Timing of dialysis initiation to reduce mortality and cardiovascular events in advanced chronic kidney disease: nationwide cohort study

OBJECTIVE

To identify the optimal estimated glomerular filtration rate (eGFR) at which to initiate dialysis in people with advanced chronic kidney disease.

DESIGN

Nationwide observational cohort study.

SETTING

National Swedish Renal Registry of patients referred to nephrologists.

PARTICIPANTS

Patients had a baseline eGFR between 10 and 20 mL/min/1.73 m2 and were included between 1 January 2007 and 31 December 2016, with follow-up until 1 June 2017.

MAIN OUTCOME MEASURES

The strict design criteria of a clinical trial were mimicked by using the cloning, censoring, and weighting method to eliminate immortal time bias, lead time bias, and survivor bias. A dynamic marginal structural model was used to estimate adjusted hazard ratios and absolute risks for five year all cause mortality and major adverse cardiovascular events (composite of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) for 15 dialysis initiation strategies with eGFR values between 4 and 19 mL/min/1.73 m2 in increments of 1 mL/min/1.73 m2. An eGFR between 6 and 7 mL/min/1.73 m2 (eGFR6-7) was taken as the reference.

RESULTS

Among 10 290 incident patients with advanced chronic kidney disease (median age 73 years; 3739 (36%) women; median eGFR 16.8 mL/min/1.73 m2), 3822 started dialysis, 4160 died, and 2446 had a major adverse cardiovascular event. A parabolic relation was observed for mortality, with the lowest risk for eGFR15-16. Compared with dialysis initiation at eGFR6-7, initiation at eGFR15-16 was associated with a 5.1% (95% confidence interval 2.5% to 6.9%) lower absolute five year mortality risk and 2.9% (0.2% to 5.5%) lower risk of a major adverse cardiovascular event, corresponding to hazard ratios of 0.89 (95% confidence interval 0.87 to 0.92) and 0.94 (0.91 to 0.98), respectively. This 5.1% absolute risk difference corresponded to a mean postponement of death of 1.6 months over five years of follow-up. However, dialysis would need to be started four years earlier. When emulating the intended strategies of the Initiating Dialysis Early and Late (IDEAL) trial (eGFR10-14 v eGFR5-7) and the achieved eGFRs in IDEAL (eGFR7-10 v eGFR5-7), hazard ratios for all cause mortality were 0.96 (0.94 to 0.99) and 0.97 (0.94 to 1.00), respectively, which are congruent with the findings of the randomised IDEAL trial.

CONCLUSIONS

Very early initiation of dialysis was associated with a modest reduction in mortality and cardiovascular events. For most patients, such a reduction may not outweigh the burden of a substantially longer period spent on dialysis.

Funnel plots of patient-reported outcomes to evaluate health-care quality: Basic principles, pitfalls and considerations

A funnel plot is a graphical method to evaluate health-care quality by comparing hospital performances on certain outcomes. So far, in nephrology, this method has been applied to clinical outcomes like mortality and complications. However, patient-reported outcomes (PROs; eg, health-related quality of life [HRQOL]) are becoming increasingly important and should be incorporated into this quality assessment. Using funnel plots has several advantages, including clearly visualized precision, detection of volume-effects, discouragement of ranking hospitals and easy interpretation of results. However, without sufficient knowledge of underlying methods, it is easy to stumble into pitfalls, such as overinterpretation of standardized scores, incorrect direct comparisons of hospitals and assuming a hospital to be in-control (ie, to perform as expected) based on underpowered comparisons. Furthermore, application of funnel plots to PROs is accompanied by additional challenges related to the multidimensional nature of PROs and difficulties with measuring PROs. Before using funnel plots for PROs, high and consistent response rates, adequate case mix correction and high-quality PRO measures are required. In this article, we aim to provide insight into the use and interpretation of funnel plots by presenting an overview of the basic principles, pitfalls and considerations when applied to PROs, using examples from Dutch routine dialysis care.

Obesity is common in chronic kidney disease and associates with greater antihypertensive usage and proteinuria: evidence from a cross-sectional study in a tertiary nephrology centre

Obesity is a treatable risk factor for chronic kidney disease progression. We audited the reporting of body-mass index in nephrology outpatient clinics to establish the characteristics of individuals with obesity in nephrology practice. Body-mass index, clinical information and biochemical measures were recorded for patients attending clinics between 3^rd August, 2018 and 18^th January, 2019. Inferential statistics and Pearson correlations were used to investigate relationships between body-mass index, type 2 diabetes, hypertension and proteinuria. Mean ± SD BMI was 28.6 ± 5.8 kg/m² (n = 374). Overweight and obesity class 1 were more common in males (P = .02). Amongst n = 123 individuals with obesity and chronic kidney disease, mean ± SD age, n (%) female and median[IQR] eGFR were 64.1 ± 14.2 years, 52 (42.3%) and 29.0[20.5] mL/min/BSA, respectively. A positive correlation between increasing body-mass index and proteinuria was observed in such patients (r = 0.21, P = .03), which was stronger in males and those with CKD stages 4 and 5. Mean body-mass index was 2.3 kg/m² higher in those treated with 4-5 versus 0-1 antihypertensives (P = .03). Amongst n = 59 patients with obesity, chronic kidney disease and type 2 diabetes, 2 (3.5%) and 0 (0%) were prescribed a GLP-1 receptor analogue and SGLT2-inhibitor, respectively. Our data provides a strong rationale not only for measuring body-mass index but also for acting on the information in nephrology practice, although prospective studies are required to guide treatment decisions in people with obesity and chronic kidney disease.

[Impact of the COVID-19 pandemic on Spanish Nephrology Services]

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has required a rapid and drastic transformation of hospitals, and consequently also of Spanish Nephrology Units, to respond to the critical situation. The Spanish Society of Nephrology conducted a survey directed to the Heads of Nephrology Departments in Spain that addressed the reorganisation of Nephrology departments and activity during the peak of COVID-19 pandemic. The survey has been focused on the integration of nephrologists in COVID-19 teams, nephrology inpatient care activities (elective admissions, kidney biopsies), the performance of elective surgeries such as vascular accesses or implantation of peritoneal catheters, the suspension of kidney transplantation programmes and the transformation of nephrology outpatient clinics. This work details the adaptation and transformation of nephrology services during the COVID-19 pandemic in Spain. During this period, elective admissions to Nephrology Services, elective surgeries and biopsies were suspended, and the kidney transplant programme was scaled back by more than 75%. It is worth noting that outpatient nephrology consultations were carried out largely by telephone. In conclusion, the pandemic has clearly impacted clinical activity in Spanish Nephrology departments, reducing elective activity and kidney transplants, and modifying activity in outpatient clinics. A restructuring and implementation plan in Nephrology focused on telemedicine and/or virtual medicine would seem to be both necessary and very useful in the near future.

