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Wild HM, Busby A, Mackintosh L, Wellsted D. Patient-Reported Experience Measures to Evaluate and Improve the Quality of Care in Nephrology. Semin Nephrol 2024:151551. [PMID: 39242286 DOI: 10.1016/j.semnephrol.2024.151551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2024]
Abstract
Patient experience is considered a pillar of high-quality care, integral to patient-centered care, but despite significant policy focus on patient-reported experience measures (PREMs), little is published regarding their development, use, or impact on clinical practice. In nephrology, PREMs are increasingly used in research to capture and quantify patients' perceptions of their experiences with health care services. It has been shown that a negative patient experience impacts patients' physical and psychological health, and a small but significant proportion of patients across a selection of settings report their experiences of health care as poor or suboptimal. Evidence of whether PREMs improve quality of care or support person-centered care in the clinical setting remains largely theoretical. Extensive effort has been invested to develop various PREMs for kidney services. Although little evidence linking PREM collection to meaningful change in delivery of care currently exists, work is underway. Early indications are that with the right facilitators, implementing PREMs in routine practice can help providers recognize where change is needed and galvanize transformation. The journey toward understanding the connection between PREM data and modifiable provider characteristics to target and enable change has started, but further evidence is needed. This article outlines the history of PREMs in nephrology and details their current use alongside implementation challenges. The use and benefits of PREMs are discussed before considering the evidence base for their impact on renal health care. Possible next steps for PREMs are suggested and best practices highlighted.
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Affiliation(s)
- Helen Munro Wild
- Health Research Methods Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Amanda Busby
- Health Research Methods Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Lucy Mackintosh
- Health Research Methods Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - David Wellsted
- Health Research Methods Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.
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Mackintosh L, Ormandy P, Busby A, Hawkins J, Klare R, Silver C, Da Silva-Gane M, Santhakumaran S, Bristow P, Sharma S, Wellsted D, Chilcot J, Sridharan S, Steenkamp R, Harris T, Muirhead S, Lush V, Afuwape S, Farrington K. Impact of COVID-19 on patient experience of kidney care: a rapid review. J Nephrol 2024; 37:365-378. [PMID: 38123835 PMCID: PMC11043167 DOI: 10.1007/s40620-023-01823-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/24/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION In March 2020, a pandemic state was declared due to SARS-COV-2 (COVID-19). Patients with kidney disease, especially those on replacement therapies, proved more susceptible to severe infection. This rapid literature review aims to help understand how the pandemic impacted patient experience of kidney care. METHODS It was conducted in accordance with Cochrane Rapid Review interim guidance. Search terms, 'coronavirus', 'kidney care', and 'patient-reported experience' and terms with similar semantic meaning, identified 1,117 articles in Medline, Scopus, and Worldwide Science. Seventeen were included in the narrative synthesis. RESULTS The findings were summarised into three themes: remote consultation and telemedicine (n = 9); psychosocial impact (n = 2); and patient satisfaction and patient-reported experience (n = 6). Patients were mostly satisfied with remote consultations, describing them as convenient and allowing avoidance of hospital visits. Anxieties included missing potentially important clinical findings due to lack of physical examination, poor digital literacy, and technical difficulties. Psychosocial impact differed between treatment modalities-transplant recipients expressing feelings of instability and dread of having to return to dialysis, and generally, were less satisfied, citing reduced ability to work and difficulty accessing medications. Those on home dialysis treatments tended to feel safer. Findings focused on aspects of patient experience of kidney care during the pandemic rather than a holistic view. CONCLUSIONS There was little direct evaluation of modality differences and limited consideration of health inequalities in care experiences. A fuller understanding of these issues would guide policy agendas to support patient experience during future public health crises.
