1
|
Ozdemir S, Choong LHL, Gan SWS, Lim LW, Malhotra C, Jafar TH, Yee ACP, Vishwanath P, Tan SNG, Finkelstein EA. Patient Decision Aid Development for Older Adults With End-Stage Kidney Disease in Singapore. Kidney Int Rep 2021; 6:2885-2896. [PMID: 34805639 PMCID: PMC8589693 DOI: 10.1016/j.ekir.2021.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 08/20/2021] [Accepted: 08/30/2021] [Indexed: 10/25/2022] Open
Abstract
Introduction In managing end-stage kidney disease (ESKD), older adults face a decision regarding whether to undergo dialysis or manage symptoms through kidney supportive care (KSC). This article describes the development of a patient decision aid (PDA) that is designed specifically for older adults with ESKD. Methods The decision context of the PDA was to choose a treatment between hemodialysis, peritoneal dialysis, and KSC. The development process used insights obtained from qualitative interviews with patients, informal caregivers, and health care providers. The PDA was then developed in English and Mandarin and was pilot-tested with patients, caregivers, and health care providers. We finalized the PDA based on feedback from pilot testing and performed a preliminary evaluation based on the International Patient Decision Aid Standards (IPDASi v4.0) criteria. Results The final PDA consists of 2 booklets and a video. During pilot testing, patients and caregivers reported high levels of ease of understanding and usefulness with ≥92.5% providing agree/strongly agree responses for the "Content"-related criteria, and ≥75% providing agree/strongly agree responses for the "Development Process and Effectiveness"-related criteria. The final PDA met 10 of 12 IPDASi v4.0 criteria. Conclusions This PDA was found useful during pilot-testing. It will be used during renal counseling in Singapore to help older adults with ESKD and their caregivers make informed decisions on which treatment option is best for the patients.
Collapse
Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | | | - Lydia Wei Lim
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Tazeen H Jafar
- Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | | | | | | | - Eric Andrew Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Signature Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| |
Collapse
|
2
|
Ho QY, Teh SP, Thangaraju S, Teo SH, Tan HK, Abdul Rahman MB, Ng LC, Lim AEL, Choong LHL, Kee T, Kaushik M. Regional Citrate Anticoagulation during Double-Filtration Plasmapheresis in Kidney Transplant Recipients: A Single-Center Retrospective Cohort Study. Blood Purif 2021; 51:376-382. [PMID: 34198288 DOI: 10.1159/000517233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/12/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Double-filtration plasmapheresis (DFPP) may be used for immunomodulation in kidney transplant (KTx). While DFPP reduces plasma product exposure, risk of circuit clotting merits adequate anticoagulation. Regional citrate anticoagulation (RCA) avoids the risks of systemic anticoagulation, but a protocol for RCA-DFPP is not previously widely described. METHODS We conducted a single-center retrospective cohort study involving adult (≥21 years old) KTx recipients who underwent RCA-DFPP from 2018 to 2020 to investigate efficacy and safety for an RCA protocol during DFPP in KTx recipients. RESULTS Fifty-one (85%) of 60 RCA-DFPP sessions in 17 patients completed without circuit clotting. Circuit clotting was associated with high post-filter ionized calcium (28 vs. 3.7%, odds ratio 10.1, 95% CI 1.1-89.4, p = 0.037). Hypo- and hypercalcemia developed in 5 (8.3%) and 8 (13.3%) sessions, respectively, but no adverse effects were noted despite severe hypocalcemia in one. There was no significant change in pre- and post-RCA-DFPP sodium, bicarbonate, albumin, and platelet levels. With regards DFPP procedure, prolongation of prothrombin time (PT) and activated partial thromboplastin time (aPTT) was observed following 38 (64.4%) and 12 (20.3%) sessions, respectively. Severely prolonged (>1.5 × upper limit normal) PT and aPTT were recorded in 2 sessions each. Expectedly, hypofibrinogenemia developed after 31 (51.7%) sessions: including 4 (6.7%) severe hypofibrinogenemia (<0.5 g/L). Two patients developed bleeding requiring blood product transfusion. The median total volume of fluids administered per session was 1.495 (1.373-1.612) L; post-RCA-DFPP significant weight gain of 0.5 (0-1.25) kg was noted. Diuretic was commenced or dose increased following 20 (33.3%) sessions for fluid balance management. DISCUSSION/CONCLUSION Protocol-based RCA for DFPP is feasible and safe in KTx recipients. However, DFPP-related coagulopathy can develop consequent to treatment; caution should be exercised for patients with bleeding risk. Close monitoring and management of the patients' electrolytes, especially hypocalcemia and hypomagnesemia, and fluid status is recommended.
