermedad renal crónica avanzada en la elección de modalidad de diálisis por parte del paciente. Metodología: Revisión bibliográfica para la que se realizaron búsquedas en las bases de datos de PubMed, Scielo, Science Direct, Proquest y Google Académico. Se analizaron los artículos que trataban la consulta prediálisis, variables que influyeran en la elección de modalidad de diálisis y satisfacción del paciente. Resultados: Se han revisado 25 artículos publicados en los años 2002-2014, de diseño observacional descriptivo y de cohortes. Se ha encontrado relación en la elección de las técnicas domiciliarias con la existencia de un programa de educación prediálisis, la información que ofrece enfermería, la entrada programada en diálisis, menor edad, menor comorbilidad y factores socioeconómicos o estructurales. Conclusion: Los factores que favorecen la elección de las técnicas de diálisis domiciliarias son la existencia de consulta de enfermedad renal crónica avanzada y la referencia oportuna del paciente a dicha consulta, ser joven, menor comorbilidad y la necesidad de contención de costes. Esta elección se ve perjudicada por factores estructurales. Las terapias domiciliarias producen mayor satisfacción en los pacientes.
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23
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Molnar MZ, Gosmanova EO, Sumida K, Potukuchi PK, Lu JL, Jing J, Ravel VA, Soohoo M, Rhee CM, Streja E, Kalantar-Zadeh K, Kovesdy CP. Predialysis Cardiovascular Disease Medication Adherence and Mortality After Transition to Dialysis. Am J Kidney Dis 2016; 68:609-618. [PMID: 27084246 PMCID: PMC5035555 DOI: 10.1053/j.ajkd.2016.02.051] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 02/21/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Medication nonadherence is a known risk factor for adverse outcomes in the general population. However, little is known about the association of predialysis medication adherence among patients with advanced chronic kidney disease and mortality following their transition to dialysis. STUDY DESIGN Observational study. SETTING & PARTICIPANTS 32,348 US veterans who transitioned to dialysis during 2007 to 2011. PREDICTORS Adherence to treatment with cardiovascular drugs, ascertained from pharmacy database records using proportion of days covered (PDC) and persistence during the predialysis year. OUTCOMES Post-dialysis therapy initiation all-cause and cardiovascular mortality, using Cox models with adjustment for confounders. RESULTS Mean age of the cohort was 72±11 (SD) years; 96% were men, 74% were white, 23% were African American, and 69% had diabetes. During a median follow-up of 23 (IQR, 9-36) months, 18,608 patients died. Among patients with PDC>80%, there were 14,006 deaths (mortality rate, 283 [95% CI, 278-288]/1,000 patient-years]); among patients with PDC>60% to 80%, there were 3,882 deaths (mortality rate, 294 [95% CI, 285-304]/1,000 patient-years); among patients with PDC≤60%, there were 720 deaths (mortality rate, 291 [95% CI, 271-313]/1,000 patient-years). Compared with patients with PDC>80%, the adjusted HR for post-dialysis therapy initiation all-cause mortality for patients with PDC>60% to 80% was 1.12 (95% CI, 1.08-1.16), and for patients with PDC≤60% was 1.21 (95% CI, 1.11-1.30). In addition, compared with patients showing medication persistence, adjusted HR risk for post-dialysis therapy initiation all-cause mortality for patients with nonpersistence was 1.11 (95% CI, 1.05-1.16). A similar trend was detected for cardiovascular mortality and in subgroup analyses. LIMITATIONS Large number of missing values; results may not be generalizable to women or the general US population. CONCLUSIONS Predialysis cardiovascular medication nonadherence is an independent risk factor for postdialysis mortality in patients with advanced chronic kidney disease transitioning to dialysis therapy. Further studies are needed to assess whether interventions targeting adherence improve survival after dialysis therapy initiation.
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Affiliation(s)
- Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Elvira O Gosmanova
- Nephrology Section, Stratton VA Medical Center, Albany, NY; Nephrology Division, Department of Medicine, Albany Medical College, Albany, NY
| | - Keiichi Sumida
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Praveen K Potukuchi
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Jun Ling Lu
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Jennie Jing
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA
| | - Vanessa A Ravel
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA
| | - Melissa Soohoo
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA
| | - Elani Streja
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California-Irvine, Orange, CA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN; Nephrology Section, Memphis VA Medical Center, Memphis, TN.
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24
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Sundqvist S, Larson T, Cauliez B, Bauer F, Dumont A, Le Roy F, Hanoy M, Fréguin-Bouilland C, Godin M, Guerrot D. Clinical Value of Natriuretic Peptides in Predicting Time to Dialysis in Stage 4 and 5 Chronic Kidney Disease Patients. PLoS One 2016; 11:e0159914. [PMID: 27548064 PMCID: PMC4993513 DOI: 10.1371/journal.pone.0159914] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 07/11/2016] [Indexed: 11/19/2022] Open
Abstract
Background Anticipating the time to renal replacement therapy (RRT) in chronic kidney disease (CKD) patients is an important but challenging issue. Natriuretic peptides are biomarkers of ventricular dysfunction related to poor outcome in CKD. We comparatively investigated the value of B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) as prognostic markers for the risk of RRT in stage 4 and 5 CKD patients, and in foretelling all-cause mortality and major cardiovascular events within a 5-year follow-up period. Methods Baseline plasma BNP (Triage, Biosite) and NT-proBNP (Elecsys, Roche) were measured at inclusion. Forty-three patients were followed-up during 5 years. Kaplan-Meier analysis, with log-rank testing and hazard ratios (HR), were calculated to evaluate survival without RRT, cardiovascular events or mortality. The independent prognostic value of the biomarkers was estimated in separate Cox multivariate analysis, including estimated glomerular filtration rate (eGFR), creatininemia and comorbidities. Results During the first 12-month follow-up period, 16 patients started RRT. NT-proBNP concentration was higher in patients who reached endpoint (3221 ng/L vs 777 ng/L, p = 0.02). NT-proBNP concentration > 1345 ng/L proved significant predictive value on survival analysis for cardiovascular events (p = 0.04) and dialysis within 60 months follow-up (p = 0.008). BNP concentration > 140 ng/L was an independent predictor of RRT after 12 months follow-up (p<0.005), and of significant predictive value for initiation of dialysis within 60 months follow-up. Conclusions Our results indicate a prognostic value for BNP and NT-proBNP in predicting RRT in stage 4 and 5 CKD patients, regarding both short- and long-term periods. NT-proBNP also proved a value in predicting cardiovascular events. Natriuretic peptides could be useful predictive biomarkers for therapeutic guidance in CKD.