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Affiliation(s)
- Lucy Mackintosh
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK.
| | | | - Amanda Busby
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
| | - Janine Hawkins
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
| | | | | | | | | | | | - Shivani Sharma
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
| | - David Wellsted
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
| | - Joseph Chilcot
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | | | | | | | | | - Sarah Afuwape
- Royal Free London NHS Foundation Trust, London, UK
- UCL Division of Medicine, University College London, London, UK
| | - Ken Farrington
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
- Qualitative Data Analysis Services, Gillingham, UK
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Rajasekaran A, Prakash A, Hatch S, Lu Y, Cutter GR, Zarjou A. Advocating for in-center hemodialysis patients via anonymous survey. Medicine (Baltimore) 2022; 101:e30937. [PMID: 36254033 PMCID: PMC9575770 DOI: 10.1097/md.0000000000030937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
We conducted an anonymous survey in 9 of our university affiliated outpatient dialysis units to address the concern that many in-center hemodialysis patients may not feel comfortable sharing their experiences. Major goals of this study: Investigating level of patient satisfaction with their care; Evaluating the subjective perception of the level of understanding of patients regarding pertinent issues of their disease and its management; Identifying potential avenues for care improvement. Survey was conducted in English, paper-based, with answer choices to individual questions for patient satisfaction and education graded using a 5-point Likert scale. Regarding potential areas of improvement, patients were asked to choose as many areas as deemed appropriate. To ensure anonymity, the completed surveys were folded and dropped into a box. Overall, 253 out of 516 (49%) screened patients were eligible and completed the survey. Patients expressed favorable responses regarding satisfaction (mean rating > 4 in each of 14 questions) and education (mean rating > 4 in 8 questions, > 3.5 in 2 questions) regarding hemodialysis. About 62% of overall study participants identified at least one area where they felt additional information would result in improvement of care. Our results indicate that patients undergoing outpatient hemodialysis were overall satisfied and had a good perceptive understanding about their health. Based on the patients' input, strategies focused on addressing pain and discomfort, privacy, providing information about palliative care/hospice, mental health resources, and the process of kidney transplantation may promote improvement in overall quality of care.
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Affiliation(s)
- Arun Rajasekaran
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Anand Prakash
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Spencer Hatch
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Yan Lu
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Gary R. Cutter
- Division of Biostatistics, University of Alabama at Birmingham, AL, USA
| | - Abolfazl Zarjou
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL, USA
- *Correspondence: Abolfazl Zarjou, Assistant Professor of Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, 618 Zeigler Research Building, 703 South 19th Street Birmingham, AL 35294, USA (e-mail: )
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Hawkins J, Wellsted D, Corps C, Fluck R, Gair R, Hall N, Busby A, Rider B, Farrington K, Sharma S, van der Veer SN. OUP accepted manuscript. Nephrol Dial Transplant 2022; 37:1507-1519. [PMID: 35138389 PMCID: PMC9317163 DOI: 10.1093/ndt/gfac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background Methods Results Conclusions
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Affiliation(s)
| | - David Wellsted
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Claire Corps
- Department of Hepatobiliary and Transplant Surgery, St James’ University Teaching Hospital, Leeds, UK
| | - Richard Fluck
- Department of Renal Medicine, Royal Derby Hospital, Derby, UK
| | | | - Natalie Hall
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Amanda Busby
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Beth Rider
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Ken Farrington
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
- Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Shivani Sharma
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Sabine N van der Veer
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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Ahmad HA, Thomas D, Alrais M, Burton A, Jagdale R. Shortcoming of Measuring Patient Satisfaction's Association With Anemia-Based Cardiovascular Risk in End-Stage Kidney Disease Patients. Cardiol Res 2022; 12:344-350. [PMID: 34970364 PMCID: PMC8683103 DOI: 10.14740/cr1332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/22/2021] [Indexed: 11/11/2022] Open
Abstract