Collapse
Affiliation(s)
- Quan Yao Ho
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore.,SingHealth-Duke NUS Transplant Centre, Singapore, Singapore
| | - Swee Ping Teh
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Sobhana Thangaraju
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore.,SingHealth-Duke NUS Transplant Centre, Singapore, Singapore
| | - Su Hooi Teo
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Han Khim Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Maslinna Binte Abdul Rahman
- SingHealth-Duke NUS Transplant Centre, Singapore, Singapore.,Nursing Division, Singapore General Hospital, Singapore, Singapore
| | - Li Choo Ng
- Nursing Division, Singapore General Hospital, Singapore, Singapore
| | - Amy Ee Lin Lim
- Nursing Division, Singapore General Hospital, Singapore, Singapore
| | - Lina Hui Lin Choong
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Terence Kee
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore.,SingHealth-Duke NUS Transplant Centre, Singapore, Singapore
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | | |
Collapse
|
3
|
Fam JM, Khoo CY, Lau YH, Lye WK, Cai XJ, Choong LHL, Allen JC, Yeo KK. Age and diabetes mellitus associated with worse outcomes after percutaneous coronary intervention in a multi-ethnic Asian dialysis patient population. Singapore Med J 2020; 62:300-304. [PMID: 32179924 DOI: 10.11622/smedj.2020025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION There is limited literature on clinical outcomes following percutaneous coronary intervention (PCI) in Asian dialysis patients. We evaluated the angiographic characteristics and clinical outcomes of dialysis patients treated with PCI in an Asian society. METHODS A retrospective analysis was performed of 274 dialysis patients who underwent PCI in a tertiary care institution from January 2007 to December 2012. Data on clinical and angiographic characteristics was collected. The primary endpoint was major adverse cardiac events (MACE), defined as a composite of cardiac death, acute myocardial infarction (AMI) and stroke at two years. RESULTS 274 patients (65.0% male, median age 62.0 years) with 336 lesions (81.8% Type B2) were treated. 431 stents (35.0% drug-eluting stents) with a mean diameter of 2.96 mm and mean length of 21.30 mm were implanted. The MACE rate was 55.8% (n = 153) at two years, from death (36.5%) and AMI (35.0%). In multivariable analysis, age and diabetes mellitus were significant predictors of both mortality (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.05-1.12, p < 0.001; OR 2.65, 95% CI 1.46-4.82, p = 0.001, respectively) and MACE (OR 1.06, 95% CI 1.03-1.08, p < 0.001; OR 1.84, 95% CI 1.07-3.15, p = 0.027, respectively). Left ventricular ejection fraction (LVEF) (OR 0.97, 95% CI 0.95-0.99, p = 0.006) was a significant predictor of mortality but not MACE. CONCLUSION Asian dialysis patients who underwent PCI had a two-year MACE rate of 55.8% due to death and AMI. Age, LVEF and diabetes mellitus were significant predictors of mortality at two years.