Nephrologist Follow-Up Care of Patients With Acute Kidney Disease Improves Outcomes: Taiwan Experience

OBJECTIVES

Acute kidney injury (AKI) and acute kidney disease (AKD) are a continuum on a disease spectrum and frequently progress to chronic kidney disease. Benefits of nephrologist subspecialty care during the AKD period after AKI are uncertain.

METHODS

Patients with AKI requiring dialysis who subsequently became dialysis independent and survived for at least 90 days, defined as the AKD period, were identified from the Taiwanese population's health insurance database. Cox proportional hazard models using death as the competing risk before and after propensity-score matching were applied to evaluate various endpoints.

RESULTS

Among a total of 20 260 patients with AKI requiring dialysis who became dialysis independent, only 7550 (37.3%) patients were followed up with by a nephrologist (F/U_nephrol group) during the AKD period. During a mean 4.04 ± 3.56 years of follow-up, the patients in the F/U_nephrol group were more often administered statin, antihypertensives, angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), diuretics, antiplatelet agents, and antidiabetic agents. The patients in the F/U_nephrol group had a lower mortality rate (hazard ratio [HR] = 0.87, P < .001) and were less likely to have major adverse cardiovascular events (MACE) (subdistribution HR [sHR] = 0.85, P < .001), congestive heart failure (CHF) (sHR = 0.81, P < .001), and severe sepsis (sHR = 0.88, P = .008) according to the Cox proportional model after adjusting for mortality as a competing risk. During the AKD period, an increase in the frequency of nephrology visits was associated with improved outcomes.

CONCLUSIONS

In this population-based cohort, even after weaning off acute dialysis, only a minority of patients visited a nephrologist during the AKD period. We showed that nephrology follow-up is associated with a decrease in MACE, CHF exacerbations, and sepsis, as well as lower mortality; thus it may improve outcomes in patients with AKD.

Implementation of a quality improvement strategy to increase outpatient kidney transplant referrals

BACKGROUND

Kidney transplantation remains the optimal therapy for patients with end stage kidney disease (ESKD), though a small fraction of patients on dialysis are on organ waitlists. An important barrier to both preemptive kidney transplantation and successful waitlisting is timely referral to a kidney transplant center. We implemented a quality improvement strategy to improve outpatient kidney transplant referrals in a single center academic outpatient nephrology clinic.

METHODS

Over a 3 month period (July 1-September 30, 2016), we assessed the baseline kidney transplantation referral rate at our outpatient nephrology clinic for patients 18-75 years old with an estimated glomerular filtration rate (eGFR) of less than 20 mL/min/1.73m2 (2 values over 90 days apart). Charts were manually reviewed by two reviewers to look for kidney transplant referrals and documentation of discussions about kidney transplantation. We then performed a root cause analysis to explore potential barriers to kidney transplantation. Our intervention began on July 1, 2017 and included the implementation of a column in the electronic medical record (EMR) which displayed the patient's last eGFR as part of the clinic schedule. In addition, physicians were given a document listing their patients to be seen that day with an eGFR of < 20 mL/min/1.73m2. Annual education sessions were also held to discuss the importance of timely kidney transplant referral.

RESULTS

At baseline, 54 unique patients with eGFR ≤20 ml/min/1.73 m2 were identified who were seen in the Clinic between July 1, 2016 and September 30, 2016. 29.6% (16) eligible patients were referred for kidney transplantation evaluation. 69.5% (37) of these patients were not referred for kidney transplant evaluation. 46.3% (25) did not have documentation regarding kidney transplant in the EMR. nephrologist's most recent note. Following the intervention, 66 unique patients met criteria for eligibility for kidney transplant evaluation. Kidney transplant referrals increased to 60.6% (p <  0.001).

CONCLUSIONS

Our pilot implementation study of a strategy to improve outpatient kidney transplant referrals showed that a free, simple, scalable intervention can significantly improve kidney transplant referrals in the outpatient setting. This intervention targeted the nephrologist's role in the transplant referral, and facilitated the process of patient recognition and performing the referral itself without significantly interrupting the workflow. Next steps include further investigation to study the impact of early referral to kidney transplant centers on preemptive and living donor kidney transplantation as well as successful waitlisting.

Time to referral to a nephrology clinic for pediatric hypertension

BACKGROUND

Rates of pediatric hypertension have increased, but adherence to the current diagnostic criteria for hypertension (HTN) in pediatrics is not well known. We investigated the timeline and predictors of time to referral for those referred to nephrology for elevated blood pressure (EBP).

METHODS

A retrospective study was conducted on patients, aged 3-18 years, referred to a nephrology clinic for EBP over a 3-year period. Patients were excluded if they were referred previously, were referred for other conditions, or did not have ≥ 1 prior visit with EBP. Analyses were performed to determine whether sex, age, ethnicity, socioeconomic status, and obesity predicted number of prior visits with EBP and time to referral.

RESULTS

There were 120 patients (64% male; 53% obese) included and 82 (68%) had ≥ 3 prior visits with EBP ≥ 95%. Medians were as follows: 15.08 years of age at referral; 5 visits with EBP and 3.45 years from first EBP ≥ 90%; 4 visits with EBP and 1.42 years from third EBP ≥ 95%. No variables significantly predicted number of prior visits with EBP or time to referral from the first EBP. Starting with the third EBP ≥ 95%, only obesity significantly predicted number of prior visits and time to referral: Obese patients had more visits (p = 0.01), and took longer to be referred (p = 0.03) than healthy patients.

CONCLUSION

Patients with EBP were generally not referred to nephrology promptly, which was especially true for obese patients. Further research is needed to identify interventions to improve time to referral for EBP.

Factors associated with late presentation of patients with chronic kidney disease in nephrology consultation in Cameroon-a descriptive cross-sectional study

BACKGROUND

Late presentation (LP) of chronic kidney disease (CKD) patients to nephrologist is a serious problem worldwide with persistent high prevalence despite known benefits of early nephrology care.

OBJECTIVE

Determine the prevalence and factors associated with LP of CKD patients to nephrologists in Cameroon.

METHODS

A cross-sectional study from October 2015 to May 2016 at the nephrology units of the Douala General and Laquintinie hospitals, including all consenting incident CKD patients. Data collected were: socio-demographic, search of CKD diagnostic criteria during prior follow up, therapeutic itinerary, clinical and biological parameters at presentation, knowledge on CKD and attitude towards dialysis. LP was defined as eGFR < 30 ml/min/1.73 m2. It was physician-related whenever no CKD screening was done in the presence of risk factor or no referral to nephrologists at early stages; patient-related whenever patients did not have recourse to hospital care while symptomatic or disrespected a referral decision. p value <.05.

RESULTS

We included 130 patients, mean age 53.10 ± 14.66 years, 60.77% males, 58.70% were referred by internal medicine physicians and 10% had recourse to complementary and alternative medicine (CAM). At presentation, 70.80% were symptomatic, 53% had CKD stage five, 86.12% were poorly graded on knowledge and 49% had a negative attitude towards dialysis. The prevalence of LP was 73.90%, 50% was physician-related, 44.79% patient-related and 5.21% both. Being accompanied (p = .038), a low level of education (p = .025) and recourse to CAM (p = .008) were associated with LP.