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Affiliation(s)
- Sofia Sundqvist
- Service de Néphrologie, CHU Hôpitaux de Rouen, Rouen, France
- Norwegian University of Science and Technology, Trondheim, Norway
| | - Thomas Larson
- Service de Biochimie, CHU Hôpitaux de Rouen, Rouen, France
| | - Bruno Cauliez
- Service de Biochimie, CHU Hôpitaux de Rouen, Rouen, France
| | - Fabrice Bauer
- Service de Cardiologie, CHU Hôpitaux de Rouen, Rouen, France
- INSERM Unité 1096, Université de Médecine-Pharmacie de Rouen, Rouen, France
| | - Audrey Dumont
- Service de Néphrologie, CHU Hôpitaux de Rouen, Rouen, France
| | - Frank Le Roy
- Service de Néphrologie, CHU Hôpitaux de Rouen, Rouen, France
| | - Mélanie Hanoy
- Service de Néphrologie, CHU Hôpitaux de Rouen, Rouen, France
| | | | - Michel Godin
- Service de Néphrologie, CHU Hôpitaux de Rouen, Rouen, France
- INSERM Unité 1096, Université de Médecine-Pharmacie de Rouen, Rouen, France
| | - Dominique Guerrot
- Service de Néphrologie, CHU Hôpitaux de Rouen, Rouen, France
- INSERM Unité 1096, Université de Médecine-Pharmacie de Rouen, Rouen, France
- * E-mail:
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Fischer MJ, Stroupe KT, Kaufman JS, O'Hare AM, Browning MM, Sohn MW, Huo Z, Hynes DM. Predialysis nephrology care and dialysis-related health outcomes among older adults initiating dialysis. BMC Nephrol 2016; 17:103. [PMID: 27473684 PMCID: PMC4966864 DOI: 10.1186/s12882-016-0324-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 07/22/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Predialysis nephrology care is associated with lower mortality and rates of hospitalization following chronic dialysis initiation. Whether more frequent predialysis nephrology care is associated with other favorable outcomes for older adults is not known. METHODS Retrospective cohort study of patients ≥66 years who initiated chronic dialysis in 2000-2001 and were eligible for VA and/or Medicare-covered services. Nephrology visits in VA and/or Medicare during the 12-month predialysis period were identified and classified by low intensity (<3 visits), moderate intensity (3-6 visits), and high intensity (>6 visits). Outcome measures included very low estimated glomerular filtration rate, severe anemia, use of peritoneal dialysis, and receipt of permanent vascular access at dialysis initiation and death and kidney transplantation within two years of initiation. Generalized linear models with propensity score weighting were used to examine the association between nephrology care and outcomes. RESULTS Among 58,014 patients, 46 % had none, 22 % had low, 13 % had moderate, and 19 % had high intensity predialysis nephrology care. Patients with a greater intensity of predialysis nephrology care had more favorable outcomes (all p < 0.001). In adjusted models, patients with high intensity predialysis nephrology care were less likely to have severe anemia (RR = 0.70, 99 % CI: 0.65-0.74) and more likely to have permanent vascular access (RR = 3.60, 99 % CI: 3.42-3.79) at dialysis initiation, and less likely to die within two years of dialysis initiation (RR = 0.80, 99 % CI: 0.77-0.82). CONCLUSION In a large cohort of older adults treated with chronic dialysis, greater intensity of predialysis nephrology care was associated with more favorable outcomes.
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Affiliation(s)
- Michael J Fischer
- Medicine/Nephrology, Jesse Brown VA Medical Center, University of Illinois Medical Center, Chicago, IL, USA. .,Center of Innovation for Complex Chronic Care, Edward Hines, Jr. VA Hospital, Hines, IL, USA.
| | - Kevin T Stroupe
- Center of Innovation for Complex Chronic Care, Edward Hines, Jr. VA Hospital, Hines, IL, USA.,Department of Public Health Sciences, Loyola University Chicago, Maywood, IL, USA
| | - James S Kaufman
- Medicine/Nephrology, VA New York Harbor Healthcare System, New York, NY, USA.,New York University School of Medicine, New York, NY, USA
| | - Ann M O'Hare
- Medicine/Nephrology, VA Puget Sound Healthcare System, Seattle, WA, USA.,Medicine/Nephrology, Group Health Research Institute, University of Washington, Seattle, WA, USA
| | - Margaret M Browning
- Center of Innovation for Complex Chronic Care, Edward Hines, Jr. VA Hospital, Hines, IL, USA.,VA Information Resource Center, Edward Hines, Jr. VA Hospital, Hines, IL, USA
| | - Min-Woong Sohn
- Center of Innovation for Complex Chronic Care, Edward Hines, Jr. VA Hospital, Hines, IL, USA.,Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Zhiping Huo
- Center of Innovation for Complex Chronic Care, Edward Hines, Jr. VA Hospital, Hines, IL, USA
| | - Denise M Hynes
- Center of Innovation for Complex Chronic Care, Edward Hines, Jr. VA Hospital, Hines, IL, USA.,VA Information Resource Center, Edward Hines, Jr. VA Hospital, Hines, IL, USA.,Medicine/Health Promotion Research, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
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Huang CY, Hsu CW, Chuang CR, Lee CC. Pre-Dialysis Visits to a Nephrology Department and Major Cardiovascular Events in Patients Undergoing Dialysis. PLoS One 2016; 11:e0147508. [PMID: 26900915 PMCID: PMC4763722 DOI: 10.1371/journal.pone.0147508] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 01/04/2016] [Indexed: 11/30/2022] Open
Abstract
Background and Objectives Pre-dialysis care by a nephrology out-patient department (OPD) may affect the outcomes of patients who ultimately undergo maintenance dialysis. This study examined the effect of pre-dialysis care by a nephrology OPD on the incidence of one-year major cardiovascular events after initiation of dialysis. Design, Setting Participants, & Measurements The study consisted of Taiwanese patients with chronic kidney disease (CKD) who commenced dialysis from 2006 to 2008. The number of nephrology OPD visits during the critical care period (within 6 months of initiation of dialysis) and the early care period (6–36 months before initiation of dialysis) were analyzed. The primary outcome measure was one-year major cardiovascular events. Results A total of 1191 CKD patients who initiated dialysis from 2006 to 2008 were included. Binary logistic regression showed that patients with ≧3 visits during the critical care period and those with ≧11 visits during the early care period had fewer composite major cardiovascular events than those with 0 visits. Patients with early referral are less likely to experience composite major cardiovascular events than those with late referral, with aOR 0.574 (95% CI = 0.43–0.77, P<0.001). Patients with both ≧3 visits during critical care period and ≧11 visits during early care period were less likely to experience composite major cardiovascular events (aOR = 0.25, 95% CI = 0.16–0.39, P < 0.001). Conclusions Patients with adequate pre-dialysis nephrology OPD visits, not just early referral, may had fewer one-year composite major cardiovascular events after initiation of dialysis. This information may be important to medical care providers and public health policy makers in their efforts to improve the well-being of CKD patients.
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Affiliation(s)
- Chih-Yuan Huang
- Division of Nephrology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Chia-Wen Hsu
- Department of Medical Research, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Taiwan
| | - Chi-Rou Chuang
- Department of Obstetrics and Gynecology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-yi, Taiwan
- * E-mail: (CCL); (CRC)
| | - Ching-Chih Lee
- Department of Otorhinolaryngology, Head and Neck Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- * E-mail: (CCL); (CRC)
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Ricardo AC, Roy JA, Tao K, Alper A, Chen J, Drawz PE, Fink JC, Hsu CY, Kusek JW, Ojo A, Schreiber M, Fischer MJ. Influence of Nephrologist Care on Management and Outcomes in Adults with Chronic Kidney Disease. J Gen Intern Med 2016; 31:22-9. [PMID: 26138006 PMCID: PMC4700009 DOI: 10.1007/s11606-015-3452-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 04/23/2015] [Accepted: 06/15/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Predialysis nephrology care for adults with late stage chronic kidney disease (CKD) is associated with improved outcomes. Less is known about the effects of nephrology care in earlier stages of CKD. OBJECTIVE We aimed to evaluate the effect of nephrology care on management of CKD risk factors and complications, CKD progression, incident cardiovascular disease (CVD), and death. DESIGN This was a prospective cohort study. PARTICIPANTS Participants included 3855 men and women aged 21 to 74 years enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study with a mean (SD) estimated glomerular filtration rate (eGFR) at entry of 45 (17) ml/min/1.73 m(2), followed for a median of 6.6 years. MAIN MEASURES The main predictor was self-reported prior contact with a nephrologist at study enrollment. Outcomes evaluated included CKD progression (≥ 50 % eGFR loss or end-stage renal disease), incident CVD, and death. RESULTS Two-thirds (67 %) of the participants reported prior contact with a nephrologist at study enrollment. They were younger, more likely to be male, non-Hispanic white, and had lower eGFR and higher urine protein (p < 0.05). A subgroup with eGFR 30- < 60 ml/min/1.73 m(2) and prior contact with a nephrologist were more likely to receive pharmacologic treatment for CKD-related complications and to report angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use. After propensity score matching (for reporting prior contact with a nephrologist vs. not) and adjusting for demographic and clinical variables, prior contact with a nephrologist was not significantly associated with CKD progression, incident CVD or death (p > 0.05). CONCLUSIONS One-third of CRIC participants had not seen a nephrologist before enrollment, and this prior contact was subject to age, sex, and ethnic-related disparities. While prior nephrology care was associated with more frequent treatment of CKD complications and use of ACEi/ARB medications, there was neither an association between this care and achievement of guideline-recommended intermediate measures, nor long-term adverse outcomes.
