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Mutatiri C, Ratsch A, McGrail M, Venuthurupalli SK, Chennakesavan SK. Primary and specialist care interaction and referral patterns for individuals with chronic kidney disease: a narrative review. BMC Nephrol 2024; 25:149. [PMID: 38689219 PMCID: PMC11061991 DOI: 10.1186/s12882-024-03585-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/23/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Timely referral of individuals with chronic kidney disease from primary care to secondary care is evidenced to improve patient outcomes, especially for those whose disease progresses to kidney failure requiring kidney replacement therapy. A shortage of specialist nephrology services plus no consistent criteria for referral and reporting leads to referral pattern variability in the management of individuals with chronic kidney disease. OBJECTIVE The objective of this review was to explore the referral patterns of individuals with chronic kidney disease from primary care to specialist nephrology services. It focused on the primary-specialist care interface, optimal timing of referral to nephrology services, adequacy of preparation for kidney replacement therapy, and the role of clinical criteria vs. risk-based prediction tools in guiding the referral process. METHODS A narrative review was utilised to summarise the literature, with the intent of providing a broad-based understanding of the referral patterns for patients with chronic kidney disease in order to guide clinical practice decisions. The review identified original English language qualitative, quantitative, or mixed methods publications as well as systematic reviews and meta-analyses available in PubMed and Google Scholar from their inception to 24 March 2023. RESULTS Thirteen papers met the criteria for detailed review. We grouped the findings into three main themes: (1) Outcomes of the timing of referral to nephrology services, (2) Adequacy of preparation for kidney replacement therapy, and (3) Comparison of clinical criteria vs. risk-based prediction tools. The review demonstrated that regardless of the time frame used to define early vs. late referral in relation to the start of kidney replacement therapy, better outcomes are evidenced in patients referred early. CONCLUSIONS This review informs the patterns and timing of referral for pre-dialysis specialist care to mitigate adverse outcomes for individuals with chronic kidney disease requiring dialysis. Enhancing current risk prediction equations will enable primary care clinicians to accurately predict the risk of clinically important outcomes and provide much-needed guidance on the timing of referral between primary care and specialist nephrology services.
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Affiliation(s)
- Clyson Mutatiri
- Renal Medicine, Wide Bay Hospital and Health Service, Bundaberg, QLD, Australia.
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Bundaberg, QLD, Australia.
| | - Angela Ratsch
- Research Services, Wide Bay Hospital and Health Service, Hervey Bay, QLD, Australia
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Hervey Bay, QLD, Australia
| | - Matthew McGrail
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Rockhampton, QLD, Australia
| | - Sree Krishna Venuthurupalli
- Kidney Service, Department of Medicine, West Moreton Hospital and Health Service, Ipswich, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Pollock C, Moon JY, Ngoc Ha LP, Gojaseni P, Ching CH, Gomez L, Chan TM, Wu MJ, Yeo SC, Nugroho P, Bhalla AK. Framework of Guidelines for Management of CKD in Asia. Kidney Int Rep 2024; 9:752-790. [PMID: 38765566 PMCID: PMC11101746 DOI: 10.1016/j.ekir.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/29/2023] [Accepted: 12/11/2023] [Indexed: 05/22/2024] Open
Affiliation(s)
- Carol Pollock
- Kolling Institute of Medical Research, University of Sydney, St Leonards, New South Wales, Australia
| | - Ju-young Moon
- Kyung Hee University School of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Le Pham Ngoc Ha
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | | | | | - Lynn Gomez
- Asian Hospital and Medical Center, Muntinlupa City, Metro Manila, Philippines
| | - Tak Mao Chan
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Ming-Ju Wu
- Taichung Veterans General Hospital, Taichung City, Taiwan
| | | | | | - Anil Kumar Bhalla
- Department of Nephrology-Sir Ganga Ram Hospital Marg, New Delhi, Delhi, India
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3
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Farrell DR, Vassalotti JA. Screening, identifying, and treating chronic kidney disease: why, who, when, how, and what? BMC Nephrol 2024; 25:34. [PMID: 38273240 PMCID: PMC10809507 DOI: 10.1186/s12882-024-03466-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/15/2024] [Indexed: 01/27/2024] Open
Abstract
1 in 7 American adults have chronic kidney disease (CKD); a disease that increases risk for CKD progression, cardiovascular events, and mortality. Currently, the US Preventative Services Task Force does not have a screening recommendation, though evidence suggests that screening can prevent progression and is cost-effective. Populations at risk for CKD, such as those with hypertension, diabetes, and age greater than 50 years should be targeted for screening. CKD is diagnosed and risk stratified with estimated glomerular filtration rate utilizing serum creatinine and measuring urine albumin-to-creatinine ratio. Once identified, CKD is staged according to C-G-A classification, and managed with lifestyle modification, interdisciplinary care and the recently expanding repertoire of pharmacotherapy which includes angiotensin converting enzyme inhibitors or angiotensin-II receptor blockers, sodium-glucose-cotransporter-2 inhibitors, and mineralocorticorticoid receptor antagonists. In this paper, we present the why, who, when, how, and what of CKD screening.
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Affiliation(s)
- Douglas R Farrell
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, 10029, New York, NY, USA.
| | - Joseph A Vassalotti
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, 10029, New York, NY, USA
- National Kidney Foundation, Inc, New York, NY, USA
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4
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Jhamb M, Weltman MR, Yabes JG, Kamat S, Devaraj SM, Fischer GS, Rollman BL, Nolin TD, Abdel-Kader K. Electronic health record based population health management to optimize care in CKD: Design of the Kidney Coordinated HeAlth Management Partnership (K-CHAMP) trial. Contemp Clin Trials 2023; 131:107269. [PMID: 37348600 PMCID: PMC10529809 DOI: 10.1016/j.cct.2023.107269] [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: 01/20/2023] [Revised: 06/06/2023] [Accepted: 06/19/2023] [Indexed: 06/24/2023]
Abstract
Primary care physicians (PCPs) provide the majority of medical care to patients with non-dialysis dependent CKD. However, PCPs report numerous limitations to providing expert CKD care, including poor patient education, inadequate diagnostic evaluation, suboptimal use of medications, and time limitations. The Kidney Coordinated HeAlth Management Partnership (Kidney CHAMP) trial is a cluster randomized controlled trial to evaluate the effectiveness of a novel centralized electronic health records (EHR)-delivered population health management (PHM) strategy for high-risk CKD patients on patient care, safety, and other outcomes of interest to patients, providers, and payors. Over a 42-month period, the trial will compare the effectiveness of a multifaceted intervention that combines early identification of high-risk patients, timely nephrology guidance, pharmacist-led medication management services, and CKD patient education to usual care and enroll 1650 high-risk CKD patients from 100 primary care practices. The primary outcome will be ≥40% decline in estimated glomerular filtration rate (eGFR) or end stage kidney disease. Key secondary outcomes will include blood pressure, renin-angiotensin aldosterone system inhibitors use, and exposure to potentially unsafe medications. If successful, our treatment approach could improve CKD care delivery and safety, resource allocation, and adoption of evidence-based CKD guideline-concordant care.
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Affiliation(s)
- Manisha Jhamb
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Melanie R Weltman
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Jonathan G Yabes
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Sanjana Kamat
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Susan M Devaraj
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Gary S Fischer
- Department of Medicine and Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Bruce L Rollman
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, PA, United States of America; Center for Behavioral Health, Media, and Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Thomas D Nolin
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, United States of America
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
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Yu Y, Meng W, Kuang H, Chen X, Zhu X, Wang L, Tan H, Xu Y, Ding P, Xiang M, Hu G, Zhou Y, Dong GH. Association of urinary exposure to multiple metal(loid)s with kidney function from a national cross-sectional study. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 882:163100. [PMID: 37023822 DOI: 10.1016/j.scitotenv.2023.163100] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Arsenic (As), cadmium (Cd) and copper (Cu) are hazardous for kidney function, while the effects of selenium (Se) and zinc (Zn) were unexplored for the narrow safe range of intake. Interactions exists between these multiple metal/metalloid exposures, but few studies have investigated the effects. METHODS A cross-sectional survey was performed among 2210 adults across twelve provinces in China between 2020 and 2021. Urinary As, Cd, Cu, Se and Zn were measured using inductively coupled plasma-mass spectrometry (ICP-MS). Serum creatinine (Scr) and N-acetyl-beta-D glucosaminidases (urine NAG) were quantified in serum and urine, respectively. Kidney function was evaluated by the estimated glomerular filtration rate (eGFR). We employed logistic regression and Bayesian kernel machine regression (BKMR) models to explore the individual and joint effects of urinary metals/metalloids on the risk of impaired renal function (IRF) or chronic kidney disease (CKD), respectively. RESULTS Association was found between As (OR = 1.24, 95 % CI: 1.03, 1.48), Cd (OR = 1.65, 95 % CI: 1.35, 2.02), Cu (OR = 1.90, 95 % CI: 1.59, 2.29), Se (OR = 1.51, 95 % CI: 1.24, 1.85) and Zn (OR = 1.33, 95 % CI: 1.09, 1.64) and the risk of CKD. Moreover, we observed association between As (OR = 1.18, 95 % CI: 1.07, 1.29), Cu (OR = 1.14, 95 % CI: 1.04, 1.25), Se (OR = 1.15, 95 % CI: 1.06, 1.26) and Zn (OR = 1.12, 95 % CI: 1.02, 1.22) and the risk of IRF. Additionally, it was found that Se exposure may strength the association of urinary As, Cd and Cu with IRF. Furthermore, it is worth noting that Se and Cu contributed greatest to the inverse association in IRF and CKD, respectively. CONCLUSION Our findings suggested that metal/metalloid mixtures were associated with kidney dysfunction, Se and Cu were inverse factors. Additionally, interactions between them may affect the association. Further studies are needed to assess the potential risks for metal/metalloid exposures.
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Affiliation(s)
- Yunjiang Yu
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou 510655, PR China.
| | - Wenjie Meng
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou 510655, PR China
| | - Hongxuan Kuang
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou 510655, PR China
| | - Xichao Chen
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou 510655, PR China
| | - Xiaohui Zhu
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou 510655, PR China
| | - Lebing Wang
- Guangdong Provincial Engineering Technology Research Center of Environmental Pollution and Health Risk Assessment, Department of Occupational and Environmental Health, School of Public Health, Sun Yat-sen University, Guangzhou 510080, PR China
| | - Haiping Tan
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou 510655, PR China
| | - Yujie Xu
- Guangdong Provincial Engineering Technology Research Center of Environmental Pollution and Health Risk Assessment, Department of Occupational and Environmental Health, School of Public Health, Sun Yat-sen University, Guangzhou 510080, PR China
| | - Ping Ding
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou 510655, PR China
| | - Mingdeng Xiang
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou 510655, PR China
| | - Guocheng Hu
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou 510655, PR China
| | - Yang Zhou
- State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Environmental Protection, Guangzhou 510655, PR China; Guangdong Provincial Engineering Technology Research Center of Environmental Pollution and Health Risk Assessment, Department of Occupational and Environmental Health, School of Public Health, Sun Yat-sen University, Guangzhou 510080, PR China.
| | - Guang-Hui Dong
- Guangdong Provincial Engineering Technology Research Center of Environmental Pollution and Health Risk Assessment, Department of Occupational and Environmental Health, School of Public Health, Sun Yat-sen University, Guangzhou 510080, PR China.