CONCLUSION

LP is high in Cameroon, attributed to physician's practical attitudes and patient's socio-cultural behaviors and economic conditions.

Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional survey

OBJECTIVE

To determine the global capacity (availability, accessibility, quality, and affordability) to deliver kidney replacement therapy (dialysis and transplantation) and conservative kidney management.

DESIGN

International cross sectional survey.

SETTING

International Society of Nephrology (ISN) survey of 182 countries from July to September 2018.

PARTICIPANTS

Key stakeholders identified by ISN's national and regional leaders.

MAIN OUTCOME MEASURES

Markers of national capacity to deliver core components of kidney replacement therapy and conservative kidney management.

RESULTS

Responses were received from 160 (87.9%) of 182 countries, comprising 97.8% (7338.5 million of 7501.3 million) of the world's population. A wide variation was found in capacity and structures for kidney replacement therapy and conservative kidney management-namely, funding mechanisms, health workforce, service delivery, and available technologies. Information on the prevalence of treated end stage kidney disease was available in 91 (42%) of 218 countries worldwide. Estimates varied more than 800-fold from 4 to 3392 per million population. Rwanda was the only low income country to report data on the prevalence of treated disease; 5 (<10%) of 53 African countries reported these data. Of 159 countries, 102 (64%) provided public funding for kidney replacement therapy. Sixty eight (43%) of 159 countries charged no fees at the point of care delivery and 34 (21%) made some charge. Haemodialysis was reported as available in 156 (100%) of 156 countries, peritoneal dialysis in 119 (76%) of 156 countries, and kidney transplantation in 114 (74%) of 155 countries. Dialysis and kidney transplantation were available to more than 50% of patients in only 108 (70%) and 45 (29%) of 154 countries that offered these services, respectively. Conservative kidney management was available in 124 (81%) of 154 countries. Worldwide, the median number of nephrologists was 9.96 per million population, which varied with income level.

CONCLUSIONS

These comprehensive data show the capacity of countries (including low income countries) to provide optimal care for patients with end stage kidney disease. They demonstrate substantial variability in the burden of such disease and capacity for kidney replacement therapy and conservative kidney management, which have implications for policy.

Developing nephrology services in low income countries: a case of Tanzania

BACKGROUND

The burden of kidney diseases is reported to be higher in lower- and middle-income countries as compared to developed countries, and countries in sub-Saharan Africa are reported to be most affected. Health systems in most sub-Sahara African countries have limited capacity in the form of trained and skilled health care providers, diagnostic support, equipment and policies to provide nephrology services. Several initiatives have been implemented to support establishment of these services.

METHODS

This is a situation analysis to examine the nephrology services in Tanzania. It was conducted by interviewing key personnel in institutions providing nephrology services aiming at describing available services and international collaborators supporting nephrology services.

RESULTS

Tanzania is a low-income country in Sub-Saharan Africa with a population of more than 55 million that has seen remarkable improvement in the provision of nephrology services and these include increase in the number of nephrologists to 14 in 2018 from one in 2006, increase in number of dialysis units from one unit (0.03 unit per million) before 2007 to 28 units (0.5 units per million) in 2018 and improved diagnostic services with introduction of nephropathology services. Government of Tanzania has been providing kidney transplantation services by funding referral of donor and recipients abroad and has now introduced local transplantation services in two hospitals. There have been strong international collaborators who have supported nephrology services and establishment of nephrology training in Tanzania.

CONCLUSION

Tanzania has seen remarkable achievement in provision of nephrology services and provides an interesting model to be used in supporting nephrology services in low income countries.

Hemodialysis Quality Metrics in the First Year Following a Failed Kidney Transplant

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.

[Waiting time on dialysis for active access to renal transplantation: a multicenter cross-sectional study in Lombardy]

BACKGROUND

The amount of time spent in dialysis waiting for a renal transplantation significantly affects its outcome. Hence, the timely planning of patients' transplant evaluation is crucial. According to data from the Nord Italia Transplant program (NITp), the average waiting time between the beginning of dialysis and the admission to the regional transplant waiting list in Lombardy is 20.2 months.

METHODS

A multicenter cross-sectional study was conducted in order to identify the causes of these delays and find solutions. Two questionnaires were administered to the directors of 47 Nephrology Units and to 106 patients undergoing dialysis in Lombardy respectively, during their first visit for admission to the transplant waiting list.

RESULTS

The comparative analysis of the results revealed that both patients (52%) and directors (75%) consider the time required for registering to the waiting list too long. Patients judge information about the transplant to be insufficient, especially regarding the pre-emptive option (63% of patients declare that they had not been informed about this opportunity). Patients report a significantly longer time for the completion of pre-transplantation tests (more than 1 year in 23% of the cases) compared to that indicated by the directors.

CONCLUSIONS

The study confirmed the necessity of providing better and more timely information to patients regarding the different kidney transplantation options and highlighted the importance of creating target-oriented and dedicated pathways in all hospitals.

Changing Trends in the Performance of Percutaneous Renal Biopsy from Nephrologist to Interventional Radiologist: A Single-Center Experience

BACKGROUND

Percutaneous renal biopsy of native kidneys (PRB) has been an integral part of the practice of nephrology. However, over the past 30 years, PRB has transitioned from a procedure performed only by nephrologists to interventional radiologists (IRs). We surveyed practicing nephrologists completing training in our program to determine the clinical practice patterns of PRB.

METHODS

The 78 fellows completing the nephrology program at Rush University Medical Center from June 1984 through June 2017 were successfully contacted and surveyed regarding their opinion on adequacy of their training and whether they performed PRB in practice and if not or no longer, why. To evaluate for differences in the performance of PRB over time, a comparison of 4 periods of fellowship completion (i.e., 1984-1990, 1991-2000, 2001-2010, 2011-2017) was performed.

RESULTS

All 78 nephrologists felt they had been adequately trained to perform PRB. PRB was performed by 45 (58%) nephrologists post-fellowship, but a significant decline was observed over the 4 periods of time from 1984 to 2017 (100 vs. 86 vs. 52 vs. 20%, p < 0.0001). The primary reason that 33 nephrologists did not perform PRB was that it was too time consuming and IR was available to perform PRB. Of the 71 nephrologists still in practice only 12 (17%) continue to perform PRB. A greater proportion of nephrologists completing training from 1984-1990 continue to perform PRB relative to those trained after 1990. The universal reason that nephrologists were no longer performing PRB was again an issue of time and the fact that IRs were available to perform PRB.

CONCLUSION

We find that there has been a significant transition over time in the performance of PRB by a nephrologist to IR. The major reason for this is the time burden associated with PRB and the availability of IRs.