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Affiliation(s)
- Ana C Ricardo
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, 820 South Wood Street, 418W CSN, M/C 793, Chicago, IL, 60612-7315, USA.
| | - Jason A Roy
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Kaixiang Tao
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Arnold Alper
- Department of Medicine, Tulane University, New Orleans, LA, USA
| | - Jing Chen
- Department of Medicine, Tulane University, New Orleans, LA, USA
| | - Paul E Drawz
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Jeffrey C Fink
- Department of Medicine, University of Maryland, Baltimore, MD, USA
| | - Chi-Yuan Hsu
- Department of Medicine, University of California, San Francisco, CA, USA
| | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Akinlolu Ojo
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Martin Schreiber
- Department of Nephrology and Hypertension, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Michael J Fischer
- Center of Innovation for Complex Chronic Healthcare, Jesse Brown VA Medical Center, Chicago, IL, USA
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
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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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29
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Gillespie BW, Morgenstern H, Hedgeman E, Tilea A, Scholz N, Shearon T, Burrows NR, Shahinian VB, Yee J, Plantinga L, Powe NR, McClellan W, Robinson B, Williams DE, Saran R. Nephrology care prior to end-stage renal disease and outcomes among new ESRD patients in the USA. Clin Kidney J 2015; 8:772-80. [PMID: 26613038 PMCID: PMC4655805 DOI: 10.1093/ckj/sfv103] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/22/2015] [Indexed: 12/22/2022] Open
Abstract
Background Longer nephrology care before end-stage renal disease (ESRD) has been linked with better outcomes. Methods We investigated whether longer pre-end-stage renal disease (ESRD) nephrology care was associated with lower mortality at both the patient and state levels among 443 761 incident ESRD patients identified in the USA between 2006 and 2010. Results Overall, 33% of new ESRD patients had received no prior nephrology care, while 28% had received care for >12 months. At the patient level, predictors of >12 months of nephrology care included having health insurance, white race, younger age, diabetes, hypertension and US region. Longer pre-ESRD nephrology care was associated with lower first-year mortality (adjusted hazard ratio = 0.58 for >12 months versus no care; 95% confidence interval 0.57–0.59), higher albumin and hemoglobin, choice of peritoneal dialysis and native fistula and discussion of transplantation options. Living in a state with a 10% higher proportion of patients receiving >12 months of pre-ESRD care was associated with a 9.3% lower relative mortality rate, standardized for case mix (R2 = 0.47; P < 0.001). Conclusions This study represents the largest cohort of incident ESRD patients to date. Although we did not follow patients before ESRD onset, our findings, both at the individual patient and state levels, reflect the importance of early nephrology care among those with chronic kidney disease.
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Affiliation(s)
- Brenda W Gillespie
- Kidney Epidemiology and Cost Center , University of Michigan , Ann Arbor, MI , USA ; Department of Biostatistics , University of Michigan , Ann Arbor, MI , USA ; Center for Statistical Consultation and Research, University of Michigan , Ann Arbor, MI , USA
| | - Hal Morgenstern
- Department of Epidemiology , University of Michigan School of Public Health , Ann Arbor, MI , USA ; Department of Environmental Health Sciences , University of Michigan School of Public Health , Ann Arbor, MI , USA ; Department of Urology , University of Michigan Medical School , Ann Arbor, MI , USA
| | | | - Anca Tilea
- Kidney Epidemiology and Cost Center , University of Michigan , Ann Arbor, MI , USA ; Department of Internal Medicine , University of Michigan , Ann Arbor, MI , USA
| | - Natalie Scholz
- Kidney Epidemiology and Cost Center , University of Michigan , Ann Arbor, MI , USA ; Department of Biostatistics , University of Michigan , Ann Arbor, MI , USA
| | - Tempie Shearon
- Kidney Epidemiology and Cost Center , University of Michigan , Ann Arbor, MI , USA ; Department of Biostatistics , University of Michigan , Ann Arbor, MI , USA
| | - Nilka Rios Burrows
- Division of Diabetes Translation , Centers for Disease Control and Prevention , Atlanta, GA , USA
| | - Vahakn B Shahinian
- Kidney Epidemiology and Cost Center , University of Michigan , Ann Arbor, MI , USA ; Department of Internal Medicine , University of Michigan , Ann Arbor, MI , USA
| | - Jerry Yee
- Henry Ford Health System , Detroit, MI , USA
| | - Laura Plantinga
- Department of Epidemiology , Emory University , Atlanta, GA , USA
| | - Neil R Powe
- Department of Medicine , San Francisco General Hospital and University of California , San Francisco, CA , USA
| | | | - Bruce Robinson
- Arbor Research Collaborative for Health , Ann Arbor, MI , USA
| | - Desmond E Williams
- Division of Diabetes Translation , Centers for Disease Control and Prevention , Atlanta, GA , USA
| | - Rajiv Saran
- Kidney Epidemiology and Cost Center , University of Michigan , Ann Arbor, MI , USA ; Department of Epidemiology , University of Michigan School of Public Health , Ann Arbor, MI , USA ; Department of Internal Medicine , University of Michigan , Ann Arbor, MI , USA
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30
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Hsu YH, Cheng JS, Ouyang WC, Lin CL, Huang CT, Hsu CC. Lower Incidence of End-Stage Renal Disease but Suboptimal Pre-Dialysis Renal Care in Schizophrenia: A 14-Year Nationwide Cohort Study. PLoS One 2015; 10:e0140510. [PMID: 26469976 PMCID: PMC4607300 DOI: 10.1371/journal.pone.0140510] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 09/25/2015] [Indexed: 01/21/2023] Open
Abstract
Schizophrenia is closely associated with cardiovascular risk factors which are consequently attributable to the development of chronic kidney disease and end-stage renal disease (ESRD). However, no study has been conducted to examine ESRD-related epidemiology and quality of care before starting dialysis for patients with schizophrenia. By using nationwide health insurance databases, we identified 54,361 ESRD-free patients with schizophrenia and their age-/gender-matched subjects without schizophrenia for this retrospective cohort study (the schizophrenia cohort). We also identified a cohort of 1,244 adult dialysis patients with and without schizophrenia (1:3) to compare quality of renal care before dialysis and outcomes (the dialysis cohort). Cox proportional hazard models were used to estimate the hazard ratio (HR) for dialysis and death. Odds ratio (OR) derived from logistic regression models were used to delineate quality of pre-dialysis renal care. Compared to general population, patients with schizophrenia were less likely to develop ESRD (HR = 0.6; 95% CI 0.4–0.8), but had a higher risk for death (HR = 1.2; 95% CI, 1.1–1.3). Patients with schizophrenia at the pre-ESRD stage received suboptimal pre-dialysis renal care; for example, they were less likely to visit nephrologists (OR = 0.6; 95% CI, 0.4–0.8) and received fewer erythropoietin prescriptions (OR = 0.7; 95% CI, 0.6–0.9). But they had a higher risk of hospitalization in the first year after starting dialysis (OR = 1.4; 95% CI, 1.0–1.8, P < .05). Patients with schizophrenia undertaking dialysis had higher risk for mortality than the general ESRD patients. A closer collaboration between psychiatrists and nephrologists or internists to minimize the gaps in quality of general care is recommended.