Collapse
Affiliation(s)
- Jiang Ming Fam
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Chun Yuan Khoo
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Yee How Lau
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | - Xinzhe James Cai
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | | | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore
| |
Collapse
|
4
|
Tan CS, Tan SG, Wong CLJ, Wee B, Wong WK, Choke ETC, Tan RY, Liu P, Homer-Vanniasinkam S, Lau T, Choong LHL. Non-randomized safety and performance evaluation of the av-Guardian vascular access system. J Vasc Access 2020; 21:665-672. [DOI: 10.1177/1129729819898306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: The ability to successfully cannulate the arteriovenous fistula reliably is a critical step in the delivery of hemodialysis therapy. The av-Guardian vascular access system (Advent Access, Singapore) is designed to overcome the technical barrier to establishing reliable blunt needle access in patients with mature arteriovenous fistula. Methods: This was a first-in-man, prospective, non-randomized trial (registered on the Australian New Zealand Clinical Trial Registry (ACTRN12617000501347)) performed to assess the safety and feasibility of achieving repeatable successful cannulation via av-Guardian vascular access system to facilitate blunt needling in patients with mature arteriovenous fistula. The primary endpoints of the study included rate of successful hemodialysis sessions via av-Guardian vascular access system cannulation over 3 months and safety of the implants. Results: A total of six patients (four patients with brachiocephalic and two with radiocephalic arteriovenous fistula) were enrolled in the study. A pair of av-Guardian vascular access system were implanted, one each at the arterial and venous cannulation sites, under local anesthesia. Overall, the rate of successful cannulation through the av-Guardian vascular access system over 3 months in 216 hemodialysis sessions was 98.1% (212/216) at the arterial site and 94.4% (204/216) at the venous site. Significantly, 90% and 85.5% of the cannulations at the arterial and venous site, respectively, were successful at first attempt. Blood flow rates within the arteriovenous fistula were unaffected by the devices. Conclusion: The results demonstrated the safety and feasibility of a subcutaneously implanted, extravascular device in achieving repeatable successful cannulation via a constant site, to facilitate blunt needling in matured arteriovenous fistula in limited number of patients.
Collapse
Affiliation(s)
- Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Seck Guan Tan
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Chi Leung Julian Wong
- Division of Vascular Surgery, Department of Cardiac, Thoracic and Vascular Surgery (CTVS), National University Heart Centre, Singapore
| | - Bernard Wee
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Weng Kin Wong
- Division of Nephrology, University Medicine Cluster, National University Health System, Singapore
| | | | - Ru Yu Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Peiyun Liu
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Shervanthi Homer-Vanniasinkam
- Leeds Vascular Institute, Leeds General Infirmary, Leeds, UK
- Division of Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
- Department of Mechanical Engineering, University College London, London, UK
| | - Titus Lau
- Division of Nephrology, University Medicine Cluster, National University Health System, Singapore
| | | |
Collapse
|
5
|
Abstract
This article described the current state of vascular access management for patients with end-stage renal disease in Singapore. Over the past 10 years, there has been a change in the demographics of end-stage renal disease patients. Aging population and the increase in prevalence of diabetes mellitus has led to the acceleration of chronic kidney disease and increase in incidence and prevalence of end-stage renal disease. Vascular access care has, therefore, been more complicated, with the physical, psychological, and social challenges that occur with increased frequency in elderly patients and patients with multiple co-morbidities. Arteriovenous fistula and arteriovenous graft are created by vascular surgeons, while maintenance of patency of vascular access through endovascular intervention has been a shared responsibility between surgeons, interventional radiologists, and interventional nephrologists. Pre-emptive access creation among end-stage renal disease patients has been low, with up to 80% of new end-stage renal disease patients being commenced on hemodialysis via a dialysis catheter. Access creation is exclusively performed by a dedicated vascular surgeon with arteriovenous fistula success rate up to 78%. The primary and cumulative patency rates of arteriovenous fistula and arteriovenous graft were consistent with the results from many international centers. Vascular access surveillance is not universally practiced in all dialysis centers due to its controversies, in addition to the cost and the limited availability of equipment for surveillance. Timely permanent access placement, with reduced dependence on dialysis catheters, and improved vascular access surveillance are the main areas for potential intervention to improve vascular access management.