[Nephrologic workforce. Who we are? Where do we go? A project by SIN]

The SIN Workforce Working Group has carried out an initial demographic study project that highlights the situation of nephrological workforce in European and non-European countries, noting in particular the apparent discrepancies between the number of nephrologists in other health systems and in the Italian one. Italy seems to have the highest number of nephrologists per capita: in fact, the number of nephrologists has decreased in recent years due to the number of retirements far higher than the entry of new specialists. The project arises from the need to define the actual number of nephrologists in Italy in relation to the population and the epidemiology of chronic renal disease, taking into account the trends of ageing and feminization of our specialty. The tools used to collect data on the demographics of Italian nephrologists are a database for demographic data collection by presidents of SIN regional sections and a questionnaire for a survey to describe demography, workload, the adhesion to the discipline and the recruitment and retirement programs of the Italian nephrological community.

Statistical Methods for Cohort Studies of CKD: Prediction Modeling

Prediction models are often developed in and applied to CKD populations. These models can be used to inform patients and clinicians about the potential risks of disease development or progression. With increasing availability of large datasets from CKD cohorts, there is opportunity to develop better prediction models that will lead to more informed treatment decisions. It is important that prediction modeling be done using appropriate statistical methods to achieve the highest accuracy, while avoiding overfitting and poor calibration. In this paper, we review prediction modeling methods in general from model building to assessing model performance as well as the application to new patient populations. Throughout, the methods are illustrated using data from the Chronic Renal Insufficiency Cohort Study.

What Are We Doing? A Survey of United States Nephrology Fellowship Program Directors

Interest in nephrology has been declining in recent years. Long work hours and a poor work/life balance may be partially responsible, and may also affect a fellowship's educational mission. We surveyed nephrology program directors using a web-based survey in order to define current clinical and educational practice patterns and identify areas for improvement. Our survey explored fellowship program demographics, fellows' workload, call structure, and education. Program directors were asked to estimate the average and maximum number of patients on each of their inpatient services, the number of patients seen by fellows in clinic, and to provide details regarding their overnight and weekend call. In addition, we asked about number of and composition of didactic conferences. Sixty-eight out of 148 program directors responded to the survey (46%). The average number of fellows per program was approximately seven. The busiest inpatient services had a mean of 21.5±5.9 patients on average and 33.8±10.7 at their maximum. The second busiest services had an average and maximum of 15.6±6.0 and 24.5±10.8 patients, respectively. Transplant-only services had fewer patients than other service compositions. A minority of services (14.5%) employed physician extenders. Fellows most commonly see patients during a single weekly continuity clinic, with a typical fellow-to-faculty ratio of 2:1. The majority of programs do not alter outpatient responsibilities during inpatient service time. Most programs (approximately 75%) divided overnight and weekend call responsibilities equally between first year and more senior fellows. Educational practices varied widely between programs. Our survey underscores the large variety in workload, practice patterns, and didactics at different institutions and provides a framework to help improve the service/education balance in nephrology fellowships.

Predictive Factors of One-Year Mortality in a Cohort of Patients Undergoing Urgent-Start Hemodialysis

Background

Chronic kidney disease (CKD) affects 10–15% of adult population worldwide. Incident patients on hemodialysis, mainly those on urgent-start dialysis at the emergency room, have a high mortality risk, which may reflect the absence of nephrology care. A lack of data exists regarding the influence of baseline factors on the mortality of these patients. The aim of this study was to evaluate the clinical and laboratory characteristics of this population and identify risk factors that contribute to their mortality.

Patients and methods

We studied 424 patients who were admitted to our service between 01/2006 and 12/2012 and were followed for 1 year. We analyzed vascular access, risk factors linked to cardiovascular disease (CVD) and mineral and bone disease associated with CKD (CKD-MBD), and clinical events that occurred during the follow-up period. Factors that influenced patient survival were evaluated by Cox regression analysis.

Results

The patient mean age was 50 ± 18 years, and 58.7% of them were male. Hypertension was the main cause of primary CKD (31.8%). Major risk factors were smoking (19.6%), dyslipidemia (48.8%), and CVD (41%). Upon admission, most patients had no vascular access for hemodialysis (89.4%). Biochemical results showed that most patients were anemic with high C-reactive protein levels, hypocalcemia, hyperphosphatemia, elevated parathyroid hormone and decreased 25-hydroxy vitamin D. At the end of one year, 60 patients died (14.1%). These patients were significantly older, had a lower percentage of arteriovenous fistula in one year, and low levels of 25-hydroxy vitamin D.

Conclusions

The combined evaluation of clinical and biochemical parameters and risk factors revealed that the mortality in urgent-start dialysis is associated with older age and low levels of vitamin D deficiency. A lack of a permanent hemodialysis access after one year was also a risk factor for mortality in this population.

[Census of the renal and dialysis units by Italian Society of Nephrology: nephrologist's workload for renal patient assistance in Italy (2014-2015)]

BACKGROUND

Given the public health challenge and burden of chronic kidney disease, the Italian Society of Nephrology (SIN) promoted acensusof the renal and dialysis units to analyse structural and human resources, organizational aspects, activities and workload referring to theyear 2014.

METHODS

An online questionnaire, including 64 items exploring structural and human resources, organization aspects, activities and epidemiological data referred to 2014, was sent to chiefs of any renal or dialysis unit.

RESULTS

Renal and dialysis activity was performed by over 2718 physicians (45 pmp). The management of the acute renal failure was one of the most frequent activities in the public renal units (12,206 patients in ICU and 140.00 dialysis sessions). There were performed about 9000 AV fistulas and 1700 central vascular catheters insertions. In the census, there are a lot of data regarding organization, workforce and workload of the renal unit in Italy. The benchmark data derived from this census show interesting comparisons between centres, regions and groups of regions. These data realised the clinical management of renal disease in Italy.

Provider Knowledge, Attitudes, and Practices Surrounding Conservative Management for Patients with Advanced CKD

BACKGROUND AND OBJECTIVES

Despite the potential benefits of conservative management, providers rarely discuss it as a viable treatment option for patients with advanced CKD. This survey was to describe the knowledge, attitudes, and practices of nephrologists and primary care providers regarding conservative management for patients with advanced CKD in the United States.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We developed a questionnaire on the basis of a literature review to include items assessing knowledge, attitudes, and self-reported practices of conservative management for patients with advanced CKD. Potential participants were identified using the American Medical Association Physician Masterfile. We then conducted a web-based survey between April and May of 2015.