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Affiliation(s)
- Yueh-Han Hsu
- Department of Public Health and Department of Health Services Administration, China Medical University, Taichung City, Taiwan
- Division of Nephrology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan
- Department of Nursing, Min-Hwei College of Health Care Management, Tainan City, Taiwan
| | - Jur-Shan Cheng
- Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Wen-Chen Ouyang
- Department of Psychiatry, Changhua Christian Hospital and Changhua Christian Healthcare System, Changhua, Taiwan
- Lutung Christian Hospital, Changhua, Taiwan
- Department of Nursing, College of Medicine and Life Science, Chung Hwa University of Medical Technology, Tainan, Taiwan
- Department of Psychiatry, Kaohsiung Medicine University, Kaohsiung, Taiwan
| | - Chen-Li Lin
- Taipei City Hospital Fuyou Branch; Taipei, Taiwan
| | - Chi-Ting Huang
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli County, Taiwan
- Department of Health Services Administration, China Medical University, Taichung City, Taiwan
- * E-mail:
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Samal L, Wright A, Waikar SS, Linder JA. Nephrology co-management versus primary care solo management for early chronic kidney disease: a retrospective cross-sectional analysis. BMC Nephrol 2015; 16:162. [PMID: 26458541 PMCID: PMC4603818 DOI: 10.1186/s12882-015-0154-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 09/28/2015] [Indexed: 12/26/2022] Open
Abstract
Background Primary care physicians (PCPs) typically manage early chronic kidney disease (CKD), but recent guidelines recommend nephrology co-management for some patients with stage 3 CKD and all patients with stage 4 CKD. We sought to compare quality of care for co-managed patients to solo managed patients. Methods We conducted a retrospective cross-sectional analysis. Patients included in the study were adults who visited a PCP during 2009 with laboratory evidence of CKD in the preceding two years, defined as two estimated glomerular filtration rates (eGFR) between 15–59 mL/min/1.73 m2 separated by 90 days. We assessed process measures (serum eGFR test, urine protein/albumin test, angiotensin converting enzyme inhibitor or angiotensin receptor blocker [ACE/ARB] prescription, and several tests monitoring for complications) and intermediate clinical outcomes (mean blood pressure and blood pressure control) and performed subgroup analyses by CKD stage. Results Of 3118 patients, 11 % were co-managed by a nephrologist. Co-management was associated with younger age (69 vs. 74 years), male gender (46 % vs. 34 %), minority race/ethnicity (black 32 % vs. 22 %; Hispanic 13 % vs. 8 %), hypertension (75 % vs. 66 %), diabetes (42 % vs. 26 %), and more PCP visits (5.0 vs. 3.9; p < 0.001 for all comparisons). After adjustment, co-management was associated with serum eGFR test (98 % vs. 94 %, p = <0.0001), urine protein/albumin test (82 % vs 36 %, p < 0.0001), and ACE/ARB prescription (77 % vs. 69 %, p = 0.03). Co-management was associated with monitoring for anemia and metabolic bone disease, but was not associated with lipid monitoring, differences in mean blood pressure (133/69 mmHg vs. 131/70 mmHg, p > 0.50) or blood pressure control. A subgroup analysis of Stage 4 CKD patients did not show a significant association between co-management and ACE/ARB prescription (80 % vs. 73 %, p = 0.26). Conclusion For stage 3 and 4 CKD patients, nephrology co-management was associated with increased stage-appropriate monitoring and ACE/ARB prescribing, but not improved blood pressure control.
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Affiliation(s)
- Lipika Samal
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St., Boston, MA, 02120-1613, USA. .,Harvard Medical School, Boston, MA, 02120, USA.
| | - Adam Wright
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St., Boston, MA, 02120-1613, USA. .,Harvard Medical School, Boston, MA, 02120, USA.
| | - Sushrut S Waikar
- Harvard Medical School, Boston, MA, 02120, USA. .,Renal Division, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02120, USA.
| | - Jeffrey A Linder
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont St., Boston, MA, 02120-1613, USA. .,Harvard Medical School, Boston, MA, 02120, USA.
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Zaza G, Rugiu C, Trubian A, Granata S, Poli A, Lupo A. How has peritoneal dialysis changed over the last 30 years: experience of the Verona dialysis center. BMC Nephrol 2015; 16:53. [PMID: 25885318 PMCID: PMC4404116 DOI: 10.1186/s12882-015-0051-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 04/01/2015] [Indexed: 11/17/2022] Open
Abstract
Background The last decade has witnessed considerable improvement in dialysis technology and changes in clinical management of patients in peritoneal dialysis (PD) with a significant impact on long term clinical outcomes. However, the identification of factors involved in this process is still not complete. Methods Therefore, to assess this objective, we retrospectively analyzed clinical records of 260 adult patients who started PD treatment from 1983 to 2012 in our renal unit. For the analysis, we divided them into three groups according to the time of starting dialysis: GROUP A (n: 62, 1983–1992), GROUP B (n: 66, 1993–2002) and GROUP C (n: 132, 2003 to 2012). Results Statistical analysis revealed that patients included in the GROUP C showed a reduction in mean patients’ age (p = 0.03), smoking habit (p = 0.001), mean systolic blood pressure (p < 0.0001) and an increment in hemoglobin levels (p < 0.0001) and residual diuresis (p = 0.016) compared to the other two study groups. Additionally, patients included in GROUP C, mainly treated with automated peritoneal dialysis, showed a reduced risk of all-causes mortality and a decreased risk to develop acute myocardial infarction and cerebrovascular disease. Patients’ age, diabetes mellitus and smoking habit were all positively associated with a significant increased risk of mortality in our PD patients, while serum albumin levels and residual diuresis were negatively correlated. Conclusions Therefore, the present study, revealed that in the last decade there has been a growth of our PD program with a concomitant modification of our patients’ characteristics. These changes, together with the evident technical advances, have caused a significant improvement of patients’ survival and a decrement of the rate of hospitalization. Moreover, it reveals that our pre-dialysis care, modifying the above-mentioned factors, has been a major cause of these clinical improvements. Electronic supplementary material The online version of this article (doi:10.1186/s12882-015-0051-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gianluigi Zaza
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, 37126, Verona, VR, Italy.
| | - Carlo Rugiu
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, 37126, Verona, VR, Italy.
| | - Alessandra Trubian
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, 37126, Verona, VR, Italy.
| | - Simona Granata
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, 37126, Verona, VR, Italy.
| | - Albino Poli
- Department of Public Health and Community Medicine, University of Verona, Verona, Italy.
| | - Antonio Lupo
- Renal Unit, Department of Medicine, University-Hospital of Verona, Piazzale A. Stefani 1, 37126, Verona, VR, Italy.
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Leimbach T, Kron J, Czerny J, Urbach B, Aign S, Kron S. Hemodialysis in patients over 80 years. Nephron Clin Pract 2015; 129:214-8. [PMID: 25765774 DOI: 10.1159/000375501] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 01/26/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In Germany, every fifth patient starting dialysis is now 80 years of age or older. The question that is currently relevant is not whether we have to treat patients who are older than 80. Rather the question now is how to treat this elderly group of patients. METHODS Single centre data of all dialysis patients aged over 80 were analyzed with regard to survival, social circumstances, vascular access, and pre-dialysis nephrology care. RESULTS Between 2001 and 2012, 76 patients over 80 years started chronic ambulatory hemodialysis treatment. One-year survival was 87%, 3-year survival 52%, 5-year survival 27% and 10-year survival 9%. Patients (n = 55) with more than 3 months of nephrological care prior to dialysis (3-161 months, median 31 months) survived significantly longer then patients (n = 21) having had less than 3 months contact with nephrologists. On 31st December 2012 there were 38 patients aged ≥80 (median age 84, 80-95 years) in the chronic hemodialysis program accounting for 19% of all dialysis patients of this center. Thirty patients (79%) had been in long-term nephrological care prior to dialysis initiation (3-161 months, median 45 months). Thirty one patients (82%) started the first dialysis treatment with a functioning shunt access. CONCLUSION Long-term pre-dialysis nephrology care is of most importance for successful dialysis treatment in the elderly, especially in octogenarians and nonagenarians. It enables the early establishment of functioning vascular access and careful scheduling of first dialysis treatment and increases survival. The long-term use of catheters can be avoided in almost all patients above the age of 80. © 2015 S. Karger AG, Basel.