Collapse
Affiliation(s)
- Suh Chien Pang
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Ru Yu Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Jia Liang Kwek
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Kian Guan Lee
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | | | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| |
Collapse
|
6
|
Wang AYM, Akizawa T, Bavanandan S, Hamano T, Liew A, Lu KC, Lumlertgul D, Oh KH, Zhao MH, Ka-Shun Fung S, Obi Y, Sumida K, Choong LHL, Goh BL, Hao CM, Kwon YJ, Tarng DC, Zuo L, Wheeler DC, Tsukamoto Y, Fukagawa M. 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) Guideline Update Implementation: Asia Summit Conference Report. Kidney Int Rep 2019; 4:1523-1537. [PMID: 31890994 PMCID: PMC6933448 DOI: 10.1016/j.ekir.2019.09.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/09/2019] [Accepted: 09/09/2019] [Indexed: 01/21/2023] Open
Abstract
Improving Global Outcomes (KDIGO) Clinical Practice Guideline on Chronic Kidney Disease–Mineral and Bone Disorder (CKD–MBD) 2009 provided recommendations on the detection, evaluation, and treatment of CKD-MBD in patients CKD who are and are not undergoing dialysis. Because of the accumulation of evidence since this initial publication, the CKD-MBD Guideline underwent a selective update in 2017. In April 2018, KDIGO convened a CKD-MBD Guideline Implementation Summit in Japan with the key objective to discuss various barriers to the uptake and implementation of the CKD-MBD Guideline in 8 Asian countries/regions. These countries/regions were comparable according to their high-to-middle economic ranking assigned by the World Bank. The discussion took into account the availability of CKD-MBD medication therapies and government health policies that may influence reimbursement and practice patterns in the region. Most importantly, Summit participants developed a framework of multifaceted strategies aimed at overcoming barriers to guideline implementation. The Summit attendees suggested a shared decision-making approach between clinicians and patients in CKD-MBD management, as well as individualized care based on the treatment risk-benefit ratio. The Summit participants also discussed how KDIGO, as a guideline development organization, may work in partnership with local and national nephrology societies to provide education and facilitate implementation of the guideline by clinicians. The conclusions drawn from this Summit in Asia may serve as an important guide for other regions to follow.
Collapse
Affiliation(s)
- Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China
| | - Tadao Akizawa
- Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Sunita Bavanandan
- Department of Nephrology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - Takayuki Hamano
- Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Adrian Liew
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
| | - Kuo-Cheng Lu
- Department of Internal Medicine, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan
| | - Dusit Lumlertgul
- Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, China.,Peking-Tsinghua Center for Life Sciences, Beijing, PR, China
| | - Samuel Ka-Shun Fung
- Department of Medicine and Geriatrics, Jockey Club Nephrology and Urology Centre, Princess Margaret Hospital, Kowloon, Hong Kong SAR, China
| | - Yoshitsugu Obi
- Department of Medicine, University of California Irvine Medical Center, Orange, California, USA
| | - Keiichi Sumida
- Nephrology Center, Toranomon Hospital, Kawasaki, Kanagawa, Japan
| | | | - Bak Leong Goh
- Department of Nephrology, Serdang Hospital, Jalan Puchong, Kajang, Selangor, Malaysia
| | - Chuan-Ming Hao
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Young-Joo Kwon
- Department of Internal Medicine, Korea University College of Medicine, Guro Hospital, Seoul, South Korea
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Yusuke Tsukamoto
- Department of Nephrology, Itabashi Chuo Medical Center, Tokyo, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology, and Metabolism, Tokai University School of Medicine, Isehara, Japan
| |
Collapse
|
7
|
Soh BYM, Kumar R, Ekstrom VSM, Lin CYH, Thangaraju SD, Tan HH, Chan KP, Choong LHL, Teo D, Chow WC. Authors' reply. Singapore Med J 2019; 60:323. [PMID: 31243464 PMCID: PMC6595062 DOI: 10.11622/smedj.2019063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Benjy Yi-Min Soh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Victoria Sze-Min Ekstrom
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Clement Yi-Hao Lin
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Sobhana D/O Thangaraju
- Duke-NUS Medical School, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Kwai Peng Chan
- Duke-NUS Medical School, Singapore
- Department of Microbiology, Singapore General Hospital, Singapore
| | - Lina Hui Lin Choong
- Duke-NUS Medical School, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Diana Teo
- Health Sciences Authority, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| |
Collapse
|
8
|
Tan HK, Kaushik M, Tan CW, Liew ZH, Teo SH, Loo CM, Ng LC, Choong LHL, Foo MWY. Augmented Adsorptive Blood Purification during Continuous Veno-Venous Haemodiafiltration in a Severe Septic, Acute Kidney Injury Patient: Use of oXiris®: A Single Centre Case Report. Blood Purif 2019; 47 Suppl 3:1-6. [PMID: 30982048 DOI: 10.1159/000499633] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The use of the oXiris® haemofilter during continuous veno-venous haemodiafiltration (CVVHDF) for acute kidney injury (AKI) and severe sepsis is not completely understood. Although this filter has in vitro adsorptive properties for blood-borne cytokines and other humoural mediators of sepsis, its clinical usefulness is uncertain. Given its inherent adsorptive limitation for septic mediators, we developed a CVVHDF protocol in which the oXiris haemofilter was electively changed every 12 h even though there was no clotting or adverse circuit pressures. Augmented filter membrane adsorption was conducted for 3 consecutive days. We treated a critically ill patient with severe sepsis secondary to a gram-negative bacterial infection and sepsis-associated acute kidney injury (SA- AKI) in this way. The patient required high-dose vasopressor support, required mechanical ventilation, had received 12 h of CVVHDF with conventional M100 haemofilter, was on broad spectrum antibiotics and other conventional intensive care unit (ICU) care, prior to institution of the frequent oXiris haemofilter change protocol. Following the start of elective 12 hourly oXiris filter change, the patient showed reduction in the need for vasopressor and by Day 4 of this SA- AKI frequent filter change protocol, vasopressor requirement ceased, he was extubated. He survived ICU and but not hospital stay. To this end, more clinical studies are needed.