RESULTS

In total, 431 (67.6% nephrologists and 32.4% primary care providers) providers completed the survey for a crude response rate of 2.7%. The respondents were generally white, men, and in their 30s and 40s. Most primary care provider (83.5%) and nephrology (78.2%) respondents reported that they were likely to discuss conservative management with their older patients with advanced CKD. Self-reported number of patients managed conservatively was >11 patients for 30.6% of nephrologists and 49.2% of primary care providers. Nephrologists were more likely to endorse difficulty determining whether a patient with CKD would benefit from conservative management (52.8% versus 36.2% of primary care providers), whereas primary care providers were more likely to endorse limited information on effectiveness (49.6% versus 24.5% of nephrologists) and difficulty determining eligibility for conservative management (42.5% versus 14.3% of nephrologists). There were also significant differences in knowledge between the groups, with primary care providers reporting more uncertainty about relative survival rates with conservative management compared with different patient groups.

CONCLUSIONS

Both nephrologists and primary care providers reported being comfortable with discussing conservative management with their patients. However, both provider groups identified lack of United States data on outcomes of conservative management and characteristics of patients who would benefit from conservative management as barriers to recommending conservative management in practice.

Early Requirement for RRT in Children at Presentation in the United Kingdom: Association with Transplantation and Survival

BACKGROUND AND OBJECTIVES

We evaluated rates and factors associating with late referral (LR) and describe association of LR with access to renal transplantation and patient survival in children in the United Kingdom. Early requirement of RRT within 90 days of presentation to a pediatric nephrologist was classed as a LR, and those >90 days as an early referral (ER).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We included patients who commenced RRT, aged ≥3 months and <16 years, from 1996 to 2012.

RESULTS

Of 1603 patients, 25.5% (n=408) were LR, of which 75% commenced RRT in <30 days following presentation. Those with LR were more likely to be older at presentation, female, and black. The primary renal disease in LR was more likely to be glomerular disease (odds ratio [OR], 1.6; 95% confidence interval [95% CI], 1.12 to 2.29), renal malignancy and associated diseases (OR, 4.11; 95% CI, 1.57 to 10.72), tubulo-interstitial diseases (OR, 2.37; 95% CI, 1.49 to 3.78), or an uncertain renal etiology (OR, 5.75; 95% CI, 3.1 to 10.65). Significant differences in rates of transplantation between LR and ER remained up to 1-year following commencement of dialysis (21% versus 61%, P<0.001) but with no differences for donor source (33.3% and 35.3% living donor in LR and ER respectively, P=0.55). The median (interquartile range) follow-up time was 4.8 years (2.9-7.6). There were 55 deaths with no statistically significant difference in survival in the LR group compared with the ER group (hazard ratio, 1.30; 95% CI, 0.7 to 2.3; P=0.40).

CONCLUSIONS

We found that 25% of children starting RRT in the United Kingdom receive a LR to pediatric renal services, with little change observed over the past two decades. Those with LR are unable to benefit from pre-emptive transplantation and require longer periods of dialysis before transplantation. There is an urgent need to understand causes of avoidable LR and develop strategies to improve kidney awareness more widely among health care professionals looking after children.

Factors Affecting the Referral Time to Nephrologists in Patients With Chronic Kidney Disease: A Prospective Cohort Study in Korea

Timely referral to nephrologists is important for improving clinical outcomes and reducing costs during transition periods. We evaluated the impact of patients' demographic, clinical, and social health characteristics on referral time.A total of 1744 CKD patients who started maintaining dialysis were enrolled in a Korean prospective cohort. The early referral (ER) and late referral group (LR) were defined as patients who were referred to a nephrologist more than or less than 1 year prior to dialysis initiation, respectively.A total of 1088 patients (62.3%) were in the ER, and 656 patients (37.6%) were in the LR. Among the patients in the LR, 398 patients (60.7%) were referred within the 3 months prior to the start of dialysis (ultralate referral group [ULR]). The ER was younger at the time of referral than the LR; however, the ER was older at the start of dialysis. Patients with diabetes or hypertension as the cause of kidney disease were more common in the LR, whereas patients with glomerulonephritis, females, and nonsmokers were more common in the ER. The ER had more well-controlled blood pressure, lower phosphorus levels, and higher hemoglobin levels at the start of dialysis. Congestive heart failure (CHF) was more common in the LR. In the multivariate analysis, male sex (odds ratio [OR] 1.465, 95% confidence interval [CI] 1.034-2.076), underlying kidney disease (diabetes mellitus [OR 1.507, 95% CI 1.057-2.148] and hypertension [OR 1.995, 95% CI 1.305-3.051]), occupation (mechanician [OR 2.975, 95% CI 1.445-6.125], laborer [OR 3.209, 95% CI 1.405-7.327], and farmer [OR 5.147, 95% CI 2.217-11.953]), CHF (OR 2.152, 95% CI 1.543-3.000), and ambulatory status (assisted-walks, OR 2.072, 95% CI 1.381-3.111) were proved as the independent risk factor for late referral.Patients with hypertensive or diabetic kidney disease are referred later than those with glomerulonephritis. Male patients with physically active occupations exhibiting CHF and restricted ambulation were associated with a late referral. Considering the various factors associated with late referral, efforts to increase early referrals should be emphasized, particularly in patients with hypertension, diabetes, or congestive heart failure.

Improving nephrology service delivery - Accessing the specialist

BACKGROUND

The increased prevalence of chronic kidney disease (CKD) is straining the medical workforce and healthcare budget. To improve efficiency, patients require streamlined access to renal and general practice specialist advice.

OBJECTIVE

The aim of this article is to profile general practitioner (GP) referrals for patients with CKD and compare these referrals to national guidelines.

METHODS

We conducted a retrospective analysis of 200 randomly selected outpatient referrals to the renal service at St George Hospital, Sydney, between 2008 and 2011. These referrals were compared against national referral guidelines.

RESULTS

Declining renal function accounted for the majority (44%; n = 78) of referrals, while advice regarding hypertension management contributed to a further 21% (n = 38) of referrals. Fifteen per cent (n = 27) of patients were referred back to their GP after one visit, while 40% (n = 72) required follow-up beyond 12 months. When compared with the National nephrology referral guidelines, 25% (n = 42) of referrals did not meet the criteria.

DISCUSSION

Access to renal specialists may be difficult because of bottlenecks in the public clinic, frustrating all parties concerned. If an alternative, more integrated, possibly web-based CKD support service existed, some formal reviews could be bypassed. This study provides preliminary data supporting the development of such a service, and simultaneously providing streamlined sup-port to the GP and relieving pressure on hospital clinics.

[Geriatric nephrology: an overview]

INTRODUCTION

Chronic kidney disease (CKD) is a highly prevalent condition and its prevalence is increasing worldwide, particularly in adults aged 70 years. Epidemiological studies showed that as many as 2054% of the older adults suffer from CKD in stages 3-5. Nevertheless the question whether this lower eGFR is a consequence of kidney disease or if it is the result of a physiological aging is still debated, even if it implies a reduced renal reserve and vulnerability to drugs overdose with increased risk of acute kidney injury (AKI).

MATERIALS AND METHODS

PubMed search was conducted for available English literature, describing the actual knowledge about specific and frequent issues reported in the acute and chronic kidney disease in older adults. Prospective and retrospective studies, as well as meta-analyses and latest systematic reviews were included.