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Affiliation(s)
- Til Leimbach
- KfH Kidney Center Berlin-Köpenick, Berlin, Germany
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Matheny ME, Peterson JF, Eden SK, Hung AM, Speroff T, Abdel-Kader K, Parr SK, Ikizler TA, Siew ED. Laboratory test surveillance following acute kidney injury. PLoS One 2014; 9:e103746. [PMID: 25117447 PMCID: PMC4130516 DOI: 10.1371/journal.pone.0103746] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 07/01/2014] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Patients with hospitalized acute kidney injury (AKI) are at increased risk for accelerated loss of kidney function, morbidity, and mortality. We sought to inform efforts at improving post-AKI outcomes by describing the receipt of renal-specific laboratory test surveillance among a large high-risk cohort. METHODS We acquired clinical data from the Electronic health record (EHR) of 5 Veterans Affairs (VA) hospitals to identify patients hospitalized with AKI from January 1st, 2002 to December 31st, 2009, and followed these patients for 1 year or until death, enrollment in palliative care, or improvement in renal function to estimated GFR (eGFR) ≥ 60 L/min/1.73 m(2). Using demographic data, administrative codes, and laboratory test data, we evaluated the receipt and timing of outpatient testing for serum concentrations of creatinine and any as well as quantitative proteinuria recommended for CKD risk stratification. Additionally, we reported the rate of phosphorus and parathyroid hormone (PTH) monitoring recommended for chronic kidney disease (CKD) patients. RESULTS A total of 10,955 patients admitted with AKI were discharged with an eGFR<60 mL/min/1.73 m2. During outpatient follow-up at 90 and 365 days, respectively, creatinine was measured on 69% and 85% of patients, quantitative proteinuria was measured on 6% and 12% of patients, PTH or phosphorus was measured on 10% and 15% of patients. CONCLUSIONS Measurement of creatinine was common among all patients following AKI. However, patients with AKI were infrequently monitored with assessments of quantitative proteinuria or mineral metabolism disorder, even for patients with baseline kidney disease.
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Affiliation(s)
- Michael E. Matheny
- Geriatrics Research Education & Clinical Center (GRECC), Tennessee Valley Healthcare System (TVHS), Veteran's Health Administration, Nashville, TN, United States of America
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Josh F. Peterson
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Svetlana K. Eden
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Adriana M. Hung
- Geriatrics Research Education & Clinical Center (GRECC), Tennessee Valley Healthcare System (TVHS), Veteran's Health Administration, Nashville, TN, United States of America
- Division of Nephrology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Theodore Speroff
- Geriatrics Research Education & Clinical Center (GRECC), Tennessee Valley Healthcare System (TVHS), Veteran's Health Administration, Nashville, TN, United States of America
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Khaled Abdel-Kader
- Division of Nephrology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Sharidan K. Parr
- Division of Nephrology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - T. Alp Ikizler
- Division of Nephrology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Edward D. Siew
- Division of Nephrology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
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Brunelli SM, Wilson S, Krishnan M, Nissenson AR. Confounders of mortality and hospitalization rate calculations for profit and nonprofit dialysis facilities: analytic augmentation. BMC Nephrol 2014; 15:121. [PMID: 25047925 PMCID: PMC4113666 DOI: 10.1186/1471-2369-15-121] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 07/15/2014] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patient outcomes have been compared on the basis of the profit status of the dialysis provider (for-profit [FP] and not-for-profit [NFP]). In its annual report, United States Renal Data System (USRDS) provides dialysis provider level death and hospitalization rates adjusted by age, race, sex, and dialysis vintage; however, recent analyses have suggested that other variables impact these outcomes. Our current analysis of hospitalization and mortality rates of hemodialysis patients included adjustments for those used by the USRDS plus other potential confounders: facility geography (end-stage renal disease network), length of facility ownership, vascular access at first dialysis session, and pre-dialysis nephrology care. METHODS We performed a provider level, retrospective analysis of 2010 hospitalization and mortality rates among US hemodialysis patients exclusively using USRDS sources. Crude and adjusted incidence rate ratios (IRRs) were calculated using the 4 standard USRDS patient factors plus the 4 potential confounders noted above. RESULTS The analysis included 366,011 and 34,029 patients treated at FP and NFP facilities, respectively. There were statistical differences between the cohorts in geography, facility length of ownership, vascular access, and pre-dialysis nephrology care (p < 0.001), as well as age (p < 0.01), race (p < 0.001), and vintage (p < 0.001), but not sex (p = 0.12). When using standard USRDS adjustments, hospitalization and mortality rates for FP and NFP facilities were most disparate, favoring the NFP facilities. Rates were most similar between providers when adjustments were made for each of the 8 factors. With the FP IRR as the referent (1.0), the hospitalization IRR for NFP facilities was 1.00 (95% confidence interval [CI] 0.97-1.02; p = 0.69), while the NFP mortality IRR was 1.01 (95% CI 0.97-1.05; p = 0.64). CONCLUSIONS These data suggest there is no difference in mortality and hospitalization rates between FP and NFP dialysis clinics when appropriate statistical adjustments are made.
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Affiliation(s)
- Steven M Brunelli
- DaVita Clinical Research, 825 South 8th Street, Suite 300, Minneapolis, Minnesota 55404, USA
| | - Steven Wilson
- DaVita Healthcare Partners Inc, Denver, Colorado, USA
| | | | - Allen R Nissenson
- DaVita Healthcare Partners Inc, Denver, Colorado, USA
- David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
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Smart NA, Dieberg G, Ladhani M, Titus T. Early referral to specialist nephrology services for preventing the progression to end-stage kidney disease. Cochrane Database Syst Rev 2014:CD007333. [PMID: 24938824 DOI: 10.1002/14651858.cd007333.pub2] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Early referral of patients with chronic kidney disease (CKD) is believed to help with interventions to address risk factors to slow down the rate of progression of kidney failure to end-stage kidney disease (ESKD) and the need for dialysis, hospitalisation and mortality. OBJECTIVES We sought to evaluate the benefits (reduced hospitalisation and mortality; increased quality of life) and harms (increased hospitalisations and mortality, decreased quality of life) of early versus late referral to specialist nephrology services in CKD patients who are progressing to ESKD and RRT. In this review, referral is defined as the time period between first nephrology evaluation and initiation of dialysis; early referral is more than one to six months, whereas late referral is less than one to six months prior to starting dialysis. All-cause mortality and hospitalisation and quality of life were measured by the visual analogue scale and SF-36. SF-36 and KDQoL are validated measurement instruments for kidney diseases. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2012; Issue 1) which contains the Cochrane Renal Group's Specialised Register; MEDLINE (1966 to February 2012), EMBASE (1980 to February 2012). Search terms were approved by the Trial Search Co-ordinator. SELECTION CRITERIA Randomised controlled trials (RCTs), quasi-RCTs, prospective and retrospective longitudinal cohort studies were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Events relating to adverse effects were collected from the studies. MAIN RESULTS No RCTs or quasi-RCTs were identified. There were 40 longitudinal cohort studies providing data on 63,887 participants; 43,209 (68%) who were referred early and 20,678 (32%) referred late.Comparative mortality was higher in patients referred to specialist services late versus those referred early. Risk ratios (RR) for mortality reductions in patients referred early were evident at three months (RR 0.61, 95% CI 0.55 to 0.67; I² = 84%) and remained at five years (RR 0.66, 95% CI 0.60 to 0.71; I² = 87%). Initial hospitalisation was 9.12 days shorter with early referral (95% CI -10.92 to -7.32 days; I² = 82%) compared to late referral. Pooled analysis showed patients referred early were more likely than late referrals to initiate RRT with peritoneal dialysis (RR 1.74, 95% CI 1.64 to 1.84; I² = 92%).Patients referred early were less likely to receive temporary vascular access (RR 0.47, 95% CL 0.45 to 0.50; I² = 97%) than those referred late. Patients referred early were more likely to receive permanent vascular access (RR 3.22, 95% CI 2.92 to 3.55; I² = 97%). Systolic blood pressure (BP) was significantly lower in early versus late referrals (MD -3.09 mm Hg, 95% CI -5.23 to -0.95; I² = 85%); diastolic BP was significantly lower in early versus late referrals (MD -1.64 mm Hg, 95% CI -2.77 to -0.51; I² = 82%). EPO use was significantly higher in those referred early (RR 2.92, 95% CI 2.42 to 3.52; I² = 0%). eGFR was higher in early referrals (MD 0.42 mL/min/1.73 m², 95% CI 0.28 to 0.56; I² = 95%). Diabetes prevalence was similar in patients referred early and late (RR 1.05, 95% CI 0.96 to 1.15; I² = 87%) as was ischaemic heart disease (RR 1.05, 95% CI 0.97 to 1.13; I² = 74%), peripheral vascular disease (RR 0.99, 95% CI 0.84 to 1.17; I² = 90%), and congestive heart failure (RR 1.00, 95% CI 0.86 to 1.15; I² = 92%). Inability to walk was less prevalent in early referrals (RR 0.66, 95% CI 0.51 to 0.86). Prevalence of chronic obstructive pulmonary disease was similar in those referred early and late (RR 0.89, 95% CI 0.70 to 1.14; I² = 94%) as was cerebrovascular disease (RR 0.90, 95% CI 0.74 to 1.11; I² = 83%).The quality of the included studies was assessed as being low to moderate based on the Newcastle-Ottawa Scale. Slight differences in the definition of early versus late referral infer some risk of bias. Generally, heterogeneity in most of the analyses was high. AUTHORS' CONCLUSIONS Our analysis showed reduced mortality and mortality and hospitalisation, better uptake of peritoneal dialysis and earlier placement of arteriovenous fistulae for patients with chronic kidney disease who were referred early to a nephrologist. Differences in mortality and hospitalisation data between the two groups were not explained by differences in prevalence of comorbid disease or serum phosphate. However, early referral was associated with better preparation and placement of dialysis access.