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Tachikart A, Vachey C, Vauchy C, Savet C, Ducloux D, Courivaud C. Determinants of urgent start dialysis in a chronic kidney disease cohort followed by nephrologists. BMC Nephrol 2023; 24:190. [PMID: 37370038 DOI: 10.1186/s12882-023-03222-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The French Renal Epidemiology and Information Network (REIN) registry collect dialysis initiation context for each patient starting dialysis with a flawed definition of urgent start dialysis (USD). The main objective of this study was to identify factors associated with USD in patients regularly followed-up by a nephrologist using a classification of USD considering the preparation to renal replacement therapy. METHODS This retrospective cohort study included adult patients who started dialysis between 2012 and 2018 in the Franche-Comté region of France after a minimum of two nephrology consultations. We classified dialysis initiation context as follows: USD for patients with no dialysis access (DA) created or planned, unplanned non urgent start dialysis (UNUSD) for patients starting with a recent or non-functional DA and planned start dialysis (PSD) for those starting with a functional and mature DA. RESULTS Four hundred and sixty-five patients met inclusion criteria. According to REIN registry, 94 (20.3%) patients were urgent starters (US) whereas with our classification 80 (17.2%) and 73 (15.7%) where respectively US and unplanned non urgent starters (UNUS). The factors independently associated with USD in our classification were: stroke (odds ratio(OR) = 2.76, 95% confidence interval (95%CI)=[1.41-5.43]), cardiac failure (OR = 1.78, 95%CI=[1.07-2.96]) and the number of nephrology consultations prior dialysis onset (OR = 0.73, 95%CI=[0.64-0.83]). Thirty-one patients died during the first year after dialysis start. According to our classification, we observed significantly different survival probabilities: 95.7%, 89.5% and 83.4% respectively for planned starters, UNUS and US (p = 0.001). CONCLUSION The two factors independently associated with USD were cardiac failure and stroke.
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Affiliation(s)
- Amin Tachikart
- Department of Nephrology, Dialysis and Renal Transplantation, Univ Hospital of Besançon, Besançon, France.
| | - Clément Vachey
- Department of Nephrology, Dialysis and Renal Transplantation, Univ Hospital of Besançon, Besançon, France
| | - Charline Vauchy
- Department of Nephrology, Dialysis and Renal Transplantation, Univ Hospital of Besançon, Besançon, France
| | - Caroline Savet
- Agence de la Biomédecine, REIN Registry, Saint Denis La Plaine Cedex, Paris, France
| | - Didier Ducloux
- Department of Nephrology, Dialysis and Renal Transplantation, Univ Hospital of Besançon, Besançon, France
| | - Cécile Courivaud
- Department of Nephrology, Dialysis and Renal Transplantation, Univ Hospital of Besançon, Besançon, France
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Correa-Rotter R, Méndez Durán A, Vallejos A, Rico-Fontalvo J, Cusumano AM, Rosa-Diez GJ, Sánchez Polo V, Goecke H, Arango JJ, Cerón VV, Diná E, Fonseca FH, Valdés RA, Vanoni M. Unmet Needs of CKD in Latin America: A Review from Expert Virtual Working Group. Kidney Int Rep 2023; 8:954-967. [PMID: 37180514 PMCID: PMC10166742 DOI: 10.1016/j.ekir.2023.02.1082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/31/2023] [Accepted: 02/19/2023] [Indexed: 03/03/2023] Open
Abstract
Chronic kidney disease (CKD) represents a major challenge for Latin American (LatAm) because of its epidemic proportions. Therefore, the current status and knowledge of CKD in Latin America is not clearly understood. Moreover, there is a paucity of epidemiologic studies that makes the comparison across the countries even more difficult. To address these gaps, a virtual kidney expert opinion meeting of 14 key opinion leaders from Argentina, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, Guatemala, Mexico, and Panama was held in January 2022 to review and discuss the status of CKD in various LatAm regions. The meeting discussed the following: (i) epidemiology, diagnosis, and treatment of CKD, (ii) detection and prevention programs, (iii) clinical guidelines, (iv) state of public policies about diagnosis and management of chronic kidney disease, and (v) role of innovative therapies in the management of CKD. The expert panel emphasized that efforts should be made to implement timely detection programs and early evaluation of kidney function parameters to prevent the development or progression of CKD. Furthermore, the panel discussed the importance of raising awareness among health care professionals; disseminating knowledge to the authorities, the medical community, and the general population about the kidney and cardiovascular benefits of novel therapies; and the need for timely updating of clinical practice guidelines, regulatory policies, and protocols across the region.
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Affiliation(s)
- Ricardo Correa-Rotter
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | | | | | - Jorge Rico-Fontalvo
- Technology and Innovation Management, Simón Bolivar University, Barranquilla, Colombia
| | | | | | | | | | | | | | - Eliana Diná
- Hospital Metropolitano de Santiago, Santiago de los Caballeros, Dominican Republic
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8
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Lim JH, Kim JH, Jeon Y, Kim YS, Kang SW, Yang CW, Kim NH, Jung HY, Choi JY, Park SH, Kim CD, Kim YL, Cho JH. The benefit of planned dialysis to early survival on hemodialysis versus peritoneal dialysis: a nationwide prospective multicenter study in Korea. Sci Rep 2023; 13:6049. [PMID: 37055558 PMCID: PMC10102303 DOI: 10.1038/s41598-023-33216-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/09/2023] [Indexed: 04/15/2023] Open
Abstract
Optimal preparation is recommended for patients with advanced chronic kidney disease to minimize complications during dialysis initiation. This study evaluated the effects of planned dialysis initiation on survival in patients undergoing incident hemodialysis and peritoneal dialysis. Patients newly diagnosed with end-stage kidney disease who started dialysis were enrolled in a multicenter prospective cohort study in Korea. Planned dialysis was defined as dialysis therapy initiated with permanent access and maintenance of the initial dialysis modality. A total of 2892 patients were followed up for a mean duration of 71.9 ± 36.7 months and 1280 (44.3%) patients initiated planned dialysis. The planned dialysis group showed lower mortality than the unplanned dialysis group during the 1st and 2nd years after dialysis initiation (1st year: adjusted hazard ratio [aHR] 0.51; 95% confidence interval [CI] 0.37-0.72; P < 0.001; 2nd year: aHR 0.71; 95% CI 0.52-0.98, P = 0.037). However, 2 years after dialysis initiation, mortality did not differ between the groups. Planned dialysis showed a better early survival rate in hemodialysis patients, but not in peritoneal dialysis patients. Particularly, infection-related mortality was reduced only in patients undergoing hemodialysis with planned dialysis initiation. Planned dialysis has survival benefits over unplanned dialysis in the first 2 years after dialysis initiation, especially in patients undergoing hemodialysis. It improved infection-related mortality during the early dialysis period.
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Affiliation(s)
- Jeong-Hoon Lim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Ji Hye Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Yena Jeon
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Statistics, Kyungpook National University, Daegu, South Korea
| | - Yon Su Kim
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Shin-Wook Kang
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Chul Woo Yang
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Nam-Ho Kim
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, South Korea
| | - Hee-Yeon Jung
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Ji-Young Choi
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Sun-Hee Park
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Chan-Duck Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea
| | - Yong-Lim Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea.
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea.
| | - Jang-Hee Cho
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, South Korea.
- Clinical Research Center for End Stage Renal Disease, Daegu, South Korea.
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Kaufman HW, Wang C, Wang Y, Han H, Chaudhuri S, Usvyat L, Hahn Contino C, Kossmann R, Kraus MA. Machine Learning Case Study: Patterns of Kidney Function Decline and Their Association With Clinical Outcomes Within 90 Days After the Initiation of Renal Dialysis. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:33-39. [PMID: 36723279 DOI: 10.1053/j.akdh.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 10/28/2022] [Accepted: 11/16/2022] [Indexed: 01/20/2023]
Abstract
A case study explores patterns of kidney function decline using unsupervised learning methods first and then associating patterns with clinical outcomes using supervised learning methods. Predicting short-term risk of hospitalization and death prior to renal dialysis initiation may help target high-risk patients for more aggressive management. This study combined clinical data from patients presenting for renal dialysis at Fresenius Medical Care with laboratory data from Quest Diagnostics to identify disease trajectory patterns associated with the 90-day risk of hospitalization and death after beginning renal dialysis. Patients were clustered into 4 groups with varying rates of estimated glomerular filtration rate (eGFR) decline during the 2-year period prior to dialysis. Overall rates of hospitalization and death were 24.9% (582/2341) and 4.6% (108/2341), respectively. Groups with the steepest declines had the highest rates of hospitalization and death within 90 days of dialysis initiation. The rate of eGFR decline is a valuable and readily available tool to stratify short-term (90 days) risk of hospitalization and death after the initiation of renal dialysis. More intense approaches are needed that apply models that identify high risks to potentially avert or reduce short-term hospitalization and death of patients with a severe and rapidly progressive chronic kidney disease.
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Affiliation(s)
| | - Catherine Wang
- Statistics and Data Science, Dietrich College of Humanities and Social Sciences, Carnegie Mellon University, Pittsburgh, PA
| | - Yuedong Wang
- Department of Statistics and Applied Probability, College of Letters and Science, University of California - Santa Barbara, Santa Barbara, CA
| | - Hao Han
- Fresenius Medical Care, Waltham, MA
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10
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Oliva-Damaso N, Delanaye P, Oliva-Damaso E, Payan J, Glassock RJ. Risk-based versus GFR threshold criteria for nephrology referral in chronic kidney disease. Clin Kidney J 2022; 15:1996-2005. [PMID: 36325015 PMCID: PMC9613424 DOI: 10.1093/ckj/sfac104] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Indexed: 02/22/2024] Open
Abstract
Chronic kidney disease (CKD) and kidney failure are global health problems associated with morbidity, mortality and healthcare costs, with unequal access to kidney replacement therapy between countries. The diversity of guidelines concerning referral from primary care to a specialist nephrologist determines different outcomes around the world among patients with CKD where several guidelines recommend referral when the glomerular filtration rate (GFR) is <30 mL/min/1.73 m2 regardless of age. Additionally, fixed non-age-adapted diagnostic criteria for CKD that do not distinguish correctly between normal kidney senescence and true kidney disease can lead to overdiagnosis of CKD in the elderly and underdiagnosis of CKD in young patients and contributes to the unfair referral of CKD patients to a kidney specialist. Non-age-adapted recommendations contribute to unnecessary referral in the very elderly with a mild disease where the risk of death consistently exceeds the risk of progression to kidney failure and ignore the possibility of effective interventions of a young patient with long life expectancy. The opportunity of mitigating CKD progression and cardiovascular complications in young patients with early stages of CKD is a task entrusted to primary care providers who are possibly unable to optimally accomplish guideline-directed medical therapy for this purpose. The shortage in the nephrology workforce has classically led to focused referral on advanced CKD stages preparing for kidney replacement, but the need for hasty referral to a nephrologist because of the urgent requirement for kidney replacement therapy in advanced CKD is still observed and changes are required to move toward reducing the kidney failure burden. The Kidney Failure Risk Equation (KFRE) is a novel tool that can guide wiser nephrology referrals and impact patients.
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Affiliation(s)
- Nestor Oliva-Damaso
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liege, Centre Hospitalier Universitaire Sart Tilman, ULgCHU, Liege, Belgium
- Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nîmes, France
| | - Elena Oliva-Damaso
- Department of Medicine, Division of Nephrology, Hospital Universitario Doctor Negrin, Las Palmas de Gran Canaria, Spain
| | - Juan Payan
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
| | - Richard J Glassock
- Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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11
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"The Disease Awareness Innovation Network" for chronic kidney disease identification in general practice. J Nephrol 2022; 35:2057-2065. [PMID: 35701727 PMCID: PMC9584961 DOI: 10.1007/s40620-022-01353-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The "awareness gap" and the under-recognition of chronic kidney disease (CKD) by general practitioners (GPs) is well documented. We set a framework to evaluate the impact in primary care of targeted training and networking with nephrologists with regard to CKD awareness in terms of potential increase of the proportion of patients classified according to KDIGO in the general population and in patients with diabetes, hypertension and heart failure. METHODS Data were extracted from the Millewin Digital Platform in use by the GPs (N = 17) at baseline (T0, N = 17,854) and after 6 months (T6, N = 18,662) of networking (education, instant messaging and selected joint visits) with nephrologists (N = 2). The following variables were extracted: age, sex, eGFR (estimated glomerular filtration rate), ACR (urinary albumin-to-creatinine ratio), presence of type 2 diabetes, hypertension and heart failure. The proportion of patients detected having an eGFR below 60 mL/min/1.73m2 was also reported as deemed clinically relevant. RESULTS We observed an increase in the use of ACR and eGFR tests in the entire cohort (+ 121% and + 73%, respectively) and in patients with comorbidities. The proportion of patients with eGFR < 60 mL/min/1.73m2 significantly increased from 2.2% to 3.8% in the entire cohort, from 6.3% to 12.7% in patients with diabetes, and from 5.6% to 9.9% in those with hypertension and finally from 10.8% to 23.7% in patients with heart failure. CONCLUSIONS Training and network support to GPs by nephrologists can improve CKD awareness and increase its identification in the general population and, even more, in categories at risk.