RESULTS

Most of the studies examined and reviewed were discarded for wrong population or intervention or deemed unfit. Only 103 met the inclusion criteria for the review. The studies included in the review were grouped into two areas: chronic and acute kidney disease in older adults and we have analysed the peculiar and frequently found issues in this population.

CONCLUSIONS

The geriatric population is increasing worldwide. We should consider peculiar aspects of this population, such as sarcopenia, malnutrition, psychological and cognitive deficits and increased risk of AKI, in order to reach a good quality of life, with improved doctor / patient relationship, a greater adherence to therapy, a reduction in health care costs, and if possible, adequate "end of life", as far as it is approved by the patient and his family. The achievement of these objectives requires an organized work in multidisciplinary teams that evaluate overall the geriatric patient.

[A Chinese Nephrology and Dialysis Unit in the eyes of a western nephrologist]

This paper reports a description of the characteristics of the Nephrology and Dialysis department of the Yangzhou Northern Peoples Hospital (Jiangsu province - China) observed by the Author in a two weeks stay. The most outstanding remark is that, in spite of the modern and highly developed structure and information technology of the hospital, the Chinese Health System, an insurance based system, doesnt cover all the care expenses, leaving the remaining cost to be payed by the patients (about 30%). This often induces an empirical method of treatment of nephropathy, because of the lack of a histologic diagnosis and a minimalistic approach for choosing drugs. Another important point is the discontinuity in the follow-up of the disease and the frequent development of uremic complications, especially hyperparathyroidism.

Vascular access creation before hemodialysis initiation and use: a population-based cohort study

BACKGROUND AND OBJECTIVES

In Canada, approximately 17% of patients use an arteriovenous access (fistula or arteriovenous graft) at commencement of hemodialysis, despite guideline recommendations promoting its timely creation and use. It is unclear if this low pattern of use is attributable to the lack of surgical creation or a high nonuse rate.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using large health care databases in Ontario, Canada, a population-based cohort of adult patients (≥18 years old) who initiated hemodialysis as their first form of RRT between 2001 and 2010 was studied. The aims were to (1) estimate the proportion of patients who had an arteriovenous access created before starting hemodialysis and the proportion who successfully used it at hemodialysis start, (2) test for secular trends in arteriovenous access creation, and (3) estimate the effect of late nephrology referral and patient characteristics on arteriovenous access creation.

RESULTS

There were 17,183 patients on incident hemodialysis. The mean age was 65.8 years, 60% were men, and 40% were referred late to a nephrologist; 27% of patients (4556 of 17,183) had one or more arteriovenous accesses created, and the median time between arteriovenous access creation and hemodialysis start was 184 days. When late referrals were excluded, 39% of patients (4007 of 10,291) had one or more arteriovenous accesses created, and 27% of patients (2724 of 10,291) used the arteriovenous access. Since 2001, there has been a decline in arteriovenous access creation before hemodialysis initiation. Women, higher numbers of comorbidities, and rural residence were consistently associated with lower rates of arteriovenous access creation. These results persisted even after removing patients with <6 months nephrology care or who had AKI 6 months before starting hemodialysis.

CONCLUSIONS

In Canada, arteriovenous access creation before hemodialysis initiation is low, even among patients followed by a nephrologist. Better understanding of the barriers and influencers of arteriovenous access creation is needed to inform both clinical care and guidelines.

Addressing missing data in clinical studies of kidney diseases

Missing data constitute a problem present in all studies of medical research. The most common approach to handling missing data-complete case analysis-relies on assumptions about missing data that rarely hold in practice. The implications of this approach are biased and inefficient descriptions of relationships of interest. Here, various approaches for handling missing data in clinical studies are described. In particular, this work promotes the use of multiple imputation methods that rely on assumptions about missingness that are more flexible than those assumptions relied on by the most common method in use. Furthermore, multiple imputation methods are becoming increasingly more accessible in mainstream statistical software packages, making them both a sound and practical choice. The use of multiple imputation methods is illustrated with examples pertinent to kidney research, and concrete guidance on their use is provided.

Early referral to specialist nephrology services for preventing the progression to end-stage kidney disease

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.

Hemodialysis patient outcomes: provider characteristics

BACKGROUND/AIMS

Physician characteristics are associated with differential performance on quality measures and patient outcomes in several medical fields. We aimed to determine whether characteristics of physicians who provide care to dialysis patients were associated with patient outcomes.

METHODS

This cohort study used United States Renal Data System data for patients who initiated in-center hemodialysis between October 1, 2003, and September 30, 2006 (n = 91,276). Patient characteristics were defined and physicians identified from Part B Medicare claims for outpatient dialysis services submitted during months 4-6 of hemodialysis. Physician characteristics were obtained from the American Medical Association Physician Master File. Associations of physician characteristics with 1-year patient mortality and first hospitalization were determined using Cox proportional hazards analysis; associations with quality of care (defined by influenza vaccination and waitlisting for kidney transplant) were determined using logistic regression.

RESULTS

Physician characteristics were not associated with patient mortality. After adjustment for patient and other provider characteristics, patients whose physicians had practiced longer or were in administrative, research, or teaching practices were more likely to be hospitalized; patients whose providers practiced in smaller metropolitan statistical areas (MSAs) were less likely. More years since training was associated with greater chance of waitlisting, and practicing in smaller MSAs with less chance. Graduation from a foreign medical school, practicing in smaller MSAs, and travelling farther from office to dialysis unit were associated with greater odds of influenza vaccination.

CONCLUSIONS

Several characteristics of physicians seeing incident outpatient hemodialysis patients were associated with hospitalization and quality of care, but none with mortality.

The long-term impact of eGFR reporting on referral patterns

BACKGROUND

The prognostic significance of CKD has driven the widespread introduction of automated estimated glomerular filtration rate (eGFR) reporting, and the incorporation of CKD in the revised Quality Outcomes Framework (QOF) of the General Medical Services (GMS) contract in the U.K.

AIMS

To assess the long-term impact of the introduction of these two initiatives, on patient referral numbers to a nephrology service.

METHODS

Data was collected on the numbers and basic characteristics of all new patients referred from April 2005 to March 2011, to one NHS Health Board.

RESULTS

Introduction of eGFR reporting and CKD QOF domains was associated with a significant increase in the number of referrals, which was sustained. The initiatives also led to a sustained increase in the mean age of the patients at referral, predominantly due to an increase in the age of female patients referred. There was also an increase in the proportion of female patients referred. In the immediate aftermath of the introduction of change there was a transient decrease in the average eGFR at referral, a decrease in age of patients referred with an eGFR <15ml/min and an increase in the eGFR of patients >70yrs of age.

CONCLUSIONS

The data demonstrates significant and sustained increase in numbers of referrals. In the short term this was associated with a reduction in referral of elderly patients with stage 5 CKD and an increase in elderly patients with mild renal impairment. In the longer term we saw an increase in referral of an older female population.