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Affiliation(s)
- Neil A Smart
- Exercise Physiology Convenor, University of New England, University Drive, Armidale, Australia, NSW 2351
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Miller LM, Vercaigne LM, Moist L, Lok CE, Tangri N, Komenda P, Rigatto C, Mojica J, Sood MM. The association between geographic proximity to a dialysis facility and use of dialysis catheters. BMC Nephrol 2014; 15:40. [PMID: 24576140 PMCID: PMC3974066 DOI: 10.1186/1471-2369-15-40] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 02/21/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Residing remotely from health care resources appears to impact quality of care delivery. It remains unclear if there are differences in vascular access based on distance of one's residence to dialysis centre at time of dialysis initiation, and whether region or duration of pre-dialysis care are important effect modifiers. METHODS We studied the association of distance from a patients' residence to the nearest dialysis centre and central venous catheter (CVC) use in an observational study of 26,449 incident adult dialysis patients registered in the Canadian Organ Replacement Registry between 2000-2009. Multivariate logistic regression was used to assess the association between distance in tertiles and CVC use, adjusted for patient demographics and comorbidities. Geographic region and duration of pre-dialysis care were examined as potential effect modifiers. RESULTS Eighty percent of patients commenced dialysis with a CVC. Incident CVC use was highest among those living > 20 km from the dialysis centre (OR 1.29 (1.24-1.34)) compared to those living < 5 km from centre. The length of pre-dialysis care and geographic region were significant effect modifiers; among patients residing in the furthest tertile (>20 km) from the nearest dialysis centre, incident CVC use was more common with shorter length of pre-dialysis care (< 1 year) and residence in central regions of the country. CONCLUSION Residing further from a dialysis centre is associated with increased CVC use, an effect modified by shorter pre-dialysis care and the geographic region of the country. Efforts to reduce geographical disparities in pre dialysis care may decrease CVC use.
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Singhal R, Hux JE, Alibhai SMH, Oliver MJ. Inadequate predialysis care and mortality after initiation of renal replacement therapy. Kidney Int 2014; 86:399-406. [PMID: 24552848 DOI: 10.1038/ki.2014.16] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 12/05/2013] [Accepted: 12/19/2013] [Indexed: 11/09/2022]
Abstract
Adequacy of chronic kidney disease (CKD) care is traditionally measured as early or late, but this does not reflect the effect of cumulative or consistent care. Here we relate alternate measures of CKD care to mortality and other outcomes in patients with end-stage renal disease (ESRD) who started renal replacement therapy (RRT) between 1998 and 2008. CKD care was defined traditionally as early or late, and alternatively as cumulative care (total visits) and consistency of care in the critical period immediately prior to start of RRT (consistent critical period care required visits in 3 or more of the 6 months prior to RRT start). The primary outcome was 1-year mortality, with secondary outcomes of inpatient start and access creation. Of 12,143 patients aged 18-97 years at the start of RRT, 75.9% had early CKD care. Only 38.3% of the early group had high cumulative (over 10 visits) and consistent critical period care. The 1-year mortality of 15.8% was more likely with late care, lower cumulative care, and inconsistent critical period care. Both cumulative care and consistent critical period care independently predicted mortality, as well as secondary outcomes. Alternate measures of CKD care are important predictors of outcomes in ESRD and should be considered when reporting adequacy of care. Thus, patients traditionally classified as receiving early CKD care often do not receive adequate care immediately prior to initiating RRT.
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Affiliation(s)
- Rajni Singhal
- Department of Nephrology, Humber River Hospital, Toronto, Ontario, Canada
| | - Janet E Hux
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Shabbir M H Alibhai
- Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Matthew J Oliver
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Slinin Y, Guo H, Li S, Liu J, Morgan B, Ensrud K, Gilbertson DT, Collins AJ, Ishani A. Provider and care characteristics associated with timing of dialysis initiation. Clin J Am Soc Nephrol 2014; 9:310-7. [PMID: 24436477 DOI: 10.2215/cjn.04190413] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES There is a trend in the United States to maintenance dialysis initiation at higher levels of estimated GFR. This study aimed to determine whether provider characteristics and pre-ESRD nephrology care and vascular access are independently associated with higher estimated GFR at initiation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This retrospective cohort study used US Renal Data System data for patients who initiated dialysis in 2006 (n=83,621) and American Medical Association Physician Master File data for provider characteristics. Patient characteristics and estimated GFR were defined, and providers at dialysis initiation were identified. Earlier dialysis initiation was defined as initiation at estimated GFR>10 ml/min per 1.73 m(2). Nephrologist density per 100 ESRD patients was calculated by Health Service Area in 2006. Associations between provider characteristics and estimated GFR were determined using logistic regression and linear regression models, accounting for provider clustering. RESULTS Of the cohort, 47.8% of patients initiated dialysis at estimated GFR>10 ml/min per 1.73 m(2), and 16.2% of patients initiated dialysis at estimated GFR≥15 ml/min per 1.73 m(2). Predialysis nephrologist care for 0-12 months was associated with greater odds of earlier initiation compared with no care. Patients initiating with an arteriovenous fistula or graft were more likely to initiate earlier than patients initiating with a catheter. Provider sex was not associated with timing of dialysis initiation as measured by estimated GFR. Care by providers who graduated from nondomestic medical schools was associated with greater odds of earlier initiation. Greater provider experience was associated with lower likelihood of earlier initiation. CONCLUSION This study supports the hypothesis that provider factors are associated with timing of dialysis initiation in the United States.
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Affiliation(s)
- Yelena Slinin
- Primary Care Service Line, Veterans Administration Health Care System, Minneapolis, Minnesota;, †Department of Medicine, University of Minnesota, Minneapolis, Minnesota, ‡Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
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40
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Aparicio M, Bellizzi V, Chauveau P, Cupisti A, Ecder T, Fouque D, Garneata L, Lin S, Mitch W, Teplan V, Yu X, Zakar G. Do ketoanalogues still have a role in delaying dialysis initiation in CKD predialysis patients? Semin Dial 2013; 26:714-9. [PMID: 24016150 DOI: 10.1111/sdi.12132] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Early versus later start of dialysis is still a matter of debate. Low-protein diets have been used for many decades to delay dialysis initiation. Protein-restricted diets (0.3-0.6 g protein/kg/day) supplemented with essential amino acids and ketoanalogues (sVLPD) can be offered, in association with pharmacological treatment, to motivated stage 4-5 chronic kidney disease (CKD) patients not having severe comorbid conditions; they probably represent 30-40% of the concerned population. A satisfactory adherence to such dietary prescription is observed in approximately 50% of the patients. While the results of the studies on the effects of this diet on the rate of progression of renal failure remain inconclusive, they are highly significant when initiation of dialysis is the primary outcome. The correction of uremic symptoms allows for initiation of dialysis treatment at a level of residual renal function lower than that usually recommended. Most of the CKD-associated complications of cardiovascular and metabolic origin, which hamper both lifespan and quality of life, are positively influenced by the diet. Lastly, with regular monitoring jointly assumed by physicians and dietitians, nutritional status is well preserved as confirmed by a very low mortality rate and by the absence of detrimental effect on the long-term outcome of patients once renal replacement therapy is initiated. On account of its feasibility, efficacy and safety, sVLPD deserves a place in the management of selected patients to safely delay the time needed for dialysis.