Collapse
Affiliation(s)
- Han Khim Tan
- Department of Renal Medicine, Singapore General Hospital, Singhealth-Duke Academic Medical Centre, Singapore, Singapore,
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singhealth-Duke Academic Medical Centre, Singapore, Singapore
| | - Chee Wooi Tan
- Department of Renal Medicine, Singapore General Hospital, Singhealth-Duke Academic Medical Centre, Singapore, Singapore
| | - Zhong Hong Liew
- Department of Renal Medicine, Singapore General Hospital, Singhealth-Duke Academic Medical Centre, Singapore, Singapore
| | - Su Hooi Teo
- Department of Renal Medicine, Singapore General Hospital, Singhealth-Duke Academic Medical Centre, Singapore, Singapore
| | - Chian Min Loo
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singhealth-Duke Academic Medical Centre, Singapore, Singapore
| | - Li Choo Ng
- Department of Renal Medicine, Singapore General Hospital, Singhealth-Duke Academic Medical Centre, Singapore, Singapore
| | - Lina Hui Lin Choong
- Department of Renal Medicine, Singapore General Hospital, Singhealth-Duke Academic Medical Centre, Singapore, Singapore
| | - Marjorie Wai Yin Foo
- Department of Renal Medicine, Singapore General Hospital, Singhealth-Duke Academic Medical Centre, Singapore, Singapore
| |
Collapse
|
9
|
Ozdemir S, Jafar TH, Choong LHL, Finkelstein EA. Family dynamics in a multi-ethnic Asian society: comparison of elderly CKD patients and their family caregivers experience with medical decision making for managing end stage kidney disease. BMC Nephrol 2019; 20:73. [PMID: 30823872 PMCID: PMC6397496 DOI: 10.1186/s12882-019-1259-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/18/2019] [Indexed: 12/02/2022] Open
Abstract
Background Elderly end stage kidney patients face a decision concerning whether or not to initiate dialysis. In Asia, this decision is highly influenced by family caregivers. The objective of this paper was to understand patients’ experience with and preferences for family involvement in treatment decisions, and via a series of hypothetical vignettes, to identify whether there was discordance in treatment preferences between patients and their caregivers, and how any potential conflicts were reconciled. Methods We conducted a survey with 151 elderly (aged ≥65) chronic kidney disease patients and their caregivers at outpatient renal clinics. The survey asked, when making treatment decisions, whom they wish makes the final decisions (i.e., preference) and who usually makes the final decisions (i.e., experience). The survey also presented a series of choice vignettes for managing patient’s condition and asked respondents to choose between two hypothetical treatment profiles in each vignette. Patients and caregivers were first interviewed separately in tandem, and then were brought together to choose a treatment jointly for vignettes where the initial treatment choice differed within the dyad. We used multivariate regressions to investigate the predictors of discordance and reconciliation. Results We found that most (51%) patients preferred and experienced (64%) significant involvement from caregivers. However, 38% of patients preferred to make final decisions alone but only 27% of patients did. In the hypothetical vignettes, caregivers chose the more intensive option (i.e., dialysis) more than patients did (26% vs 19%; p < 0.01). Overall, 44% of the dyads had discordance in at least 3 vignettes, and the odds of discordance within patient-caregiver dyads was higher when caregivers chose dialysis or treatment with the higher cost (p < 0.01). In half the cases, discordance resolved in the patients’ favor, and this was more likely to be the case if the patient was employed and wanted to be in charge of final decisions (p < 0.01). Conclusions Our results highlight the important role of caregivers in decision-making but also the potential for them to overstep. Clinicians should be aware of this challenge and identify strategies that minimize the chances that patients may receive treatments not consistent with their preferences. Electronic supplementary material The online version of this article (10.1186/s12882-019-1259-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.,Programme in Health Services and Systems Research Programme, Duke-NUS Medical School Singapore, 8 College Road, Singapore, 169857, Singapore
| | - Tazeen H Jafar
- Programme in Health Services and Systems Research Programme, Duke-NUS Medical School Singapore, 8 College Road, Singapore, 169857, Singapore
| | - Lina Hui Lin Choong
- Department of Renal Medicine, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
| | - Eric Andrew Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore. .,Programme in Health Services and Systems Research Programme, Duke-NUS Medical School Singapore, 8 College Road, Singapore, 169857, Singapore.