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12
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Kuma A, Kato A. Lifestyle-Related Risk Factors for the Incidence and Progression of Chronic Kidney Disease in the Healthy Young and Middle-Aged Population. Nutrients 2022; 14:nu14183787. [PMID: 36145162 PMCID: PMC9506421 DOI: 10.3390/nu14183787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/10/2022] [Accepted: 09/11/2022] [Indexed: 11/16/2022] Open
Abstract
The prevalence of chronic kidney disease (CKD) increased by 88% from 1990 to 2016. Age of onset of lifestyle-related diseases (such as hypertension, diabetes mellitus, obesity, dyslipidemia, and hyperuricemia), which are risk factors for incident CKD, is lower now compared with the past. Thus, we aimed to evaluate the risk factors for the incidence and progression of CKD in the young and middle-aged population. There are differences in the risk for CKD among the young, middle-aged, and elderly populations. We aimed to assess obesity (which is basic component of metabolic syndrome), waist circumference, and abdominal adiposity, which are predictive factors of CKD in the younger population. Furthermore, we described the management and clinical evidence of hypertension, diabetes mellitus, dyslipidemia, and hyperuricemia for young and middle-aged patients, along with diet management and nutrients associated with kidney function. Kidney function in the young and middle-aged population is mostly normal, and they are considered a low-risk group for incident CKD. Thus, we expect this review to be useful in reducing the prevalence of CKD.
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Affiliation(s)
- Akihiro Kuma
- Kidney Center, Hospital of the University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8556, Fukuoka, Japan
| | - Akihiko Kato
- Blood Purification Unit, Hamamatsu University Hospital, 1-20-1 Handayama, Higashi-ku, Hamamatsu 431-3125, Shizuoka, Japan
- Correspondence:
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13
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Kampmann JD, Heaf JG, Mogensen CB, Mickley H, Wolff DL, Kristensen FB. Referral rate of chronic kidney disease patients to a nephrologist in the region of Southern Denmark: results from KidDiCo. Clin Kidney J 2022; 15:2116-2123. [DOI: 10.1093/ckj/sfac165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Data on the referral rate of chronic kidney disease (CKD) patients to specialists are sparse. Investigating referral rates and characterising patients with kidney disease not followed by a nephrologist is relevant for future measures in order to optimize public health and guideline implementation.
Methods
Data were extracted from the Kidney Disease Cohort of Southern Denmark (KidDiCo). Referral rates for all incident CKD patients below 60ml/min/1.73m² and referral rates according to the KDIGO guidelines based glomerular filtration rates below 30 ml/min/1.73m² were calculated. Information on contact with one of the nephrologist outpatient clinics in the Region of Southern Denmark was collected from the Danish National Patient Registry. The individual follow up time for nephrology contact was 12 months. Additional data was accessed via the respective national databases. CKD patients on dialysis and kidney transplanted patients were excluded.
Result
Three % of patients with an eGFR < 60 ml/min/1.73m² sixteen % of patients with an eGFR < 30 ml/min/1.73m² and thirty-five % of patients with an eGFR < 15 ml/min/1.73m² were in contact with a nephrologist in the outpatient settings. Younger age, male sex, diabetes, hypertension, higher education and proximity to a nephrology outpatient clinic increased the chance of nephrology follow up.
Conclusion
Only a small fraction of CKD patients are followed by a nephrologist. More studies should be performed in order to find out which patients will profit the most from renal referral and how to optimize the collaboration between nephrologists and general practitioners.
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Affiliation(s)
- Jan Dominik Kampmann
- Department of Internal Medicine, Hospital of Southern Jutland, Sønderborg, Sonderborg , Denmark
- Institute of Regional Health Research, University of Southern Denmark , Odense , Denmark
| | - James Goya Heaf
- Department of Medicine, Zealand University Hospital, Roskilde , Roskilde , Denmark
| | - Christian Backer Mogensen
- Department of Emergency Medicine, Hospital of Southern Jutland , Aabenraa , Denmark
- Institute of Regional Health Research, University of Southern Denmark , Odense , Denmark
| | - Hans Mickley
- Department of Cardiology, Odense University Hospital , Odense , Denmark
| | - Donna Lykke Wolff
- Department of Internal Medicine, Hospital of Southern Jutland, Sønderborg, Sonderborg , Denmark
- Institute of Regional Health Research, University of Southern Denmark , Odense , Denmark
| | - Frans Brandt Kristensen
- Department of Internal Medicine, Hospital of Southern Jutland, Sønderborg, Sonderborg , Denmark
- Institute of Regional Health Research, University of Southern Denmark , Odense , Denmark
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14
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Rodrigues AS, de Abreu LC, Morais MJDD, Leitao FNC, do Amaral GLG, de Sousa Santos EF, do Souto RP. Temporal trend of mortality and hospitalization for chronic kidney disease in adults from Northern Brazil. Medicine (Baltimore) 2022; 101:e29702. [PMID: 35777060 PMCID: PMC9239633 DOI: 10.1097/md.0000000000029702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 04/22/2022] [Indexed: 01/05/2023] Open
Abstract
We aimed to evaluate mortality and hospital admissions for chronic kidney disease in young adults according to sex and state in the northern region of Brazil, between 1996 and 2017. A population-based time series study using official data on mortality and hospital admissions due to chronic kidney disease in individuals aged 20 to 49 years old, residents of the northern region of Brazil, in the periods 1996-2017 and to 2008-2017, respectively. Chronic kidney disease was defined according to the International Classification of Diseases, 10th revision (N18). The evolution of mortality from chronic kidney disease decreased by 0.881% per year over the period (1996-2017). In the states of Acre and Amapá, there was a reduction of 5.85% and -5.68% per year, respectively, and in Tocantins, an increase of 4.16% per year. The incidence of hospitalization did not vary between 2008 and 2017. However, 2 states showed an increase in hospitalization rates: Acre (6.08% per year) and Pará (2.83% per year), and 2 states showed a reduction: Amazonas (5.09% per year) and Tocantins (6.23% per year). In general, there was decrease in mortality rate overtime. However, rate of mortality due to chronic kidney disease increased in the state of Tocantins. The evolution of hospitalization due to chronic kidney disease in a population of young adults remained stationary.
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Affiliation(s)
- Alliny Sales Rodrigues
- Centro Universitário FMABC, Santo André, Sao Paulo, Brazil
- Acre State Health Secretariat (SESACRE), Rio Branco, Acre, Brazil
- Multidisciplinary Laboratory for Studies and Scientific Writing in Health Sciences (LaMEECCS), Federal University of Acre (UFAC), Rio Branco, Acre, Brazil
- Laboratory of Study Design and Scientific Writing (LaDEEC/FMABC), Santo Andre, Sao Paulo, Brazil
| | - Luiz Carlos de Abreu
- Centro Universitário FMABC, Santo André, Sao Paulo, Brazil
- Laboratory of Study Design and Scientific Writing (LaDEEC/FMABC), Santo Andre, Sao Paulo, Brazil
| | - Mauro Jose de Deus Morais
- Multidisciplinary Laboratory for Studies and Scientific Writing in Health Sciences (LaMEECCS), Federal University of Acre (UFAC), Rio Branco, Acre, Brazil
- Laboratory of Study Design and Scientific Writing (LaDEEC/FMABC), Santo Andre, Sao Paulo, Brazil
- Federal University of Acre (UFAC), Cruzeiro do Sul, Acre, Brazil
| | - Francisco Naildo Cardoso Leitao
- Centro Universitário FMABC, Santo André, Sao Paulo, Brazil
- Multidisciplinary Laboratory for Studies and Scientific Writing in Health Sciences (LaMEECCS), Federal University of Acre (UFAC), Rio Branco, Acre, Brazil
- Laboratory of Study Design and Scientific Writing (LaDEEC/FMABC), Santo Andre, Sao Paulo, Brazil
| | | | - Edige Felipe de Sousa Santos
- Centro Universitário FMABC, Santo André, Sao Paulo, Brazil
- Laboratory of Study Design and Scientific Writing (LaDEEC/FMABC), Santo Andre, Sao Paulo, Brazil
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15
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Heaf J, Heiro M, Petersons A, Vernere B, Povlsen JV, Sørensen AB, Clyne N, Bumblyte I, Zilinskiene A, Randers E, Løkkegaard N, Rosenberg M, Kjellevold S, Kampmann JD, Rogland B, Lagreid I, Heimburger O, Qureshi AR, Lindholm B. First-year mortality in incident dialysis patients: results of the Peridialysis study. BMC Nephrol 2022; 23:229. [PMID: 35761193 PMCID: PMC9235232 DOI: 10.1186/s12882-022-02852-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Controversy surrounds which factors are important for predicting early mortality after dialysis initiation (DI). We investigated associations of predialysis course and circumstances affecting planning and execution of DI with mortality following DI. Methods Among 1580 patients participating in the Peridialysis study, a study of causes and timing of DI, we registered features of predialysis course, clinical and biochemical data at DI, incidence of unplanned suboptimal DI, contraindications to peritoneal dialysis (PD) or hemodialysis (HD), and modality preference, actual choice, and cause of modality choice. Patients were followed for 12 months or until transplantation. A flexible parametric model was used to identify independent factors associated with all-cause mortality. Results First-year mortality was 19.33%. Independent factors predicting death were high age, comorbidity, clinical contraindications to PD or HD, suboptimal DI, high eGFR, low serum albumin, hyperphosphatemia, high C-reactive protein, signs of overhydration and cerebral symptoms at DI. Among 1061 (67.2%) patients who could select dialysis modality based on personal choice, 654 (61.6%) chose PD, 368 (34.7%) center HD and 39 (3.7%) home HD. The 12-months survival did not differ significantly between patients receiving PD and in-center HD. Conclusions First-year mortality in incident dialysis patients was in addition to high age and comorbidity, associated with clinical contraindications to PD or HD, clinical symptoms, hyperphosphatemia, inflammation, and suboptimal DI. In patients with a “free” choice of dialysis modality based on their personal preferences, PD and in-center HD led to broadly similar short-term outcomes.
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16
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Iakoubova OA, Tong CH, Rowland CM, Arellano AR, Bare LA, Fragala MS, Birse CE. Workplace Outreach Program Improves Management of Chronic Kidney Disease. J Occup Environ Med 2022; 64:482-487. [PMID: 34967765 PMCID: PMC9275843 DOI: 10.1097/jom.0000000000002475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Assess whether an employee outreach program improved management of chronic kidney disease (CKD). METHODS Participants with suspected CKD (eGFR <60 mL/min/1.73m 2 ) identified in employee health assessments in 2017 and 2018 were contacted by phone and offered physician consultation. Subsequent nephrologist visits at 11 months of follow up were compared between those who were (outreach group) and were not (control group) successfully contacted. RESULTS Most CKD risk factors at baseline were similar in outreach and control groups. At the end of the follow-up, outreach participants had more than 2-fold greater incidence of visiting a nephrologist compared with controls (HR = 2.3; 95% CI 1.2-4.2, P = 0.01), after adjusting for potential confounders. Conclusions: Employee outreach program increased utilization of nephrologist care.