Background Patient-reported humanistic outcomes like patient satisfaction are becoming more important in clinical practice, but their use has limitations. Improvements are needed to better demonstrate how patient satisfaction and clinical outcomes are associated. The objective of the study was to observe the correlation between patient’s hemoglobin and patient satisfaction. Methods A cross-sectional study was conducted at a University Hospital hemodialysis unit among end-stage kidney disease (ESKD) patients on maintenance hemodialysis in February and March, 2021. During this time period patient satisfaction was measured using an instrument from the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) study. Spearman’s correlation coefficient was used to find a correlation between patient satisfaction domains and hemoglobin. P value was set at 0.05, and SPSS version 26 was used for the analysis. Results Out of 41 patients studied, their satisfaction on care by interprofessional staff was 77.3%, information received was 68.8%, and effectiveness of care was 71.3% for “very good” and “excellent” responses combined. Out of 40 patients, hemoglobin levels were lower in 17 (42.5%) and higher in seven (17.5%) patients than the optimal range of 10 - 12 g/dL. Spearman’s correlation coefficients were not statistically significant for anemia and any patient satisfaction domain (rs: 0.244, 0.101, 0.048, respectively for the three domains). Spearman’s correlation coefficients were high or moderate between patient satisfaction domains; interprofessional staff with information (rs: 0.745, P value < 0.001) and interprofessional staff with the effectiveness of care (rs: 0.619, P value < 0.001). Information domain had a moderate correlation with the effectiveness of care (rs: 0.527, P value < 0.001). Conclusions No correlation was observed between patient satisfaction with hemoglobin. Although patient satisfaction among hemodialysis patients was mostly “very good” or “excellent”, nearly half of the patients were anemic, and some had higher hemoglobin than the target. Since both of these groups have higher cardiovascular risk this provides an opportunity for the development of patient satisfaction tools with greater sensitivity to awareness of patients’ cardiovascular risk.
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Affiliation(s)
| | - Dixon Thomas
- College of Pharmacy, Gulf Medical University, Ajman, United Arab Emirates
| | - Maryam Alrais
- College of Pharmacy, Gulf Medical University, Ajman, United Arab Emirates
| | - Aaron Burton
- School of Pharmacy and Physician Assistant Studies, University of Saint Joseph, West Hartford, CT, USA
| | - Rajaram Jagdale
- Department of Nephrology, Thumbay University Hospital, Ajman, United Arab Emirates
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Hawkins J, Smeeton N, Busby A, Wellsted D, Rider B, Jones J, Steenkamp R, Stannard C, Gair R, van der Veer SN, Corps C, Farrington K. Contributions of treatment centre and patient characteristics to patient-reported experience of haemodialysis: a national cross-sectional study. BMJ Open 2021; 11:e044984. [PMID: 33853800 PMCID: PMC8054084 DOI: 10.1136/bmjopen-2020-044984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To examine the relative importance of patient and centre level factors in determining self-reported experience of care in patients with advanced kidney disease treated by maintenance haemodialysis (HD). DESIGN Analysis of data from a cross sectional national survey; the UK Renal Registry (UKRR) national Kidney patient-reported experience measure (PREM) survey (2018). Centre-level data were obtained from the UKRR report (2018). SETTING National survey of patients with advanced kidney disease receiving treatment with maintenance HD in UK renal centres in 2018. PARTICIPANTS The Kidney PREM was distributed to all UK renal centres by the UKRR in May 2018. Each centre invited patients receiving outpatient treatment for kidney disease to complete the PREM. These included patients with chronic kidney disease, those receiving dialysis-both HD and peritoneal dialysis, and those with a functioning kidney transplant. There were no formal inclusion/exclusion criteria. MAIN OUTCOME MEASURES The Kidney PREM has 38 questions in 13 subscales. Responses were captured using a 7-point Likert scale (never 1, always 7). The primary outcome of interest was the mean PREM score calculated across all questions. Multilevel modelling was used to determine the proportion of variation of the mean PREM score across centres due to patient-related and centre-related factors. RESULTS There were records for 8253 HD patients (61% men, 77% white) from 69 renal centres (9-710 patients per centre). There was significant variation in mean PREM score across centres (5.35-6.53). In the multivariable analysis there was some variation in relation to both patient- and centre-level factors but these contributed little to explaining the overall variation. However, multilevel modelling showed that the overwhelming proportion of the explained variance (45%) was explained by variation between centres (40%), only a small proportion of which is identified by measured factors. Only 5% of the variation was related to patient-level factors. CONCLUSIONS Centre rather than patient characteristics determine the experience of care of patients receiving HD. Further work is required to define the characteristics of the treating centre which determine patient experience.