| |
Collapse
|
10
|
Soh BYM, Kumar R, Ekstrom VSM, Lin CYH, Thangaraju SD, Tan HH, Chan KP, Choong LHL, Teo D, Chow WC. Prevalence of hepatitis C virus infection and the IL28B genotype polymorphism among blood donors and high-risk populations. Singapore Med J 2019; 60:34-39. [PMID: 29926111 PMCID: PMC6351688 DOI: 10.11622/smedj.2018078] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION To study the prevalence of hepatitis C virus (HCV) infection in blood donor (BD), haemodialysis (HD) and intravenous drug user (IVDU) populations in Singapore and assess the IL28B polymorphism if HCV positive. METHODS The BD population were healthy volunteers, the HD population were patients who were on haemodialysis for at least six months of follow-up between January 2009 and December 2014. IVDU population was from inmates at halfway houses who consented. RESULTS Between 2011 and 2014, of 161,658 individuals who underwent screening prior to blood donation, 95 (0.059%) were positive for HCV. Of the 42 sera available, common genotypes (GTs) were GT-3 (47.6%) and GT-1 (31.0%). Of 1,575 HD patients, 2.2% were anti-HCV positive. The HCV GT distribution was HCV GT-1 (32.4%), HCV GT-3 (20.5%) and GT-6 (8.8%). 83 halfway house inmates were screened. Of the 47 IVDUs, 36.2% were anti-HCV positive with predominant GT-3 (%). IL28B polymorphism was noted to be CC predominantly 85.3%. CONCLUSION Prevalence of HCV infection has decreased in both the BD and HD populations. However, it remains high in the IVDU population. GT-1 remains the most common in the HD population; however, GT-3 infection is now more common among the BD population in Singapore. IL28B - CC is the predominant variant among the HCV-infected individuals in Singapore.