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Affiliation(s)
- Olga A Iakoubova
- From the Department of Quest Diagnostics, San Juan Capistrano, California (Dr Iakoubova, Ms Tong, Mr Rowland, Arellano, Dr Bare, Dr Fragala, and Dr Birse)
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17
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Samal L, D’Amore JD, Gannon MP, Kilgallon JL, Charles JP, Mann DM, Siegel LC, Burdge K, Shaykevich S, Lipsitz S, Waikar SS, Bates DW, Wright A. Impact of Kidney Failure Risk Prediction Clinical Decision Support on Monitoring and Referral in Primary Care Management of CKD: A Randomized Pragmatic Clinical Trial. Kidney Med 2022; 4:100493. [PMID: 35866010 PMCID: PMC9293940 DOI: 10.1016/j.xkme.2022.100493] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Rationale & Objective To design and implement clinical decision support incorporating a validated risk prediction estimate of kidney failure in primary care clinics and to evaluate the impact on stage-appropriate monitoring and referral. Study Design Block-randomized, pragmatic clinical trial. Setting & Participants Ten primary care clinics in the greater Boston area. Patients with stage 3-5 chronic kidney disease (CKD) were included. Patients were randomized within each primary care physician panel through a block randomization approach. The trial occurred between December 4, 2015, and December 3, 2016. Intervention Point-of-care noninterruptive clinical decision support that delivered the 5-year kidney failure risk equation as well as recommendations for stage-appropriate monitoring and referral to nephrology. Outcomes The primary outcome was as follows: Urine and serum laboratory monitoring test findings measured at one timepoint 6 months after the initial primary care visit and analyzed only in patients who had not undergone the recommended monitoring test in the preceding 12 months. The secondary outcome was nephrology referral in patients with a calculated kidney failure risk equation value of >10% measured at one timepoint 6 months after the initial primary care visit. Results The clinical decision support application requested and processed 569,533 Continuity of Care Documents during the study period. Of these, 41,842 (7.3%) documents led to a diagnosis of stage 3, 4, or 5 CKD by the clinical decision support application. A total of 5,590 patients with stage 3, 4, or 5 CKD were randomized and included in the study. The link to the clinical decision support application was clicked 122 times by 57 primary care physicians. There was no association between the clinical decision support intervention and the primary outcome. There was a small but statistically significant difference in nephrology referral, with a higher rate of referral in the control arm. Limitations Contamination within provider and clinic may have attenuated the impact of the intervention and may have biased the result toward null. Conclusions The noninterruptive design of the clinical decision support was selected to prevent cognitive overload; however, the design led to a very low rate of use and ultimately did not improve stage-appropriate monitoring. Funding Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award K23DK097187. Trial Registration ClinicalTrials.gov Identifier: NCT02990897.
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Affiliation(s)
- Lipika Samal
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Address for Correspondence: Lipika Samal, MD, MPH, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, 1620 Tremont St, Boston, MA 02120.
| | | | - Michael P. Gannon
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA
| | - John L. Kilgallon
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA
| | - Jean-Pierre Charles
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA
| | - Devin M. Mann
- New York University School of Medicine, New York, NY
| | - Lydia C. Siegel
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Mass General Brigham Digital Health eCare, Boston, MA
| | - Kelly Burdge
- Nephrology, Mass General Brigham-Salem Hospital, Salem, MA
| | - Shimon Shaykevich
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA
| | - Stuart Lipsitz
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Sushrut S. Waikar
- Nephrology, Mass General Brigham-Salem Hospital, Salem, MA
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, MA
| | - David W. Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
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18
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Duggal V, Montez-Rath ME, Thomas IC, Goldstein MK, Tamura MK. Nephrology Referral Based on Laboratory Values, Kidney Failure Risk, or Both: A Study Using Veterans Affairs Health System Data. Am J Kidney Dis 2022; 79:347-353. [PMID: 34450193 PMCID: PMC9973036 DOI: 10.1053/j.ajkd.2021.06.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 06/16/2021] [Indexed: 01/07/2023]
Abstract
RATIONALE & OBJECTIVE Current guidelines for nephrology referral are based on laboratory criteria. We sought to evaluate whether nephrology referral patterns reflect current clinical practice guidelines and to estimate the change in referral volume if they were based on the estimated risk of kidney failure. STUDY DESIGN Observational cohort. SETTING & PARTICIPANTS Retrospective study of 399,644 veterans with chronic kidney disease (October 1, 2015 through September 30, 2016). EXPOSURE Laboratory referral criteria based on Veterans Affairs/Department of Defense guidelines, categories of predicted risk for kidney failure using the Kidney Failure Risk Equation, and the combination of laboratory referral criteria and predicted risk. OUTCOME Number of patients identified for referral. ANALYTICAL APPROACH We evaluated the number of patients who were referred and their predicted 2-year risk for kidney failure. For each exposure, we estimated the number of patients who would be identified for referral. RESULTS There were 66,276 patients who met laboratory indications for referral. Among these patients, 11,752 (17.7%) were referred to nephrology in the following year. The median 2-year predicted risk of kidney failure was 1.5% (interquartile range, 0.3%-4.7%) among all patients meeting the laboratory referral criteria. If referrals were restricted to patients with a predicted risk of ≥1% in addition to laboratory indications, the potential referral volume would be reduced from 66,276 to 38,229 patients. If referrals were based on predicted risk alone, a 2-year risk threshold of 1% or higher would identify a similar number of patients (72,948) as laboratory-based criteria with median predicted risk of 2.3% (interquartile range, 1.4%-4.6%). LIMITATIONS Missing proteinuria measurements. CONCLUSIONS The current laboratory-based guidelines for nephrology referral identify patients who are, on average, at low risk for progression, most of whom are not referred. As an alternative, referral based on a 2-year kidney failure risk exceeding 1% would identify a similar number of patients but with a higher median risk of kidney failure.
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Affiliation(s)
- Vishal Duggal
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Department of Medicine, Division of Nephrology, School of Medicine, Stanford University, Stanford, California; Center for Primary Care and Outcomes Research, Stanford University, Stanford, California.
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19
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Tsai JW, Cerdeña JP, Goedel WC, Asch WS, Grubbs V, Mendu ML, Kaufman JS. Evaluating the Impact and Rationale of Race-Specific Estimations of Kidney Function: Estimations from U.S. NHANES, 2015-2018. EClinicalMedicine 2021; 42:101197. [PMID: 34849475 PMCID: PMC8608882 DOI: 10.1016/j.eclinm.2021.101197] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 10/20/2021] [Accepted: 10/26/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Standard equations for estimating glomerular filtration rate (eGFR) employ race multipliers, systematically inflating eGFR for Black patients. Such inflation is clinically significant because eGFR thresholds of 60, 30, and 20 ml/min/1.73m2 guide kidney disease management. Racialized adjustment of eGFR in Black Americans may thereby affect their clinical care. In this study, we analyze and extrapolate national data to assess potential impacts of the eGFR race adjustment on qualification for kidney disease diagnosis, nephrologist referral, and transplantation listing. METHODS Using population-representative cross-sectional data from the United States National Health and Nutrition Examination Survey (NHANES) from 2015-2018, eGFR values for Black Americans were calculated using the Modification of Diet in Renal Disease (MDRD) equation with and without the 1.21 race-specific coefficient using cohort data on age, sex, race, and serum creatinine. FINDINGS Without the MDRD eGFR race adjustment, 3.3 million (10.4%) more Black Americans would reach a diagnostic threshold for Stage 3 Chronic Kidney Disease, 300,000 (0.7%) more would qualify for beneficial nephrologist referral, and 31,000 (0.1%) more would become eligible for transplant evaluation and waitlist inclusion. INTERPRETATION These findings suggest eGFR race coefficients may contribute to racial differences in the management of kidney. We provide recommendations for addressing this issue at institutional and individual levels. FUNDING No external funding was received for this study.
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Affiliation(s)
- Jennifer W. Tsai
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Jessica P. Cerdeña
- Yale University School of Medicine, New Haven, CT
- Department of Anthropology, Yale University, New Haven, CT
| | | | - William S. Asch
- Section of Nephrology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Vanessa Grubbs
- Division of Nephrology, Department of Medicine, University of California, San Francisco, CA
| | - Mallika L. Mendu
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jay S. Kaufman
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Quebec, Canada
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20
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Chou CL, Chung CH, Chiu HW, Liao CT, Wu CC, Hsu YH, Chien WC. Association of pre-ESRD care education with patient outcomes in a 10-year longitudinal study of patients with CKD stages 3-5 in Taiwan. Sci Rep 2021; 11:22602. [PMID: 34799610 PMCID: PMC8604975 DOI: 10.1038/s41598-021-01860-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/01/2021] [Indexed: 11/30/2022] Open
Abstract
There is little comprehensive education for people with end-stage renal disease (ESRD) progress. We investigated the differences in terms of outcomes between patients with CKD stages 3-5 who enrolled and did not enroll in the pre-ESRD care education in Taiwan. This retrospective cohort study was conducted using data from the National Health Insurance Research Database (NHIRD). All patients diagnosed with CKD stages 3-5 who received the pre-ESRD care education through the pay for performance (P4P) program were enrolled. Based on whether or not they participated in the program, they were categorized into P4P or non-P4P groups. All analyses were performed from January 2006 through December 2015. Study outcomes were risk of hemodialysis dependency, hospitalization, and all-cause mortality. In this study of 29,337 patients, those with CKD stages 3-5 in the P4P group had lower events of hemodialysis, hospitalization, and all-cause mortality compared to patients in the non-P4P group. This study suggested that pre-ESRD care education is associated with increased patient outcomes, resulting in lower hemodialysis and hospitalization events and a higher overall survival rate in patients with CKD stages 3-5. Patient education could raise opportunities to improve pre-ESRD care by reaching patients outside the traditional health care setting.
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Affiliation(s)
- Chu-Lin Chou
- grid.260565.20000 0004 0634 0356Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan ,grid.412896.00000 0000 9337 0481Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, No. 250, Wuxing Street, Xinyi District, Taipei City, 110 Taiwan ,grid.412896.00000 0000 9337 0481Taipei Medical University-Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan ,grid.412955.e0000 0004 0419 7197Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan ,grid.412896.00000 0000 9337 0481Division of Nephrology, Department of Internal Medicine, Hsin Kuo Min Hospital, Taipei Medical University, Taoyuan City, Taiwan
| | - Chi-Hsiang Chung
- grid.260565.20000 0004 0634 0356School of Public Health, National Defense Medical Center, Taipei, Taiwan ,Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan
| | - Hui-Wen Chiu
- grid.412896.00000 0000 9337 0481Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, No. 250, Wuxing Street, Xinyi District, Taipei City, 110 Taiwan ,grid.412896.00000 0000 9337 0481Taipei Medical University-Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan ,grid.412896.00000 0000 9337 0481Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan ,grid.412896.00000 0000 9337 0481Department of Medical Research, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chia-Te Liao
- grid.412896.00000 0000 9337 0481Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, No. 250, Wuxing Street, Xinyi District, Taipei City, 110 Taiwan ,grid.412896.00000 0000 9337 0481Taipei Medical University-Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan ,grid.412955.e0000 0004 0419 7197Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chia-Chao Wu
- grid.260565.20000 0004 0634 0356Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yung-Ho Hsu
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, No. 250, Wuxing Street, Xinyi District, Taipei City, 110, Taiwan. .,Taipei Medical University-Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan. .,Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Division of Nephrology, Department of Internal Medicine, Hsin Kuo Min Hospital, Taipei Medical University, Taoyuan City, Taiwan.
| | - Wu-Chien Chien
- School of Public Health, National Defense Medical Center, Taipei, Taiwan. .,Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan. .,Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, 7115R, No. 325, Section 2, Cheng-Kung Road, Neihu District, Taipei City, 11490, Taiwan, Republic of China. .,Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan.
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Terlizzi V, Sandrini M, Vizzardi V, Tonoli M, Facchini A, Manili L, Zeni L, Cancarini G. Ten-year experience of an outpatient clinic for CKD-5 patients with multidisciplinary team and educational support. Int Urol Nephrol 2021; 54:949-957. [PMID: 34331637 PMCID: PMC8924108 DOI: 10.1007/s11255-021-02963-y] [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: 01/15/2021] [Accepted: 07/07/2021] [Indexed: 10/31/2022]
Abstract
PURPOSE To analyze the results of an outpatient clinic with a multidisciplinary team and educational support for patients with late-stage CKD (lsCKD), to check its possible effect on their outcomes. METHODS Longitudinal cohort study on patients followed up in the MaReA (Malattia Renale Avanzata = CKD5) outpatient clinic at ASST Spedali Civili of Brescia from 2005 to 2015 for at least six months. Trajectory of renal function over time has been evaluated only in those patients with at least four estimations of eGFR before referring to MaReA. RESULTS Seven hundred and six patients were enrolled, their mean age was 72 ± 14 years, 59% were males. At the end of the study, 147 (21%) were still on MaReA, 240 (34%) on dialysis, 92 (13%) on very low-protein diet (VLPDs), 13 (2%) on pre-hemodialysis clinic, 23 (3%) improved renal function, 10 (1%) transplanted, 62 (9%) transferred/lost to follow-up, and 119 (17%) died. Optimal dialysis start (defined as start with definitive dialysis access, as an out-patient and without lsCKD complications) occurred in 180/240 (75%) patients. The results showed a slower eGFR decrease during MaReA follow-up compared to previous renal follow-up: - 2.0 vs. - 4.0 mL/min/1.73 m2 BSA/year (p < 0.05), corresponding to a median delay of 17.7 months in dialysis start in reference to our policy in starting dialysis. The patient cumulative survival was 75% after 24 months and 25% after 70. LIMITATIONS (1) lack of a control group, (2) one-center-study, (3) about all patients were Caucasians. CONCLUSION The follow-up of lsCKD patients on MaReA is associated with an optimal and delayed initiation of dialysis.