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Affiliation(s)
- Michel Aparicio
- Nephrology Department, Hopital Pellegrin et Université Bordeaux II, Bordeaux, France
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Winkelmayer WC, Kurella Tamura M. Predialyis nephrology care of older individuals approaching end-stage renal disease. Semin Dial 2013; 25:628-32. [PMID: 23173891 DOI: 10.1111/sdi.12036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Many older patients with advanced CKD approaching ESRD do not receive timely nephrology care, although data suggest that the situation may be improving. In 2005-2008, 43% of older patients who initiated renal replacement therapy had experienced an outpatient nephrologist consultation more than 1 year before starting treatment. Earlier consultation with a nephrologist has been found to provide better access to peritoneal dialysis and kidney transplantation, better preparation for the chosen dialytic modality, and improved survival after start of dialysis or receipt of a kidney transplant. Recent data suggest that older individuals are less likely to receive treatment for ESRD compared with younger individuals in whom almost all receive dialysis treatment or transplantation. Little is known about the role nephrologists play in the decision whether to initiate dialysis or choose a conservative route among older adults with ESRD. Defining the appropriate role and involvement of nephrologists in the decision about initiating renal replacement therapy in older adults seems ripe for further investigation and discussion.
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Affiliation(s)
- Wolfgang C Winkelmayer
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California 94304, USA.
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Thompson S, Bello A, Wiebe N, Manns B, Hemmelgarn B, Klarenbach S, Pelletier R, Tonelli M. Quality-of-care indicators among remote-dwelling hemodialysis patients: a cohort study. Am J Kidney Dis 2013; 62:295-303. [PMID: 23518196 DOI: 10.1053/j.ajkd.2013.01.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 01/16/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND We hypothesized that the higher mortality for hemodialysis patients who live farther from the closest attending nephrologist compared with patients living closer might be due to lower quality of care. STUDY DESIGN Population-based longitudinal study. SETTING & PARTICIPANTS All adult maintenance hemodialysis patients with measurements of quality-of-care indicators initiating hemodialysis therapy between January 2001 and June 2010 in Northern Alberta, Canada. PREDICTORS Hemodialysis patients were classified into categories based on the distance by road from their residence to the closest nephrologist: ≤50 (referent), 50.1-150, 150.1-300, and >300 km. OUTCOMES Quality-of-care indicators were based on published guidelines. MEASUREMENTS Quality-of-care indicators at 90 days following initiation of hemodialysis therapy and, in a secondary analysis, at 1 year. RESULTS Measurements were available for 1,784 patients. At baseline, the proportions of patients residing in each category were 69% for ≤50 km to closest nephrologist; 17%, 50.1-150 km; 7%, 150.1-300 km; and 7%, >300 km. Those who lived farther away from the closest nephrologist were less likely to have seen a nephrologist 90 days prior to the initiation of hemodialysis therapy (P for trend = 0.008) and were less likely to receive Kt/V of 1.2 (adjusted OR, 0.50; 95% CI, 0.30-0.84; P for trend = 0.01). Remote location also was associated with suboptimal levels of phosphate control (P for trend = 0.005). There were no differences in the prevalence of arteriovenous fistulas or grafts or hemoglobin levels across distance categories. LIMITATIONS Registry data with limited data for non-guideline-based quality indicators. CONCLUSIONS Although several quality-of-care indicators were less common in remote-dwelling hemodialysis patients, these differences do not appear sufficient to explain the previously noted disparities in clinical outcomes by residence location.
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Affiliation(s)
- Stephanie Thompson
- Division of Nephrology, University of Alberta, Edmonton, Alberta, Canada
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Watson D. Acute Start-Chronic Needs: Education and Support for Adults who have had Acute Start Dialysis. Semin Dial 2013; 26:184-7. [DOI: 10.1111/sdi.12060] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rao MK, Morris CD, O'Malley JP, Davis MM, Mori M, Anderson S. Documentation and management of CKD in rural primary care. Clin J Am Soc Nephrol 2013; 8:739-48. [PMID: 23371962 DOI: 10.2215/cjn.02410312] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Recognition of CKD by primary care practitioners is essential in rural communities where nephrology access is limited. This study determined the prevalence of undocumented CKD in patients cared for in rural primary care practices and evaluated characteristics associated with undocumented CKD as well as CKD management. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A retrospective cohort study, conducted within the Oregon Rural Practice Based Research Network, consisted of 865 CKD patients with serum creatinine≥1.5 mg/dl in males and ≥1.3 mg/dl in females and an estimated GFR<60 ml/min per 1.73 m(2). Documentation of a CKD diagnosis and laboratory values were abstracted by chart review. RESULTS Of CKD patients, 51.9% had no documentation of CKD. Undocumented CKD occurred more frequently in female patients (adjusted odds ratio=2.93, 95% confidence interval=2.04, 4.21). The association of serum creatinine reporting versus automating reporting of estimated GFR on CKD documentation was dependent on patient sex, years of practitioner experience, and practitioner clinical training. Hypertensive patients with documented CKD were more likely to have a BP medication change than patients with undocumented CKD (odds ratio=2.07, 95% confidence interval=1.15, 3.73). Only 2 of 449 patients with undocumented CKD were comanaged with a nephrologist compared with 20% of patients with documented CKD (odds ratio=53.20, 95% confidence interval=14.90, 189.90). CONCLUSIONS Undocumented CKD in a rural primary care setting is frequent, particularly in female patients. Depending on practitioner characteristics, automatic reporting of estimated GFR might improve documentation of CKD in this population.
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Affiliation(s)
- Maya K Rao
- Department of Medicine, Division of Nephrology and Hypertension, Oregon Health and Science University, Portland, Oregon, USA.
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Bowman BT, Kleiner A, Bolton WK. Comanagement of diabetic kidney disease by the primary care provider and nephrologist. Med Clin North Am 2013; 97:157-73. [PMID: 23290736 DOI: 10.1016/j.mcna.2012.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
DKD is a complex and multifaceted disease. A substantial portion of patients remain unable to attain clinical targets for glycosylated hemoglobin, lipids, and blood pressure. Improving outcomes requires multifactorial interventions that are best delivered through collaborative care. Targets for improvement should include screening, diagnosis, and early referral. Following referral, the patient should be cared for in an integrated framework using the 4 elements of an effective DKD care delivery model: clear roles and responsibilities, integrated QI programs, MDT approach, and effective communication facilitated through access to a shared EMR. Given the differences in the pathophysiology of DM in the renal population, a nephrologist and endocrinologist can be invaluable in improving care for this population. Large-scale trials are needed to validate the cost and usefulness of collaborative care as current data are insufficient. Based on available data, models such as the one proposed here should serve to maximize the strengths of individual providers and provide improved quality of care to patients.