Collapse
Affiliation(s)
- Benjy Yi-Min Soh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Victoria Sze-Min Ekstrom
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Clement Yi-Hao Lin
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Sobhana D/O Thangaraju
- Duke-NUS Medical School, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | | | - Kwai Peng Chan
- Duke-NUS Medical School, Singapore
- Department of Microbiology, Singapore General Hospital, Singapore
| | - Lina Hui Lin Choong
- Duke-NUS Medical School, Singapore
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Diana Teo
- Health Sciences Authority, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| |
Collapse
|
11
|
Tan RY, Lee KG, Gan SWS, Li H, Yeon W, Pang SC, Teh SP, Htay H, Teo SH, Kwek JL, Tok PL, Poh CB, Ng CY, Liu P, Tay HB, Koniman R, Foo MWY, Choong LHL, Tan CS. Impact of simulation‐based learning on immediate outcomes of temporary haemodialysis catheter placements by nephrology fellows. Nephrology (Carlton) 2018; 23:933-939. [DOI: 10.1111/nep.13156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/21/2017] [Accepted: 08/13/2017] [Indexed: 01/02/2023]
Affiliation(s)
- Ru Yu Tan
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Kian Guan Lee
- Department of Renal MedicineSingapore General Hospital Singapore
| | | | - Huihua Li
- Health Services Research UnitSingapore General Hospital Singapore
| | - Wenxiang Yeon
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Suh Chien Pang
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Swee Ping Teh
- Health Services Research UnitSingapore General Hospital Singapore
| | - Htay Htay
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Su Hooi Teo
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Jia Liang Kwek
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Pei Loo Tok
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Cheng Boon Poh
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Chee Yong Ng
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Peiyun Liu
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Hui Boon Tay
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Riece Koniman
- Department of Renal MedicineSingapore General Hospital Singapore
| | | | | | - Chieh Suai Tan
- Department of Renal MedicineSingapore General Hospital Singapore
| |
Collapse
|
12
|
Tan CS, Loh HL, Foo MWY, Choong LHL, Wong KS, Kee TYS. Epstein-Barr virus-associated smooth muscle tumors after kidney transplantation: treatment and outcomes in a single center. Clin Transplant 2013; 27:E462-8. [PMID: 23682851 DOI: 10.1111/ctr.12139] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2013] [Indexed: 01/20/2023]
Abstract
BACKGROUND Epstein-Barr virus-associated smooth muscle tumors (EBV SMT) in adult kidney transplant recipients (KTR) are rare. The aims of this study are to document the clinical features, types of treatment given, and outcomes of KTR with EBV SMT in our institution. METHODS Sixteen patients were identified from our institution's databases. Patients' survival, tumor outcome, and graft survival were compared between patients who remained on cyclosporine-based immunosuppressant and those who converted to sirolimus-based therapy. RESULTS The median time of diagnosis was 9.4 yr after kidney transplantation, and majority of the patients had multifocal disease at the time of diagnosis. Overall, the patient survival rate was 75% over a mean follow-up period of five yr. Two patients with non-functioning allograft at the time of diagnosis of EBV SMT were excluded from the treatment outcome analysis. Comparing the sirolimus (n = 7) vs. cyclosporine groups (n = 7), patient survival rate was 100% vs. 42.9% (p = 0.08), graft survival 71.4% vs. 28.7% (p = 0.53), and disease-free status 42.9% vs. 14.3% (p = 0.73), respectively. CONCLUSION Surgical resection in combination with decreasing immunosuppression or conversion to sirolimus appears to be effective in the treatment of EBV SMT in KTR.
Collapse
Affiliation(s)
- Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore.
| | | | | | | | | | | |
Collapse
|
13
|
Tan HK, Lim JSS, Tan CK, Ng HS, Chow P, Lui HF, Wong GC, Tan PHC, Raghuram J, Ng HN, Choong LHL, Wong KS, Woo KT. MARS therapy in critically ill patients with advanced malignancy: a clinical and technical report. Liver Int 2004; 23 Suppl 3:52-60. [PMID: 12950962 DOI: 10.1034/j.1478-3231.23.s.3.3.