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Affiliation(s)
- Vincenzo Terlizzi
- Operative Unit of Nephrology, ASST Spedali Civili Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - Massimo Sandrini
- Operative Unit of Nephrology, ASST Spedali Civili Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - Valerio Vizzardi
- Operative Unit of Nephrology, ASST Spedali Civili Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy.
| | - Mattia Tonoli
- Postgraduate School in Nephrology, University of Brescia, Brescia, Italy
| | - Annalisa Facchini
- Postgraduate School in Nephrology, University of Brescia, Brescia, Italy
| | - Luigi Manili
- Operative Unit of Nephrology, ASST Spedali Civili Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - Letizia Zeni
- Operative Unit of Nephrology, ASST Spedali Civili Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - Giovanni Cancarini
- Operative Unit of Nephrology, ASST Spedali Civili Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy.,Postgraduate School in Nephrology, University of Brescia, Brescia, Italy
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22
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Assessing the Delivery of Coordinated Care to Patients with Advanced Chronic Kidney Disease in Ontario, Canada: A Survey of Patients and Healthcare Professionals. Int J Integr Care 2021; 21:30. [PMID: 34220394 PMCID: PMC8231462 DOI: 10.5334/ijic.5587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction: Patients with advanced Chronic Kidney Disease (CKD) have complex health needs, and thus require care that is coordinated across professionals and organizations. This study aimed to describe the extent of coordinated care delivery for patients with advanced CKD from the perspectives of both patients and healthcare professionals. Methods: The Coordination Scale of the Patient Assessment of Chronic Illness Care (PACIC-26) survey was administered to a random sample of 14,257 patients on maintenance dialysis or receiving care in end-stage kidney disease preparation clinics in Ontario, Canada. A five-item survey was administered to 596 multidisciplinary nephrology professionals. Results: Among the 1,925 patient respondents, 67% reported they had been referred to an allied health professional; 19% had been encouraged to attend programs in the community; and 34% had been told how their visits with other types of doctors helped their treatment (% reporting “always” or “most of the time”). Patient responses were significantly different by treatment modality/setting, but not by gender or geographic location of treatment facility. Among the 276 professional respondents, 37% reported their patients’ care was well-coordinated across settings; 56% reported participating in interdisciplinary care planning discussions; and 53% reported they are aware of appropriate home and community services to support their patients (% reporting “always” or “most of the time”). Conclusion: The results suggest that care for patients with advanced CKD in Ontario is not consistently coordinated. Healthcare professionals may enhance patient perceptions of coordinated care through explicit communication with patients about how the professionals they see and treatments or services they receive influence their overall health and well-being. At a systems level, there is a need to improve professional awareness of and linkages to home- and community-based services.
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23
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Atieh AS, Shamasneh AO, Hamadah A, Gharaibeh KA. Predialysis nephrology care amongst Palestinian hemodialysis patients and its impact on initial vascular access type. Ren Fail 2021; 42:200-206. [PMID: 32506996 PMCID: PMC7048207 DOI: 10.1080/0886022x.2020.1727512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Referral time for end-stage renal disease (ESRD) patients to nephrologists and initial vascular access method are considered significant factors that impact health outcomes at the time of hemodialysis (HD) initiation. Native arteriovenous fistula (AVF) is strongly recommended as initial access. However, little is known about the referral rate among ESRD receiving HD in Palestine and its correlation with AVF creation. In Ramallah Hemodialysis Center, we investigated the pre-dialysis nephrology care and AVF usage in 156 patients. Type of access at HD initiation was temporary central venous catheter (CVC) in 114 (73%), tunneled hemodialysis catheter (TDC) in 21 (13%) and AVF in 21 (13%). Out of all participants, 120 (77%) were seen by nephrologist prior to dialysis. Of the participants who initiated dialysis with a CVC, 36 (31%) had not received prior nephrology care. All participants who initiated dialysis with functional AVF had received prior nephrology care. Patients who were not seen by a nephrologist prior to HD initiation had no chance at starting HD with AVF, whereas 17% of those who had nephrology care >12 months started with AVF. In conclusion, a relatively large percentage of Palestinian HD patients who were maintained on HD did not have any predialysis nephrology care. In addition, patients who received predialysis nephrology care were significantly more likely to start their HD through AVF whereas all those without predialysis nephrology care started through CVC. More in-depth national studies focusing on improving nephrology referral in ESRD patients are needed to increase AVF utilization.
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Affiliation(s)
- Anwar S Atieh
- Department of Internal Medicine, Faculty of Medicine, Al-Quds University, Abu Dis, Palestine
| | - Ala O Shamasneh
- Department of Internal Medicine, Faculty of Medicine, Al-Quds University, Abu Dis, Palestine
| | - Abdurrahman Hamadah
- Department of Internal Medicine, Faculty of Medicine, Hashemite University, Zarqa, Jordan
| | - Kamel A Gharaibeh
- Department of Internal Medicine, Faculty of Medicine, Al-Quds University, Abu Dis, Palestine
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Darbà J, Marsà A. Chronic kidney disease in Spain: analysis of patient characteristics, incidence and direct medical costs (2011-2017). J Med Econ 2020; 23:1623-1629. [PMID: 33000981 DOI: 10.1080/13696998.2020.1830782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To review the characteristics of patients with chronic kidney disease (CKD) who attended primary and specialized care centers in Spain, and to analyze patients' use of medical resources and direct medical costs of specialized care. METHODS Records of patients with CKD admitted to primary and specialized healthcare centers in Spain between 2011 and 2017 from two national discharge databases were analyzed in a retrospective multicenter observational study. Records were classified into one-to-five CKD stages plus a 5b stage, indicating end-stage renal disease. RESULTS Most of the patients registered in hospital settings were in stage 5. Registered secondary conditions included hypertensive chronic kidney, diabetes, anemia, hypercholesterolemia, and hypertension. The number of cases registered in primary care settings increased over time, whereas in specialized care centers incidence decreased; hospital incidence of CKD in 2017 was 10.72 per 10,000 persons. Mean in-hospital mortality was 5.90%, which remained stable during the study period. Mortality was associated with respiratory and heart failure. Mean length of hospital stay was 8.19 days, decreasing over the study period, whilst increasing with CKD progression. Mean annual direct medical cost of specialized care was €10,436 per patient. Complications of a transplant and bacterial infections were responsible for major increases in medical costs, that otherwise decreased over the study period. CONCLUSIONS The costs of specialized care decreased with the length of hospital stay reduction. Cardiovascular risk factors were crucial in in-hospital mortality. This study provides population-based data to assist decision-makers at the national level and to contribute to worldwide evaluations and disease surveillance.
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Affiliation(s)
- Josep Darbà
- Department of Economics, Universitat de Barcelona, Barcelona, Spain
| | - Alicia Marsà
- Department of Health Economics, BCN Health Economics & Outcomes Research S.L., Barcelona, Spain
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25
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Fong JMN, Tsang LPM, Kwek JL, Guo W. Diabetic kidney disease in primary care. Singapore Med J 2020; 61:399-405. [PMID: 32875340 DOI: 10.11622/smedj.2020127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
| | | | - Jia Liang Kwek
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Weiwen Guo
- Department of Renal Medicine, Sengkang General Hospital, Singapore
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26
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Vajravelu RK, Copelovitch L, Osterman MT, Scott FI, Mamtani R, Lewis JD, Denburg MR. Inflammatory Bowel Diseases Are Associated With an Increased Risk for Chronic Kidney Disease, Which Decreases With Age. Clin Gastroenterol Hepatol 2020; 18:2262-2268. [PMID: 31683056 PMCID: PMC7569504 DOI: 10.1016/j.cgh.2019.10.043] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/09/2019] [Accepted: 10/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is not clear what factors affect risk of chronic kidney disease (CKD) in patients with inflammatory bowel disease (IBD); increased risk has been inconsistently associated with use of 5-aminosalicylates (5-ASAs). We aimed to calculate the relative hazard of CKD among patients with IBD, adjusted for CKD risk factors, and to determine whether IBD medications are associated with change in estimated glomerular filtration rate (eGFR). METHODS We performed a retrospective cohort study of data from The Health Improvement Network. Patients with IBD (n = 17,807) were matched for age, sex, and practice to individuals without IBD (n = 63,466). The relative hazard of CKD, stages 3 through 5D, in patients with IBD was calculated using a Cox proportional hazards model adjusted for common CKD risk factors. We also evaluated the association of 5-ASAs, azathioprine, and methotrexate with change in eGFR using a longitudinal model. RESULTS After we controlled for risk factors associated with CKD, we found IBD to be associated with development of CKD in patients 16-77 years old. As patient age increased, the adjusted hazard ratio for CKD decreased monotonically, from 7.88 (95% CI, 2.56-24.19) at age 16 to 1.13 (95% CI, 1.01-1.25) at age 77. In the longitudinal analysis, exposure to 5-ASAs or methotrexate was not associated with change in eGFR, whereas azathioprine was associated with a slightly higher eGFR (0.32 mL/min/1.73 m2; 95% CI, 0.16-0.48). CONCLUSIONS In a retrospective study of more than 80,000 persons, we found that IBD is associated with increased risk of CKD, and the hazard ratio is highest among younger patients. Commonly used non-biologic therapeutic agents were not associated with lower eGFR.
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Affiliation(s)
- Ravy K Vajravelu
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Lawrence Copelovitch
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark T Osterman
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frank I Scott
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology, Department of Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Ronac Mamtani
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Lewis
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle R Denburg
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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27
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Rangaiah SKK, Kaur S, Sidhu NS, Ramesh D, Veerappa K, Manjunath CN. Sex differences in acute coronary syndrome: insights from an observation study in low socio-economic cohort from India. Future Cardiol 2020; 17:329-336. [PMID: 32755322 DOI: 10.2217/fca-2020-0072] [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: 11/21/2022] Open
Abstract
Aim: To study sex-related differences in acute coronary syndrome (ACS) presentation, management and in-hospital outcomes. Materials & methods: We studied 621 ACS patients (150 women, 471 men) of low socio-economic status from South India from February 2015 to January 2016. Multivariable logistic regression methods were used to assess sex differences in the in-hospital outcomes. Adjudicated major adverse cardiovascular events (MACE) included in-hospital cardiac arrest, cardiogenic shock, heart failure, re-infarction, stroke, major bleeding and mortality. Results & conclusion: Mean age in women was 60.97 ± 11.23 years versus 54.5 ± 10.87 years in men (p < 0.001). Women had higher prevalence of hypertension and diabetes and presented with more non-ST elevation ACS. There were no differences in the use of antiplatelets, statins and other pharmacotherapy except for the higher use of nitrates in women. There were no differences in MACE rates between women and men (15.3 vs 9.6%; adjusted odds ratio: 1.43; CI: 0.76-2.69).