Nephrologist caseload and hemodialysis patient survival in an urban cohort

Physician caseload may be a predictor of patient outcomes associated with various medical conditions and procedures, but the association between patient-physician ratio and mortality among patients undergoing hemodialysis has not been determined. We examined whether a higher patient-nephrologist ratio affects patient mortality risk using de-identified data from DaVita dialysis clinics and the U.S. Renal Data System. A total of 41 nephrologists with a caseload of 50-200 hemodialysis patients from an urban California region were retrospectively ranked according to their hemodialysis patient mortality rate during a 6-year period between 2001 and 2007. We calculated all-cause mortality hazard ratios for each nephrologist and compared patient- and provider-level characteristics between the 10 nephrologists with the highest patient mortality rates and the 10 nephrologists with the lowest patient mortality rates. Nephrologists with the lowest patient mortality rates had significantly lower patient caseloads than nephrologists with the highest mortality rates (median [interquartile range], 65 [55-76] versus 103 [78-144] patients per nephrologist, respectively; P<0.001). Additionally, patients treated by nephrologists with the lowest patient mortality rates received higher dialysis doses, had longer sessions, and received more kidney transplants. In demographic characteristic-adjusted analyses, each 50-patient increase in caseload was associated with a 2% increase in patient mortality risk (hazard ratio, 1.02; 95% confidence interval, 1.00 to 1.04; P<0.001). Hence, these results suggest that nephrologist caseload influences hemodialysis patient outcomes, and future research should focus on identifying the factors underlying this association.

Prevalence of pre-end-stage renal disease care and associated outcomes among urban, micropolitan, and rural dialysis patients

BACKGROUND/AIMS

Pre-end-stage renal disease (ESRD) care is associated with improved outcomes among patients receiving dialysis. It is unknown what proportion of US micropolitan and rural dialysis patients receive pre-ESRD care and benefit from such care when compared to urban.

METHODS

A retrospective cohort study was performed using data from the US Renal Data System. Patients ≥18 years old who initiated dialysis in 2006 and 2007 were classified as rural, micropolitan or urban and the prevalence of pre-ESRD care (early nephrology care >6 months, permanent vascular access, -dietary education) was determined using the medical evidence report. The association of pre-ESRD care with dialysis mortality and transplantation was assessed using Cox regression with stratification for geographic residence.

RESULTS

Of 204,463 dialysis patients, 80% were urban, 10.2% were micropolitan and 9.8% were rural. Overall attainment of pre-ESRD care was poor. After adjustment, there were no significant geographic differences in attainment of early nephrology care or permanent dialysis access. Receiving care reduced all-cause mortality and increased the likelihood of transplantation to a similar degree regardless of geographic residence. Both micropolitan and rural patients received less dietary education (relative risk = 0.80, 95% CI = 0.76-0.84 and relative risk = 0.85, 95% CI = 0.80-0.89, respectively).

CONCLUSION

Among patients who receive dialysis, the prevalence of early nephrology care and permanent dialysis access is poor and does not vary by geographic residence. Micropolitan and rural patients receive less dietary education despite an observed mortality benefit, suggesting that barriers may exist to quality dietary care in more remote locations.

Nutritional vitamin D use in chronic kidney disease: a survey of pediatric nephrologists

BACKGROUND

Vitamin D deficiency may contribute to risk of cardiovascular disease, diabetes, and infections, in addition to known effects on mineral metabolism. Controversy remains regarding the use of nutritional vitamin D supplementation in chronic kidney disease (CKD), and the supplementation practices of pediatric nephrologists are unknown.

METHODS

An electronic survey containing eight vignettes was sent to physician members of the International Pediatric Nephrology Association in 2011 to identify physician and patient characteristics that influence nephrologists to supplement CKD patients with nutritional vitamin D. Vignettes contained patient characteristics including light vs dark skin, CKD stage, cause of renal disease, parathyroid hormone (PTH), and 25(OH) vitamin D levels. Multivariate logistic generalized estimating equation regression was used to identify predictors of supplementation.

RESULTS

Of 1,084 eligible physicians, 504 (46%) completed the survey. Supplementation was recommended in 73% of cases overall (ranging from 91% of those with vitamin D levels <10 ng/mL to 35% with levels >30). Greater CKD severity was associated with greater recommendation of supplementation, especially for patients with higher vitamin D levels (test for interaction p < 0.0001). PTH level above target for CKD stage was associated with greater recommendation to supplement in pre-dialysis CKD, but did not have an impact on recommendations in dialysis patients (test for interaction p < 0.0001). Skin color, cause of CKD, and albumin levels were not associated with supplementation recommendation.

CONCLUSIONS

Recommending nutritional vitamin D is common worldwide, driven by CKD stage and vitamin D and PTH levels. Future studies are needed to establish the risks and benefits of supplementation.

Inequalities in outcomes of acute kidney injury in England

BACKGROUND

Renal replacement is managed by renal specialists and is well documented in national registries. In contrast, nation-wide data on acute kidney injury (AKI) are difficult to capture as it presents in many different ways to all acute hospitals. This paucity impacts on the coordination of appropriate services.

AIMS

We have set out to use all the information submitted by all hospitals in England to identify emergency patients in whom AKI was a major contributor to their hospital stay. We then examined workload in relation to specialist provision and outcomes of care.

DESIGN AND METHODS

All English hospitals submit a sequential list of International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD 10) codes to describe the diagnosis of each admission. An algorithm was applied to all emergency admissions over a 2-year period to identify AKI. The level of renal specialist care available within each hospital trust was compared with patient outcomes, including 30-day mortality.

RESULTS

The incidence of AKI was 1.34% of all emergency admissions. The numbers and types of AKI cases were similar in all trusts, regardless of the service available. Thirty-day mortality was 30.0%. More than half the acute hospitals did not have on-site renal specialists and their AKI mortality rates were significantly higher (P < 0.001). These differences persisted despite adjusting for multiple variables.

CONCLUSION

The country has created specialist renal units in 45% of hospital trusts, but AKI presents as emergencies to all hospitals and there is an increased risk of mortality in the 55% of trusts without renal specialists.

Improving the fistula rate: the northwest renal network experience

In November 2010, Northwest Renal Network was the first of the 18 ESRD Networks to reach the Fistula First goal of greater than 66% prevalent hemodialysis patients using an arteriovenous fistula (AVF). The network has sustained that goal over time and as of August 2011, has achieved an AVF rate of 67.7%. The Northwest Renal Network has been successfully motivating facilities to embrace change using thorough root cause analyses and targeted quality improvement projects throughout the Network's five-state region.