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND/METHODS Molecular Adsorbent Recirculating System (MARS) was used in three consecutive critically ill patients at the Singapore General Hospital with advanced malignancy and acute liver failure (ALF). Case 1 was a male patient with hepatocellular carcinoma (HCC) for which initial right hepatectomy was followed by left hepatectomy 5 months later for recurrent HCC. The postoperative course following second surgery was complicated by severe methicillin-resistant Staphylococcus aureus (MRSA) sepsis, mild azotaemia and subacute cholestatic liver failure. MARS was used thrice in this patient. Case 2 was a female patient with advanced acute lymphoblastic leukaemia (ALL) with post bone marrow transplantation (BMT) acute haemolytic-uraemic syndrome (HUS) secondary to cyclosporin A (Cy A), cytomegalovirus (CMV) infection, severe nosocomial pneumonia, acute renal failure (ARF) treated with continuous haemofiltration and acute veno-occlusive disease resulting in Budd-Chiari syndrome. The latter precipitated ALF. MARS was instituted twice. Case 3 was a male patient with advanced, refractory Hodgkin's disease previously treated with multiple courses of chemotherapy. ALF developed secondary to acute viral hepatitis B flare. He was given a trial of MARS once in the ICU. All the three patients eventually died. RESULTS Mean MARS intradialytic systemic pressures were as follows: systolic pressure range was 95 +/- 17 to 128 +/- 17 mmHg and diastolic pressure range was 51 +/- 5 to 67 +/- 7 mmHg. Pressure at albumin dialysate exit point from dialyser 1 (Ae) ranged from 253 +/- 11 to 339 +/- 15 mmHg and that at albumin dialysate entry point into dialyser 1 (Aa) ranged from 142 +/- 11 to 210 +/- 6 mmHg. Ultrafiltration (UF) was 633 +/- 622 mL over mean treatment duration of 6.3 +/- 0.9 h with a total heparin dose of 1583 +/- 817 IU. Coagulation status pre- and 6-h post-MARS was similar: aPTT (P=0.116) and platelet count (P=0.753). There were no bleeding complications or circuit thromboses. MARS had a significant de-uraemization effect (pre- and post-MARS serum creatinine and urea: P=0.046 and 0.028, respectively) but did not significantly attenuate blood lactate, ammonia or total bilirubin levels. Albumin dialysate (Ae - Aa) urea and creatinine concentrations appeared to be sharply attenuated after 6 h of MARS. In contrast, the removal of total bilirubin by albumin dialysate from the blood compartment appeared to plateau after 4 h of continuous MARS operation. CONCLUSIONS MARS was well-tolerated in critically ill patients with advanced and complicated cancer. Low-dose heparin was safe and did not compromise MARS circuit integrity. Although MARS had a significant de-uraemization effect, this appeared to be limited by the duration of MARS operation. Our data suggested that such a limit was reached earlier for total bilirubin. More data are needed to confirm the present findings and further delineate the saturation limit of MARS for different toxins that accumulate in ALF. This would affect the optimal duration of MARS therapy.
Collapse
Affiliation(s)
- H K Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Liem LK, Choong LHL, Woo KT. Porous graphitic carbon shows promise for the rapid screening partial DPD deficiency in lymphocyte dihydropyrimidine dehydrogenase in Chinese, Indian and Malay in Singapore by using semi-automated HPLC-radioassay. Clin Biochem 2002; 35:181-7. [PMID: 12074825 DOI: 10.1016/s0009-9120(02)00303-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Dihydropyrimidine dehydrogenase (DPD) catalyzes the degradation of thymine, uracil, and the chemotherapeutic drug 5-Fluorouracil. In general reverse-phase high pressure liquid chromatography is the standard method for separating 5-[2-(14)C]Fluorouracil and 5-[2-(14)C]Fluoro-5,6-dihydrouracil. However, the use of 100% aqueous solution (as HPLC mobile phase) may collapse the C-18 bonded phase and result in a retention time shift. The aim of this study is to develop a rapid, reproducible, sensitive method for screening partial DPD deficiency in healthy volunteers. DESIGN AND METHODS The activity of DPD was measured using 5-[2- (14)C]Fluorouracil (5-[2-(14)C]FUra) followed by separation of substrate and product 5-[2-(14)C]FUraH(2) with a 15 x 4.6 mm I.D., 5 microm particle size (d(p)) porous graphitic carbon (PGC) column (Hypercarb(R)) and HPLC with online detection of the radioactivity. This was standardized using the protein concentration of the cytosol (NanoOrange(R) Protein Quantitation). RESULTS Complete baseline separation of 5-[2-(14)C]Fluorouracil (5-[2-(14)C]FUra) and 5-[2-(14)C]Fluoro-5,6-dihydrouracil (5-[2-(14)C]FUraH(2)) was achieved using a porous graphitic carbon (PGC) column. The detection limit for 5-[2-(14)C]FUraH(2) was 0.4 pmol. CONCLUSIONS By using linear gradient separation (0.1% Trifluoroacetic acid [TFA] in water to 100% Methanol) protocols in concert with PGC columns (Hypercarb(R)), we have demonstrated that a PGC column has a distinct advantage over C-18 reverse phase columns in terms of column stability (pH 1-14). This method provides an improvement on the specific assay for DPD enzyme activity. It is rapid, reproducible and sensitive and can be used for routine screening for healthy and cancer patients for partial and profound DPD deficiency before treatment with 5- FUra.
Collapse
Affiliation(s)
- Lie Kuo Liem
- Donner Laboratory, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, USA.
| | | | | |
Collapse
|