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Affiliation(s)
| | - Sumandeep Kaur
- University College of Nursing, Baba Farid University of Health Sciences, Faridkot, Punjab, India
| | - Navdeep Singh Sidhu
- Department of Cardiology, GGS Medical College & Hospital & Baba Farid University of Health Sciences, Faridkot, Punjab, India
| | - Dwarikaprasad Ramesh
- Department of Cardiology, Vydehi Institute Of Medical Sciences And Research Centre, Bengaluru, Karnataka, India
| | - Kumaraswamy Veerappa
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bengaluru, Karnataka, India
| | - Cholenahally N Manjunath
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bengaluru, Karnataka, India
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Provenzano M, De Francesco M, Iannazzo S, Garofalo C, Andreucci M, Genualdo R, Borrelli S, Minutolo R, Conte G, De Nicola L. Cost-analysis of persistent hyperkalaemia in non-dialysis chronic kidney disease patients under nephrology care in Italy. Int J Clin Pract 2020; 74:e13475. [PMID: 31909866 DOI: 10.1111/ijcp.13475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/19/2019] [Accepted: 01/06/2020] [Indexed: 12/21/2022] Open
Abstract
AIM In patients with chronic kidney disease (CKD), hyperkalaemia (HK) (potassium level ≥ 5.0 mEq/L) is associated with poor clinical outcomes. This study provides novel insights by comparing management costs of CKD patients with normokalaemia vs those with persistent HK regularly followed in renal clinics in Italy. METHODS To this aim, a Markov model over life-time horizon was developed. Time to end-stage renal disease (ESRD) and time to death in CKD patients were derived from an observational multi-centre database including 1665 patients with non-dialysis CKD stage 1-5 under nephrology care in Italy (15 years follow-up). Resource use for CKD and HK management was obtained from the observational database, KDIGO international guidelines, and clinical expert opinion. RESULTS Results showed that patients with normokalaemia vs persistent HK brought an average per patient lifetime cost-saving of €16 059 besides delayed onset of ESRD by 2.29 years and increased survival by 1.79 years with increment in total survival and dialysis-free survival in normokalaemia that decreased from early to advanced disease. Cost-saving related to normokalaemia increased at more advanced CKD; however, it was already evident at early stage (3388.97€ at stage 1-3a). OWSA confirmed cost-saving associated with normokalaemia across all parameter variations. DISCUSSION AND CONCLUSION This model is the first to simulate the impact of HK in non-dialysis CKD patients on economic and clinical outcomes using real-world data from nephrology clinics. In these patients, persistent HK results into higher lifetime costs, besides poorer clinical outcomes, that are evident since the early stages of CKD. Maintaining normokalaemia should therefore be of main concern in CKD treatment planning to improve long-term economic and clinical outcomes.
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Affiliation(s)
- Michele Provenzano
- Nephrology and Dialysis Division, University Magna Graecia in Catanzaro, Catanzaro, Italy
| | | | | | - Carlo Garofalo
- Division of Nephrology, Department of Advanced Medical and Surgical Sciences, Nephrology Unit - University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Michele Andreucci
- Nephrology and Dialysis Division, University Magna Graecia in Catanzaro, Catanzaro, Italy
| | - Raffaele Genualdo
- Nephrology and Dialysis Unit, Pellegrini Hospital, ASL NA1 Centro, Naples, Italy
| | - Silvio Borrelli
- Division of Nephrology, Department of Advanced Medical and Surgical Sciences, Nephrology Unit - University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Roberto Minutolo
- Division of Nephrology, Department of Advanced Medical and Surgical Sciences, Nephrology Unit - University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuseppe Conte
- Division of Nephrology, Department of Advanced Medical and Surgical Sciences, Nephrology Unit - University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Luca De Nicola
- Division of Nephrology, Department of Advanced Medical and Surgical Sciences, Nephrology Unit - University of Campania "Luigi Vanvitelli", Naples, Italy
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Bobot M, Gondouin B. Dialyse. Nephrol Ther 2020; 16:1S1-1S4. [DOI: 10.1016/s1769-7255(20)30069-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Crews DC, Novick TK. Achieving equity in dialysis care and outcomes: The role of policies. Semin Dial 2020; 33:43-51. [PMID: 31899828 DOI: 10.1111/sdi.12847] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Socially disadvantaged persons, including racial and ethnic minorities, individuals with low incomes, homeless persons, and non-US citizens bear a disproportionate burden of end-stage kidney disease (ESKD). Inequities in nephrology referral, vascular access, use of home dialysis modalities, kidney transplantation, and mortality are prominent. Public policies, including the Patient Protection and Affordable Care Act, end-stage renal disease Quality Incentive Program, and the Prospective Payment System, were enacted to improve healthcare access and dialysis care. Here, we highlight inequities in dialysis care and outcomes, how current ESKD and other public policies may influence or exacerbate these inequities, and gaps in the literature needed to inform future policies toward achieving equity in ESKD. We give special attention to the 2019 Advancing American Kidney Health Executive Order, which has high potential to radically transform dialysis care.
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Affiliation(s)
- Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Center for Health Equity, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Tessa K Novick
- Division of Nephrology, Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, USA
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Kamath CC, Dobler CC, Lampman MA, Erwin PJ, Matulis J, Elrashidi M, McCoy RG, Alsawaz M, Pajouhi A, Vasdev A, Shah ND, Murad MH, Thorsteinsdottir B. Implementation strategies for interventions to improve the management of chronic kidney disease (CKD) by primary care clinicians: protocol for a systematic review. BMJ Open 2019; 9:e027206. [PMID: 31399451 PMCID: PMC6701820 DOI: 10.1136/bmjopen-2018-027206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION There is a considerable implementation gap in managing early stage chronic kidney disease (CKD) in primary care despite the high prevalence and risk for increased morbidity and mortality associated with CKD. This systematic review aims to synthesise the evidence of efficacy of implementation interventions aimed at primary care practitioners (PCPs) to improve CKD identification and management. We further aim to describe the interventions' behavioural change components. METHODS AND ANALYSIS We will conduct a systematic review of studies from 2000 to October 2017 that evaluate implementation interventions targeting PCPs and which include at least one clinically meaningful CKD outcome. We will search several electronic data bases and conduct reference mining of related systematic reviews and publications. An interdisciplinary team will independently and in duplicate, screen publications, extract data and assess the risk of bias. Clinical outcomes will include all clinically meaningful medical management outcomes relevant to CKD management in primary care such as blood pressure, chronic heart disease and diabetes target achievements. Quantitative evidence synthesis will be performed, where possible. Planned subgroup analyses include by (1) study design, (2) length of follow-up, (3) type of intervention, (4) type of implementation strategy, (5) whether a behavioural or implementation theory was used to guide study, (6) baseline CKD severity, (7) patient minority status, (8) study location and (9) academic setting or not. ETHICS AND DISSEMINATION Approval by research ethics board is not required since the review will only include published and publicly accessible data. Review findings will inform a future trial of an intervention to promote uptake of CKD diagnosis and treatment guidelines in our primary care setting and the development of complementary tools to support its successful adoption and implementation. We will publish our findings in a peer-reviewed journal and develop accessible summaries of the results. PROSPERO REGISTRATION NUMBER CRD42018102441.
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Affiliation(s)
- Celia C Kamath
- Health Care Policy and Research, Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Claudia C Dobler
- Evidence-Based Practice Center, Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle A Lampman
- Health Care Policy and Research, Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Patricia J Erwin
- Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - John Matulis
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Muhamad Elrashidi
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rozalina Grubina McCoy
- Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mouaz Alsawaz
- Evidence-Based Practice Center, Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Atieh Pajouhi
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amrit Vasdev
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nilay D Shah
- Health Care Policy and Research, Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - M Hassan Murad
- Evidence-Based Practice Center, Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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Xue N, Fang Y, Ding X, Wang L, Xu L, Jiang X, Zhang X. Serum Triglycerides Are Related to Chronic Kidney Disease (CKD) Stage 2 in Young and Middle-Aged Chinese Individuals During Routine Health Examination. Med Sci Monit 2019; 25:2445-2451. [PMID: 30944297 PMCID: PMC6461005 DOI: 10.12659/msm.913506] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The aim of this study was to determine the risk factors for early chronic kidney disease (CKD) (GFR 60-89 ml/min/1.73 m²; CKD stage 2) in asymptomatic Chinese individuals undergoing routine health examination. MATERIAL AND METHODS This cross-sectional study enrolled 9100 individuals who received voluntary medical examinations between 10/01/2011 and 09/30/2017. Demographic data, clinical history, clinical examination, medication, smoking, alcohol, blood biochemistry, urinalysis, and carotid ultrasound were extracted from the medical records. All laboratory analyses were performed routinely. Multivariable logistic regression for factors predicting CKD stage 2 was performed. RESULTS A total of 9100 individuals were enrolled (age of 18-65 and 65.4% male). CKD stage 2 was found in 1989/9100 individuals (21.9%). Male gender (OR=6.711, 95%CI: 5.376-8.403, P<0.001), older age (OR=1.077, 95%CI: 1.068-1.086, P<0.001), hemoglobin levels (OR=1.051, 95%CI: 1.046-1.057, P<0.001), triglycerides levels (OR=1.174, 95%CI: 1.067-1.292, P=0.001), HDL-C (OR=0.539, 95%CI: 0.380-0.763, P<0.001), Lp(a) levels (OR=1.000, 95%CI: 1.000-1.001, P=0.03), and carotid atherosclerosis (OR=1.248, 95%CI: 1.005-1.550, P=0.045) were associated with CKD stage 2 among all subjects. Serum triglycerides levels were associated with CKD stage 2 in the 18-45 and 45-65 years of age subgroups. CONCLUSIONS Factors that are routinely assessed during routine health examinations (male gender, age, hemoglobin levels, triglycerides levels, HDL-C, Lp(a) levels, and carotid atherosclerosis) can help identify individuals at higher risk of having CKD stage 2. The Chinese dyslipidemia is characterized by high triglycerides and low HDL-C and occurs in young and middle-aged individuals. Those factors could help identify individuals at higher risk for CKD stage 2 and who could benefit from preventive treatments.
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Affiliation(s)
- Ning Xue
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China (mainland)
| | - Yi Fang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China (mainland)
| | - Xiaoqiang Ding
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China (mainland)
| | - Li Wang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China (mainland)
| | - Linghan Xu
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China (mainland)
| | - Xiaotian Jiang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China (mainland)
| | - Xiaoyan Zhang
- Department of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China (mainland)
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Bian Z, Gu H, Chen P, Zhu S. Comparison of prognosis between emergency and scheduled hemodialysis. J Int Med Res 2019; 47:1221-1231. [PMID: 30704325 PMCID: PMC6421369 DOI: 10.1177/0300060518807092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background The survival rate of patients undergoing hemodialysis and other renal
replacement therapies has been extensively studied, but comparative studies
of emergency and scheduled hemodialysis are limited. Methods This study included 312 patients who underwent emergency hemodialysis and 274
who received scheduled hemodialysis. We investigated the prognostic
differences between these two groups of patients, including the short-term
and long-term survival rates. Results The overall survival rate was significantly better among the patients in the
scheduled hemodialysis group than emergency hemodialysis group. The
mortality rate within 3 months of emergency hemodialysis was 4.8%, while
that within 3 months of scheduled hemodialysis was 1.1%. Conclusions Significant differences were present between emergency and scheduled
hemodialysis, especially the levels of serum creatinine and hemoglobin.
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Affiliation(s)
- Zhixiang Bian
- Department of Urology, The Ninth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Huiyi Gu
- Department of Urology, The Ninth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Peihua Chen
- Department of Urology, The Ninth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shijian Zhu
- Department of Urology, The Ninth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Arulkumaran N, Navaratnarajah A, Pillay C, Brown W, Duncan N, McLean A, Taube D, Brown EA. Causes and risk factors for acute dialysis initiation among patients with end-stage kidney disease-a large retrospective observational cohort study. Clin Kidney J 2018; 12:550-558. [PMID: 31384448 PMCID: PMC6671523 DOI: 10.1093/ckj/sfy118] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Indexed: 12/02/2022] Open
Abstract
Background Patients who require acute initiation of dialysis have higher mortality rates when compared with patients with planned starts. Our primary objective was to explore the reasons and risk factors for acute initiation of renal replacement therapy (RRT) among patients with end-stage kidney disease (ESKD). Our secondary objective was to determine the difference in glomerular filtration rate (GFR) change in the year preceding RRT between elective and acute dialysis starts. Methods We conducted a single-centre retrospective observational study. ESKD patients either started dialysis electively (planned starters) or acutely and were known to renal services for >90 (unplanned starters) or <90 days (urgent starters). Results In all, 825 consecutive patients initiated dialysis between January 2013 and December 2015. Of these, 410 (49.7%) patients had a planned start. A total of 415 (50.3%) patients had an acute start on dialysis: 244 (58.8%) unplanned and 171 (41.2%) urgent. The reasons for acute dialysis initiation included acute illness (58%) and unexplained decline to ESKD (33%). Cardiovascular disease [n = 30 (22%)] and sepsis [n = 65 (48%)] accounted for the majority of acute systemic illness. Age and premorbid cardiovascular disease were independent risk factors for acute systemic illness among unplanned starts, whereas autoimmune disease accounted for the majority of urgent starts. The rate of decline in GFR was greater in the month preceding RRT among acute dialysis starters compared with planned starters (P < 0.001). Conclusions Cardiovascular disease and advancing age were independent risk factors for emergency dialysis initiation among patients known to renal services for >3 months. The rapid and often unpredictable loss of renal function in the context of acute systemic illness poses a challenge to averting emergency dialysis start.