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Affiliation(s)
- Brendan T Bowman
- Division of Nephrology, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA
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Siew ED, Peterson JF, Eden SK, Hung AM, Speroff T, Ikizler TA, Matheny ME. Outpatient nephrology referral rates after acute kidney injury. J Am Soc Nephrol 2012; 23:305-12. [PMID: 22158435 PMCID: PMC3269178 DOI: 10.1681/asn.2011030315] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 10/05/2011] [Indexed: 01/22/2023] Open
Abstract
AKI associates with an increased risk for the development and progression of CKD and mortality. Processes of care after an episode of AKI are not well described. Here, we examined the likelihood of nephrology referral among survivors of AKI at risk for subsequent decline in kidney function in a US Department of Veterans Affairs database. We identified 3929 survivors of AKI hospitalized between January 2003 and December 2008 who had an estimated GFR (eGFR) <60 ml/min per 1.73 m(2) 30 days after peak injury. We analyzed time to referral considering improvement in kidney function (eGFR ≥60 ml/min per 1.73 m(2)), dialysis initiation, and death as competing risks over a 12-month surveillance period. Median age was 73 years (interquartile range, 62-79 years) and the prevalence of preadmission kidney dysfunction (baseline eGFR <60 ml/min per 1.73 m(2)) was 60%. Overall mortality during the surveillance period was 22%. The cumulative incidence of nephrology referral before dying, initiating dialysis, or experiencing an improvement in kidney function was 8.5% (95% confidence interval, 7.6-9.4). Severity of AKI did not affect referral rates. These data demonstrate that a minority of at-risk survivors are referred for nephrology care after an episode of AKI. Determining how to best identify survivors of AKI who are at highest risk for complications and progression of CKD could facilitate early nephrology-based interventions.
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Affiliation(s)
| | - Josh F. Peterson
- Division of General Internal Medicine, Department of Medicine
- Department of Biomedical Informatics, and
- Geriatrics Research Education & Clinical Center, Tennessee Valley Healthcare System VA Medical Center, Veterans Health Administration, Nashville, Tennessee
| | - Svetlana K. Eden
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Adriana M. Hung
- Division of Nephrology and
- Geriatrics Research Education & Clinical Center, Tennessee Valley Healthcare System VA Medical Center, Veterans Health Administration, Nashville, Tennessee
| | - Theodore Speroff
- Division of General Internal Medicine, Department of Medicine
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee; and
- Geriatrics Research Education & Clinical Center, Tennessee Valley Healthcare System VA Medical Center, Veterans Health Administration, Nashville, Tennessee
| | | | - Michael E. Matheny
- Division of General Internal Medicine, Department of Medicine
- Department of Biomedical Informatics, and
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee; and
- Geriatrics Research Education & Clinical Center, Tennessee Valley Healthcare System VA Medical Center, Veterans Health Administration, Nashville, Tennessee
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Identification and management of chronic kidney disease complications by internal medicine residents: a national survey. Am J Ther 2012; 18:e40-7. [PMID: 19918169 DOI: 10.1097/mjt.0b013e3181bbf6fc] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Many patients with chronic kidney disease (CKD) receive care from primary care physicians. Identification and management of CKD complications in primary care is suboptimal. It is not known if current residency curriculum adequately prepares a future internist in this aspect of CKD care. We performed an online questionnaire survey of internal medicine residents in the United States to determine knowledge of CKD complications and their management. Four hundred seventy-nine residents completed the survey with postgraduate year (PGY) distribution 166 PGY1, 187 PGY2, and 126 PGY3. Most of the residents correctly recognized anemia (91%) and bone disease (82%) as complications at estimated glomerular filtration rate less than 60 mL/min/1.73 m; however, only half of the residents identified coronary artery disease (54%) as a CKD complication. For a patient with estimated glomerular filtration rate less than 60 mL/min/1.73 m, two thirds of the residents would workup for anemia (62%), whereas half of them would check for mineral and bone disorder (56%). With regard to anemia of CKD, less than half of the residents knew the CKD goal hemoglobin level of 11 to 12 g/dL (44%); most would supplement iron stores (86%), whereas fewer would consider nephrology referral (28%). For mineral and bone disorders, many residents would recommend dietary phosphorus restriction (68%) and check 25-hydroxyvitamin D (62%); fewer residents would start 1,25-dihydroxyvitamin D (40%) or refer to the nephrologist (45%). Residents chose to discontinue angiotensin-converting enzyme inhibitor for medication-related complication of greater than 50% decline in estimated glomerular filtration rate (68%) and potassium greater than 5.5 mEq/L (93%). Mean performance score improved with increasing PGY (PGY1 59.4% ± 17.6%, PGY2 63.6% ± 15.6%, and PGY3 66.2% ± 16.5%; P = 0.002). Our study identified specific gaps in knowledge of CKD complications and management among internal medicine residents. Educational efforts such as instruction on use of CKD clinical practice guidelines may help raise awareness of CKD complications, benefits of early intervention, and improve CKD management.
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Luxton G. The CARI guidelines. Timing of referral of chronic kidney disease patients to nephrology services (adult). Nephrology (Carlton) 2012; 15 Suppl 1:S2-11. [PMID: 20591032 DOI: 10.1111/j.1440-1797.2010.01224.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Campbell GA, Bolton WK. Referral and comanagement of the patient with CKD. Adv Chronic Kidney Dis 2011; 18:420-7. [PMID: 22098660 DOI: 10.1053/j.ackd.2011.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 10/18/2011] [Accepted: 10/21/2011] [Indexed: 11/11/2022]
Abstract
CKD is a common condition with well-documented associated morbidity and mortality. Given the substantial disease burden of CKD and the cost of ESRD, interventions to delay progression and decrease comorbidity remain an important part of CKD care. Early referral to nephrologists has been shown to delay progression of CKD. Conversely, late referral has been associated with increased hospitalizations, higher mortality, and worsened secondary outcomes. Late referral to nephrology has been consequent to numerous factors, including the health care system, provider issues, and patient related factors. In addition to timely referral to nephrologists, the optimal modality to provide care for CKD patients has also been evaluated. Multidisciplinary clinics have shown significant improvements in other disease states. Data for the use of these clinics have shown benefit in mortality, progression, and laboratory markers of disease severity. However, studies supporting the use of multidisciplinary clinics in CKD have been mixed. Evidence-based guidelines from groups, including Renal Physicians Association and NKF, provide tools for management of CKD patients by both generalists and nephrologists. Through the use of guidelines, timely referral, and a multidisciplinary approach to care, the ability to provide effective and efficient care for CKD patients can be improved. We present a model to guide a multidisciplinary comanagement approach to providing care to patients with CKD.
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Villa G, Fernández-Ortiz L, Cuervo J, Rebollo P, Selgas R, González T, Arrieta J. Cost-effectiveness analysis of the Spanish renal replacement therapy program. Perit Dial Int 2011; 32:192-9. [PMID: 21965620 DOI: 10.3747/pdi.2011.00037] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND We undertook a cost-effectiveness analysis of the Spanish Renal Replacement Therapy (RRT) program for end-stage renal disease patients from a societal perspective. The current Spanish situation was compared with several hypothetical scenarios. METHODS A Markov chain model was used as a foundation for simulations of the Spanish RRT program in three temporal horizons (5, 10, and 15 years). The current situation (scenario 1) was compared with three different scenarios: increased proportion of overall scheduled (planned) incident patients (scenario 2); constant proportion of overall scheduled incident patients, but increased proportion of scheduled incident patients on peritoneal dialysis (PD), resulting in a lower proportion of scheduled incident patients on hemodialysis (HD) (scenario 3); and increased overall proportion of scheduled incident patients together with increased scheduled incidence of patients on PD (scenario 4). RESULTS The incremental cost-effectiveness ratios (ICERs) of scenarios 2, 3, and 4, when compared with scenario 1, were estimated to be, respectively, -€83 150, -€354 977, and -€235 886 per incremental quality-adjusted life year (ΔQALY), evidencing both moderate cost savings and slight effectiveness gains. The net health benefits that would accrue to society were estimated to be, respectively, 0.0045, 0.0211, and 0.0219 ΔQALYs considering a willingness-to-pay threshold of €35 000/ΔQALY. CONCLUSIONS Scenario 1, the current Spanish situation, was dominated by all the proposed scenarios. Interestingly, scenarios 3 and 4 showed the best results in terms of cost-effectiveness. From a cost-effectiveness perspective, an increase in the overall scheduled incidence of RRT, and particularly that of PD, should be promoted.
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Affiliation(s)
- Guillermo Villa
- BAP Health Outcomes Research1 and Department of Medicine, Universidad de Oviedo, Oviedo, Spain.
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