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Affiliation(s)
- Janine Hawkins
- Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Nigel Smeeton
- Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Amanda Busby
- Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - David Wellsted
- Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Beth Rider
- Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Julia Jones
- Health and Social Work, University of Hertfordshire, Hatfield, UK
| | | | | | - Rachel Gair
- UK Renal Registry, Renal Association, Bristol, UK
| | | | - Claire Corps
- St James's University Teaching Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ken Farrington
- Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
- Renal Unit, Lister Hospital, Stevenage, UK
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Qi AC, Butler AM, Joynt Maddox KE. The Role Of Social Risk Factors In Dialysis Facility Ratings And Penalties Under A Medicare Quality Incentive Program. Health Aff (Millwood) 2019; 38:1101-1109. [DOI: 10.1377/hlthaff.2018.05406] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Andrew C. Qi
- Andrew C. Qi is a medical student at the Washington University School of Medicine, in Saint Louis, Missouri
| | - Anne M. Butler
- Anne M. Butler is an instructor of medicine at the Washington University School of Medicine, in Saint Louis
| | - Karen E. Joynt Maddox
- Karen E. Joynt Maddox is an assistant professor of medicine (cardiology) at the Washington University School of Medicine, in Saint Louis
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Abstract
In the United States, end-stage renal disease patients receiving hemodialysis have an exceedingly high risk of sudden cardiac death (SCD), accounting for 29% of death events, likely relating to their uremic milieu, recurring exposure to fluid and electrolyte fluxes, and underlying cardiovascular pathology. Furthermore, epidemiologic studies have shown that SCD events, as well as mortality and hospitalizations, occur most frequently on the first dialysis day after the long interdialytic gap, suggesting that abrupt fluctuations in the accumulation and removal of electrolytes, fluid, and uremic toxins over the dialysis cycle may be contributory. Some population-based observational studies have suggested that lower dialysate potassium concentrations appear to be associated with a heightened risk of postdialysis cardiac arrest in hemodialysis patients, although the optimal serum-to-dialysate potassium gradient remains unclear. Some observational studies have suggested that low dialysate calcium concentrations and high serum-to-dialysate calcium gradients may predispose patients to SCD. There is ongoing controversy about an association between higher dialysate bicarbonate concentrations and higher risk of cardiac arrest, likely owing to confounding by indication. Some observational studies also have shown that large interdialytic weight gains, fluid retention, and high ultrafiltration rates are linked with higher risk of SCD and mortality. However, there remains considerable controversy regarding the pros and cons of designating a specific upper ultrafiltration limit with extended treatment times as a clinical practice measure, and further studies are needed to define the optimal tools, metrics, targets, and implementation measures for volume control in the hemodialysis population. In this review, we highlight the epidemiology and pathophysiology of how specific aspects of the hemodialysis procedure may relate to the risk of SCD, as well as preventative strategies and future research directions that can address this risk.