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Affiliation(s)
- Nish Arulkumaran
- Renal Section, Department of Medicine, Hammersmith Hospital Campus, Imperial College London, London, UK
| | - Arunraj Navaratnarajah
- Renal Section, Department of Medicine, Hammersmith Hospital Campus, Imperial College London, London, UK
| | - Camilla Pillay
- Renal Section, Department of Medicine, Hammersmith Hospital Campus, Imperial College London, London, UK
| | - Wendy Brown
- Renal Section, Department of Medicine, Hammersmith Hospital Campus, Imperial College London, London, UK
| | - Neill Duncan
- Renal Section, Department of Medicine, Hammersmith Hospital Campus, Imperial College London, London, UK
| | - Adam McLean
- Renal Section, Department of Medicine, Hammersmith Hospital Campus, Imperial College London, London, UK
| | - David Taube
- Renal Section, Department of Medicine, Hammersmith Hospital Campus, Imperial College London, London, UK
| | - Edwina A Brown
- Renal Section, Department of Medicine, Hammersmith Hospital Campus, Imperial College London, London, UK
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Minutolo R, Aghemo A, Chirianni A, Fabrizi F, Gesualdo L, Giannini EG, Maggi P, Montinaro V, Paoletti E, Persico M, Perticone F, Petta S, Puoti M, Raimondo G, Rendina M, Zignego AL. Management of hepatitis C virus infection in patients with chronic kidney disease: position statement of the joint committee of Italian association for the study of the liver (AISF), Italian society of internal medicine (SIMI), Italian society of infectious and tropical disease (SIMIT) and Italian society of nephrology (SIN). Intern Emerg Med 2018; 13:1139-1166. [PMID: 30255464 DOI: 10.1007/s11739-018-1940-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/09/2018] [Indexed: 12/14/2022]
Abstract
Hepatitis C virus (HCV) infection is now considered a systemic disease due to the occurrence of extra-hepatic manifestations. Among these, the renal involvement is frequent. HCV infection, in fact, is strongly associated with proteinuria and chronic kidney disease (CKD) and negatively affects the prognosis of renal patients. In the last few years, availability of more specific and effective drugs against HCV has dramatically changed the clinical course of this disease. These drugs may provide further advantages in the CKD population as a whole by reducing progression of renal disease, mortality rate and by increasing the survival of graft in renal transplant recipients. The strict pathogenetic and prognostic link between HCV infection and CKD requires an ongoing relationship among the healthcare professionals involved in the treatment of both HCV infection and CKD. Therefore, Scientific Societies involved in the care of this high-risk population in Italy have organized a joint expert panel. The aim of the panel is to produce a position statement that can be used in daily clinical practice for the management of HCV infected patients across the whole spectrum of renal disease, from the conservative phase to renal replacement treatments (dialysis and transplantation). Sharing specific evidence-based expertise of different professional healthcare is the first step to obtain a common ground of knowledge on which to instate a model for multidisciplinary management of this high-risk population. Statements cover seven areas including epidemiology of CKD, HCV-induced glomerular damage, HCV-related renal risk, staging of liver disease in patients with CKD, prevention of transmission of HCV in hemodialysis units, treatment of HCV infection and management of HCV in kidney transplantation.
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Affiliation(s)
- Roberto Minutolo
- Division of Nephrology, Department of Scienze Mediche, Chirurgiche, Neurologiche, Metaboliche e dell'Invecchiamento, University of Campania "Luigi Vanvitelli", Via M. Longo 50, 80138, Naples, Italy.
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Internal Medicine and Hepatology, Humanitas Clinical and Research Center, Milan, Italy
| | - Antonio Chirianni
- Third Department of Infectious Diseases Azienda Ospedaliera Ospedali dei Colli, Naples, Italy
| | - Fabrizio Fabrizi
- Division of Nephrology, Maggiore Hospital and IRCCS Foundation, Milan, Italy
| | - Loreto Gesualdo
- Division of Nephrology, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Paolo Maggi
- Infectious Disease Clinic, University of Bari, Bari, Italy
| | - Vincenzo Montinaro
- Division of Nephrology, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Marcello Persico
- Internal Medicine and Hepatology Unit, AOU San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Francesco Perticone
- Department of Medical and Surgical Sciences, University Magna Græcia, Catanzaro, Italy
| | - Salvatore Petta
- Gastroenterology and Hepatology Unit, Di.Bi.M.I.S., University of Palermo, Palermo, Italy
| | - Massimo Puoti
- Division of Infectious Diseases, Niguarda Cà Granda Hospital, Milan, Italy
| | - Giovanni Raimondo
- Department of Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - Maria Rendina
- Department of Emergency and Organ Transplantation, Section of Gastroenterology, University Hospital, Bari, Italy
| | - Anna Linda Zignego
- Department of Experimental and Clinical Medicine, Interdepartmental Hepatology Center MaSVE, University of Florence, Florence, Italy
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Oliva-Damaso N, Oliva-Damaso E, Rivas-Ruiz F, Lopez F, Castilla MDM, Baamonde-Laborda E, Rodriguez-Perez JC, Payan J. Impact of a phone app on nephrology referral. Clin Kidney J 2018; 12:427-432. [PMID: 31198544 PMCID: PMC6543955 DOI: 10.1093/ckj/sfy105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Indexed: 12/04/2022] Open
Abstract
Background Various factors can lead to inadequate nephrology referral decisions being taken by clinicians, but a major cause is unawareness of guidelines, recommendations and indications, or of appropriate timing. Today, tools such as smartphone applications (Apps) can make this knowledge more accessible to non-nephrologist clinicians. Our study aim is to determine the effectiveness of a purpose-built app in this respect. Methods In a retrospective study, nephrology referrals were compared before and after the introduction of the app in clinical practice. The initial study population consisted of first visits by patients referred to our department in 2015, before the introduction of the app. In 2016, the smartphone app NefroConsultor began to be implemented in our hospital. We compared the initial study population with the results obtained for patients referred in 2017, when the app was in use, taking into account clinical features considered, such as urinalysis, proteinuria or kidney ultrasound, to determine whether these patients met currently recommended criteria for referral. Results The total study population consisted of 628 patients, of whom 333 were examined before the introduction of the app (in 2015) and 295 when it was in use (in 2017). Among the first group, 132 (39.6%) met established KDIGO criteria for nephrology referral and were considered to be correctly referred. Among the second group, 200 (67.8%) met the criteria and were considered to be properly referred (P = 0.001). The increase in the rate of intervention success (before–after app) was 28.8% with a binomial effect size display (Cohen’s d effect size) of 0.751. Before the introduction of the app, data for albuminuria were included in 62.5% of nephrology referrals; in 2017, the corresponding value was 87.5% (P = 0.001). In the same line, referrals including urinalysis rose from 68.5% to 85.8% (P = 0.001). Multivariate regression analysis, using referrals meeting KDIGO criteria as the dependent variable and adjusting for age, sex and referring department, showed that the 2017 group (after the introduction of NefroConsultor) was associated with an odds ratio of 3.57 (95% confidence interval 2.52–5.05) for correct referrals, compared with the 2015 group (P = 0.001). References to proteinuria as the reason for nephrology referral also increased from 23.7% to 34.2% (P = 0.004). Conclusions Use of the app is associated with more frequent studies of albuminuria at the time of referral and a greater likelihood of proteinuria being cited as the reason for referral. The smartphone app considered can improve the accessibility of information concerning nephrology referrals and related studies.
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Affiliation(s)
- Nestor Oliva-Damaso
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
| | - Elena Oliva-Damaso
- Department of Medicine, Division of Nephrology, Hospital Doctor Negrin, Las Palmas de Gran Canaria, Spain
| | - Francisco Rivas-Ruiz
- Department of Research Unit, Hospital Costa del Sol, Malaga, Spain.,Research Network in Health Services in Chronic Diseases (REDISSEC), Madrid, Spain
| | - Francisca Lopez
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
| | - Maria Del Mar Castilla
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
| | - Eduardo Baamonde-Laborda
- Department of Medicine, Division of Nephrology, Hospital Doctor Negrin, Las Palmas de Gran Canaria, Spain
| | | | - Juan Payan
- Department of Medicine, Division of Nephrology, Hospital Costa del Sol, Marbella, Malaga, Spain
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Minutolo R, Aghemo A, Chirianni A, Fabrizi F, Gesualdo L, Giannini EG, Maggi P, Montinaro V, Paoletti E, Persico M, Perticone F, Petta S, Puoti M, Raimondo G, Rendina M, Zignego AL. Management of hepatitis C virus infection in patients with chronic kidney disease: position statement of the joint committee of Italian association for the study of the liver (AISF), Italian society of internal medicine (SIMI), Italian society of infectious and tropical disease (SIMIT) and Italian society of nephrology (SIN). Dig Liver Dis 2018; 50:1133-1152. [PMID: 30266305 DOI: 10.1016/j.dld.2018.08.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/09/2018] [Indexed: 12/11/2022]
Abstract
Hepatitis C virus (HCV) infection is now considered a systemic disease due to the occurrence of extra-hepatic manifestations. Among these, the renal involvement is frequent. HCV infection, in fact, is strongly associated with proteinuria and chronic kidney disease (CKD) and negatively affects the prognosis of renal patients. In the last few years, availability of more specific and effective drugs against HCV has dramatically changed the clinical course of this disease. These drugs may provide further advantages in the CKD population as a whole by reducing progression of renal disease, mortality rate and by increasing the survival of graft in renal transplant recipients. The strict pathogenetic and prognostic link between HCV infection and CKD requires an ongoing relationship among the healthcare professionals involved in the treatment of both HCV infection and CKD. Therefore, Scientific Societies involved in the care of this high-risk population in Italy have organized a joint expert panel. The aim of the panel is to produce a position statement that can be used in daily clinical practice for the management of HCV infected patients across the whole spectrum of renal disease, from the conservative phase to renal replacement treatments (dialysis and transplantation). Sharing specific evidence-based expertise of different professional healthcare is the first step to obtain a common ground of knowledge on which to instate a model for multidisciplinary management of this high-risk population. Statements cover seven areas including epidemiology of CKD, HCV-induced glomerular damage, HCV-related renal risk, staging of liver disease in patients with CKD, prevention of transmission of HCV in hemodialysis units, treatment of HCV infection and management of HCV in kidney transplantation.
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Affiliation(s)
- Roberto Minutolo
- Division of Nephrology, Department of Scienze Mediche, Chirurgiche, Neurologiche, Metaboliche e dvecchiamento, University of Campania "Luigi Vanvitelli", Via M. Longo 50, 80138 Naples, Italy.