Autosomal dominant polycystic kidney disease in University Clinic of Nephrology and Haemodialysis of Cotonou: clinical and genetical findings

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease, but poorly studied in Africa. Its frequency in the University Clinic of Nephrology and Hemodialysis of Cotonou during the ten last years was 7 cases per year with a hospital prevalence estimated at 18 per 1000. The mean age of patients was 47.2 years extending from 29 to 70 years. Males were predominant with a sex ratio of 1.13. Family history was found in 47% of patients. The most common manifestations were lumbar pain (62%), high blood pressure (59%) urinary tract infections (53%), hematuria (46%), and abdominal masses (43%). Hepatic cysts were the most extra renal manifestations, found in 34% of cases. Renal failure was observed in 72% of patients of our series, six of them were under dialysis. Direct sequencing of polycystin 1 gene enabled us to identify some new mutations: 4 nonsense mutations (p.Q2824X exon 23, p.Q1651X exon 15, p.W1666X exon 15, p.R966W exon 12), a duplication (c_1761.1745 dup exon 9), a deletion (c.9397 + 1_9397 + 8del intron 26) and a deletion-insertion (c.7290_7291delins CTGCA exon 18).

Patient and provider determinants of nephrology referral in older adults with severe chronic kidney disease: a survey of provider decision making

BACKGROUND

Although chronic kidney disease (CKD) disproportionately affects older adults, they are less likely to be referred to a nephrologist. Factors that influence the referral decisions of primary care providers (PCPs) specifically for older CKD patients have been incompletely described. Patient factors such as dementia, functional disability, and co-morbidity may complicate the decision to refer an older adult. This study evaluated the role of patient and PCP factors in the referral decisions for older adults with stage 4 CKD.

METHODS

We administered a two-part survey to study the decisions of practicing PCPs. First, using a blocked factorial design, vignettes systematically varied 6 patient characteristics: age, race, gender, co-morbidity, functional status, and cognitive status. CKD severity, patient preferences, and degree of anemia were held constant. Second, covariates from a standard questionnaire included PCP estimates of life expectancy, demographics, reaction to clinical uncertainty, and risk aversion. The main outcome was the decision to refer to the nephrologist. Random effects logistic regression models tested independent associations of predictor variables with the referral decision.

RESULTS

More than half (62.5%) of all PCP decisions (n = 680) were to refer to a nephrologist. Vignette-based factors that independently decreased referral included older patient age (OR = 0.27; 95% CI, 0.15 to 0.48) and having moderate dementia (OR = 0.14; 95%CI, 0.07 to 0.25). There were no associations between co-morbidity or impaired functional activity with the referral decision. Survey-based PCP factors that significantly increased the referral likelihood include female gender (OR = 7.75; 95%CI, 2.07 to 28.93), non-white race (OR = 30.29; 95%CI, 1.30 to 703.73), those who expect nephrologists to discuss goals of care (OR = 53.13; 95%CI, 2.42 to 1168.00), those with higher levels of anxiety about uncertainty (OR = 1.28; 95%CI, 1.04 to 1.57), and those with greater risk aversion (OR = 3.39; 95%CI, 1.02 to 11.24).

CONCLUSIONS

In this decision making study using hypothetical clinical vignettes, we found that the PCP decision to refer older patients with severe CKD to a nephrologist reflects a complex interplay between patient and provider factors. Age, dementia, and several provider characteristics weighed more heavily than co-morbidity and functional status in PCP referral decisions. These results suggest that practice guidelines should develop a more nuanced approach to the referral of older adults with CKD.

Nephrologists' perceptions of renal transplant as treatment of choice for end-stage renal disease, preemptive transplant, and transplanting older patients: an international survey

OBJECTIVES

To explore the relation between nephrologists' characteristics and their views of transplant as the treatment of choice for end-stage renal disease, preemptive transplant, and transplant of older patients.

MATERIALS AND METHODS

A comprehensive international Web-based survey explored the relation between nephrologists' characteristics and their views of transplant as the treatment of choice for end-stage renal disease, preemptive transplant, and transplant of older patients.

RESULTS

A total of 1448 nephrologists completed the survey. The majority of respondents agreed with transplant as the treatment of choice for end-stage renal disease (75%), preemptive transplant (71%), and transplant for patients > 60 years of age (59%). The likelihood of agreement was higher among transplant and academic nephrologists, and practice at hospitals with ≥ 50 transplants per year. Urban location and ≥ 10 years in practice were associated with higher likelihood of viewing transplant as treatment of choice and favoring preemptive transplant.

CONCLUSIONS

Demographic and practice characteristics influence nephrologists' attitudes about transplant as the treatment of choice for end-stage renal disease, preemptive transplant, and transplant as an option for older patients. Detailed studies exploring the determinants of nephrologists' attitudes are likely to identify sources of variations in perceptions of patient suitability for transplant. Our findings underscore the need for continuing educational programs addressing evolving aspects of transplant particularly targeting nephrologists practicing within nonacademic centers and in rural areas.

Epidemiology of hemodialysis vascular access in the United States

Reemergence of the importance of vascular access in the care of the chronic hemodialysis patient has gained prominence due to renewed interest in clinical outcomes and evidence-based interventions. Further fueled by anticipated regulatory changes in the reimbursement for dialysis care in the United States by 2011 and beyond, the drive to improve quality of care for hemodialysis patients has identified vascular access issues as a key contributor to outcomes. Focus has shifted from simply providing any hemodialysis vascular access to a strong preference for the use of native arteriovenous fistulas and subsequently to a need for reducing exposure to central venous catheters. Combined, these goals have forced a reevaluation of the role of arteriovenous grafts. The context and events associated with the evolution of thinking on these issues as well as available data supporting them are discussed. The key leadership role of nephrologists is emphasized along with a summary of problems and proposed solutions.

Scientific publications in nephrology and urology journals from Chinese authors in East Asia: a 10-year survey of the literature

BACKGROUND

Diseases of the kidneys and genitourinary tract are common health problems that affect people of all ages and demographic backgrounds. In this study, we compared the quantity and quality of nephrological and urological articles published in international journals from the three major regions of China: the mainland (ML), Hong Kong (HK), and Taiwan (TW).

METHODS

Nephrological and urological articles originating from ML, TW, and HK that were published in 61 journals from 1999-2008 were retrieved from the PubMed database. We recorded the numbers of total articles, clinical trials, randomized controlled trials, case reports, impact factors (IF), citations, and articles published in the leading general-medicine journals. We used these data to compare the quantity and quality of publication output from the three regions.

RESULTS

The total number of articles increased significantly from 1999 to 2008 in the three regions. The number of articles from ML has exceeded that from HK since 2004, and surpassed that from TW in 2008. Publications from TW had the highest accumulated IF, total citations of articles, and the most articles published in leading general-medicine journals. However, HK publications had the highest average IF. Although ML produced the largest quantity of articles, it exhibited the lowest quality among the three regions.

CONCLUSION

The number of nephrological and urological publications originating from the three major regions of China increased significantly from 1999 to 2008. The annual number of publications by ML researchers exceeded those from TW and HK. However, the quality of articles from TW and HK was higher than that from ML.