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Brady BM, Zhao B, Niu J, Winkelmayer WC, Milstein A, Chertow GM, Erickson KF. Patient-Reported Experiences of Dialysis Care Within a National Pay-for-Performance System. JAMA Intern Med 2018; 178:1358-1367. [PMID: 30208398 PMCID: PMC6233760 DOI: 10.1001/jamainternmed.2018.3756] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Medicare's End-Stage Renal Disease Quality Incentive Program incorporates measures of perceived value into reimbursement calculations. In 2016, patient experience became a clinical measure in the Quality Incentive Program scoring system. Dialysis facility performance in patient experience measures has not been studied at the national level to date. OBJECTIVE To examine associations among dialysis facility performance with patient experience measures and patient, facility, and geographic characteristics. DESIGN In this cross-sectional analysis, patients from a national end-stage renal disease registry receiving in-center hemodialysis in the United States on December 31, 2014, were linked with dialysis facility scores on the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) survey. Of 4977 US dialysis facilities, 2939 (59.1%) reported ICH-CAHPS scores from April 8, 2015, through January 11, 2016. Multivariable linear regression models with geographic random effects were used to examine associations of facility ICH-CAHPS scores with patient, dialysis facility, and geographic characteristics and to identify the amount of total between-facility variation in patient experience scores explained by these categories. Data were analyzed from September 15, 2017, through June 1, 2018. EXPOSURES Dialysis facility, geographic characteristic, and 10% change in patient characteristics. MAIN OUTCOMES AND MEASURES Dialysis facility ICH-CAHPS scores and the total between-facility variation explained by different categories of characteristics. RESULTS Of the 2939 facilities included in the analysis, adjusted mean ICH-CAHPS scores were 2.6 percentage points (95% CI, 1.5-3.7) lower in for-profit facilities, 1.6 percentage points (95% CI, 0.9-2.2) lower in facilities owned by large dialysis organizations, and 2.3 percentage points (95% CI, 0.5-4.2) lower in free-standing facilities compared with their counterparts. More nurses per patient was associated with 0.2 percentage points (95% CI, 0.03-0.3) higher scores; a privately insured patient population was associated with 1.2 percentage points (95% CI, 0.2-2.2) higher scores. Facilities with higher proportions of black patients had 0.95 percentage points (95% CI, 0.78-1.12) lower scores; more Native American patients, 1.00 percentage point (95% CI, 0.39-1.60) lower facility scores. Geographic location and dialysis facility characteristics explained larger proportions of the overall between-facility variation in ICH-CAHPS scores than did patient characteristics. CONCLUSIONS AND RELEVANCE This study suggests that for-profit operation, free-standing status, and large dialysis organization designation were associated with less favorable patient-reported experiences of care. Patient experience scores varied geographically, and black and Native American populations reported less favorable experiences. The study findings suggest that perceived quality of care delivered in these settings are of concern, and that there may be opportunities for improved implementation of patient experience surveys as is highlighted.
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Affiliation(s)
- Brian M Brady
- Division of Nephrology, Stanford University School of Medicine, Stanford, California.,Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, California
| | - Bo Zhao
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Jingbo Niu
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, California
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Kevin F Erickson
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas.,Baker Institute for Public Policy, Rice University, Houston, Texas
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Abstract
Chronic kidney disease (CKD) is defined by persistent urine abnormalities, structural abnormalities or impaired excretory renal function suggestive of a loss of functional nephrons. The majority of patients with CKD are at risk of accelerated cardiovascular disease and death. For those who progress to end-stage renal disease, the limited accessibility to renal replacement therapy is a problem in many parts of the world. Risk factors for the development and progression of CKD include low nephron number at birth, nephron loss due to increasing age and acute or chronic kidney injuries caused by toxic exposures or diseases (for example, obesity and type 2 diabetes mellitus). The management of patients with CKD is focused on early detection or prevention, treatment of the underlying cause (if possible) to curb progression and attention to secondary processes that contribute to ongoing nephron loss. Blood pressure control, inhibition of the renin-angiotensin system and disease-specific interventions are the cornerstones of therapy. CKD complications such as anaemia, metabolic acidosis and secondary hyperparathyroidism affect cardiovascular health and quality of life, and require diagnosis and treatment.
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