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Division of Internal Medicine and Hepatology, Humanitas Clinical and Research Center, Milan, Italy
| | - Antonio Chirianni
- Third Department of Infectious Diseases Azienda Ospedaliera Ospedali dei Colli, Naples, Italy
| | - Fabrizio Fabrizi
- Division of Nephrology, Maggiore Hospital and IRCCS Foundation, Milan, Italy
| | - Loreto Gesualdo
- Division of Nephrology, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Paolo Maggi
- Infectious Disease Clinic, University of Bari, Bari, Italy
| | - Vincenzo Montinaro
- Division of Nephrology, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Marcello Persico
- Internal Medicine and Hepatology Unit, AOU San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Francesco Perticone
- Department of Medical and Surgical Sciences, University Magna Græcia, Catanzaro, Italy
| | - Salvatore Petta
- Gastroenterology and Hepatology Unit, Di.Bi.M.I.S., University of Palermo, Palermo, Italy
| | - Massimo Puoti
- Division of Infectious Diseases, Niguarda Cà Granda Hospital, Milan, Italy
| | - Giovanni Raimondo
- Department of Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - Maria Rendina
- Department of Emergency and Organ Transplantation, Section of Gastroenterology, University Hospital, Bari, Italy
| | - Anna Linda Zignego
- Department of Experimental and Clinical Medicine, Interdepartmental Hepatology Center MaSVE, University of Florence, Florence, Italy
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38
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Minutolo R, Aghemo A, Chirianni A, Fabrizi F, Gesualdo L, Giannini EG, Maggi P, Montinaro V, Paoletti E, Persico M, Perticone F, Petta S, Puoti M, Raimondo G, Rendina M, Zignego AL. Management of hepatitis C virus infection in patients with chronic kidney disease: position statement of the joint committee of Italian association for the study of the liver (AISF), Italian society of internal medicine (SIMI), Italian society of infectious and tropical disease (SIMIT) and Italian society of nephrology (SIN). Infection 2018; 47:141-168. [PMID: 30255389 DOI: 10.1007/s15010-018-1209-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/09/2018] [Indexed: 10/28/2022]
Abstract
Hepatitis C virus (HCV) infection is now considered a systemic disease due to the occurrence of extra-hepatic manifestations. Among these, the renal involvement is frequent. HCV infection, in fact, is strongly associated with proteinuria and chronic kidney disease (CKD) and negatively affects the prognosis of renal patients. In the last few years, availability of more specific and effective drugs against HCV has dramatically changed the clinical course of this disease. These drugs may provide further advantages in the CKD population as a whole by reducing progression of renal disease, mortality rate and by increasing the survival of graft in renal transplant recipients. The strict pathogenetic and prognostic link between HCV infection and CKD requires an ongoing relationship among the healthcare professionals involved in the treatment of both HCV infection and CKD. Therefore, Scientific Societies involved in the care of this high-risk population in Italy have organized a joint expert panel. The aim of the panel is to produce a position statement that can be used in daily clinical practice for the management of HCV infected patients across the whole spectrum of renal disease, from the conservative phase to renal replacement treatments (dialysis and transplantation). Sharing specific evidence-based expertise of different professional healthcare is the first step to obtain a common ground of knowledge on which to instate a model for multidisciplinary management of this high-risk population. Statements cover seven areas including epidemiology of CKD, HCV-induced glomerular damage, HCV-related renal risk, staging of liver disease in patients with CKD, prevention of transmission of HCV in hemodialysis units, treatment of HCV infection and management of HCV in kidney transplantation.
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Affiliation(s)
- Roberto Minutolo
- Division of Nephrology, Department of Scienze Mediche, Chirurgiche, Neurologiche, Metaboliche e dell'Invecchiamento, University of Campania "Luigi Vanvitelli", Via M. Longo 50, 80138, Naples, Italy.
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Division of Internal Medicine and Hepatology, Humanitas Clinical and Research Center, Milan, Italy
| | - Antonio Chirianni
- Third Department of Infectious Diseases Azienda Ospedaliera Ospedali dei Colli, Naples, Italy
| | - Fabrizio Fabrizi
- Division of Nephrology, Maggiore Hospital and IRCCS Foundation, Milan, Italy
| | - Loreto Gesualdo
- Division of Nephrology, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Paolo Maggi
- Infectious Disease Clinic, University of Bari, Bari, Italy
| | - Vincenzo Montinaro
- Division of Nephrology, Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis, and Transplantation, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Marcello Persico
- Internal Medicine and Hepatology Unit, AOU San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Francesco Perticone
- Department of Medical and Surgical Sciences, University Magna Græcia, Catanzaro, Italy
| | - Salvatore Petta
- Gastroenterology and Hepatology Unit, Di.Bi.M.I.S., University of Palermo, Palermo, Italy
| | - Massimo Puoti
- Division of Infectious Diseases, Niguarda Cà Granda Hospital, Milan, Italy
| | - Giovanni Raimondo
- Department of Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - Maria Rendina
- Department of Emergency and Organ Transplantation, Section of Gastroenterology, University Hospital, Bari, Italy
| | - Anna Linda Zignego
- Department of Experimental and Clinical Medicine, Interdepartmental Hepatology Center MaSVE, University of Florence, Florence, Italy
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Management of hepatitis C virus infection in patients with chronic kidney disease: position statement of the joint committee of Italian association for the study of the liver (AISF), Italian society of internal medicine (SIMI), Italian society of infectious and tropical disease (SIMIT) and Italian society of nephrology (SIN). J Nephrol 2018; 31:685-712. [PMID: 30255440 DOI: 10.1007/s40620-018-0523-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/09/2018] [Indexed: 12/13/2022]
Abstract
Hepatitis C virus (HCV) infection is now considered a systemic disease due to the occurrence of extra-hepatic manifestations. Among these, the renal involvement is frequent. HCV infection, in fact, is strongly associated with proteinuria and chronic kidney disease (CKD) and negatively affects the prognosis of renal patients. In the last few years, availability of more specific and effective drugs against HCV has dramatically changed the clinical course of this disease. These drugs may provide further advantages in the CKD population as a whole by reducing progression of renal disease, mortality rate and by increasing the survival of graft in renal transplant recipients. The strict pathogenetic and prognostic link between HCV infection and CKD requires an ongoing relationship among the healthcare professionals involved in the treatment of both HCV infection and CKD. Therefore, Scientific Societies involved in the care of this high-risk population in Italy have organized a joint expert panel. The aim of the panel is to produce a position statement that can be used in daily clinical practice for the management of HCV infected patients across the whole spectrum of renal disease, from the conservative phase to renal replacement treatments (dialysis and transplantation). Sharing specific evidence-based expertise of different professional healthcare is the first step to obtain a common ground of knowledge on which to instate a model for multidisciplinary management of this high-risk population. Statements cover seven areas including epidemiology of CKD, HCV-induced glomerular damage, HCV-related renal risk, staging of liver disease in patients with CKD, prevention of transmission of HCV in hemodialysis units, treatment of HCV infection and management of HCV in kidney transplantation.
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Michel A, Pladys A, Bayat S, Couchoud C, Hannedouche T, Vigneau C. Deleterious effects of dialysis emergency start, insights from the French REIN registry. BMC Nephrol 2018; 19:233. [PMID: 30223784 PMCID: PMC6142323 DOI: 10.1186/s12882-018-1036-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 09/03/2018] [Indexed: 11/13/2022] Open
Abstract
Background Emergency start (ES) of dialysis has been associated with worse outcome, but remains poorly documented. This study aims to compare the profile and outcome of a large cohort of patients starting dialysis as an emergency or as a planned step in France. Methods Data on all patients aged 18 years or older who started dialysis in mainland France in 2012 or in 2006 were collected from the Renal Epidemiology and Information Network and compared, depending on the dialysis initiation condition: ES or Planned Start (PS). ES was defined as a first dialysis within 24 h after a nephrology visit due to a life-threatening event. Three-year survival were compared, and a multivariate model was performed after multiple imputation of missing data, to determine the parameters independently associated with three-year survival. Results In 2012, 30.3% of all included patients (n = 8839) had ES. Comorbidities were more frequent in the ES than PS group (≥ 2 cardiovascular diseases: 39.2% vs 28.8%, p < 0.001). ES was independently associated with worse three-year survival (57% vs. 68.2%, p = 0.029, HR 1.10, 95% CI 1.01–1.19) in multivariate analysis. Among ES group, a large part had a consistent previous follow-up: 36.4% of them had ≥3 nephrology consultations in the previous year. This subgroup of patients had a particularly high comorbidity burden. ES rate was stable between 2006 and 2012, but some proactive regions succeeded in reducing markedly the ES rate. Conclusion ES remains frequent and is independently associated with worse three-year survival, demonstrating that ES deleterious impact is never overcome. This study shows that a large part of patients with ES had a previous follow-up, but high comorbidity burden that could favor acute decompensation with life-threatening conditions before uremic symptoms appearance. This suggests the need of closer end-stage renal disease follow-up or early dialysis initiation in these high-risk patients. Electronic supplementary material The online version of this article (10.1186/s12882-018-1036-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alain Michel
- CHU Pontchaillou, Service de néphrologie, 2 rue H Le Guilloux, 35033, Rennes cedex, France.
| | - Adelaide Pladys
- EHESP, Département d'Epidémiologie et de Biostatistiques, Rennes, France.,Université Rennes 1, UMR CNRS 6290, Rennes, France
| | - Sahar Bayat
- EHESP, Département d'Epidémiologie et de Biostatistiques, Rennes, France.,EA MOS EHESP, Rennes, France
| | - Cécile Couchoud
- Registre REIN, Agence de la biomédecine, La Plaine Saint Denis, France
| | - Thierry Hannedouche
- Faculté de médecine de Strasbourg, Hôpitaux universitaires de Strasbourg, 1 place de l'Hôpital, 67091, Strasbourg cedex, France
| | - Cécile Vigneau
- CHU Pontchaillou, Service de néphrologie, 2 rue H Le Guilloux, 35033, Rennes cedex, France.,Université de Rennes 1, 2 av prof L Bernard, 35000, Rennes, France.,Inserm (Institut national de la santé et de la recherche médicale), IRSET, U1085, SFR Biosit, 9 Avenue du Professeur Léon Bernard, 35000, Rennes, France
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41
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Vallianou N, Stratigou T, Paikopoulou A, Apostolou T, Vlassopoulou B, Tsagarakis S, Ioannidis G. Monitoring of patients with type 2 diabetes and nephropathy in a specialized diabetic nephropathy clinic seems to be beneficial. Diabetes Metab Syndr 2018; 12:689-692. [PMID: 29685824 DOI: 10.1016/j.dsx.2018.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 04/09/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the outcome of DM2 patients with nephropathy when they are under surveillance of a joined clinic run by endocrinologists & nephrologists. PATIENTS AND METHODS A cohort of 106 patients with DM2, 42-83 years of age, and eGFR < 60 ml/min/m2 were included. Age, sex, duration of diabetes, duration of attending our clinic, smoking habits, BMI, data regarding ischemic heart disease and induction of hemodialysis, urine albumin excretion (UAE) levels, eGFR (MDRD equation) and values of various biochemical parameters were recorded too. Follow-up period ranged from one to 25 years. Paired samples t-test and non-parametrical Kruskal-Wallis test were used for the analyses of the data. RESULTS Fifty percent of patients had no further progression, 25.9% improvement, while 24.1% had worsening of the UAE levels. During the follow-up in the joined clinic, there was a smaller than the expected from the medical literature decrease in median eGFR, i.e. 2,3 ml/min/m2 and a statistically significant improvement in glycosylated hemoglobin levels from 8.0% to 7.4% (p = 0.016). Time in years of follow-up in the joined clinic of our hospital appeared to be the most significant factor in the improvement or stabilization against deterioration of the UAE levels (p = 0.018). CONCLUSIONS Close follow-up of DM2 patients with eGFR < 60 ml/min/m2 has resulted in a minor annual eGFR decrease. Monitoring of these patients in a specialized diabetic nephropathy clinic is beneficial for this group of patients for delaying the occurrence of end-stage renal disease.
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Affiliation(s)
- N Vallianou
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece.
| | - T Stratigou
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
| | - A Paikopoulou
- Department of Nephrology, Evangelismos Hospital, Athens, Greece
| | - T Apostolou
- Department of Nephrology, Evangelismos Hospital, Athens, Greece
| | - B Vlassopoulou
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
| | - S Tsagarakis
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
| | - G Ioannidis
- Department of Endocrinology, Diabetes & Metabolism, Evangelismos Hospital, Athens, Greece
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42
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Liu P, Quinn RR, Oliver MJ, Ronksley PE, Hemmelgarn BR, Quan H, Hiremath S, Bello AK, Blake PG, Garg AX, Johnson J, Verrelli M, Zacharias JM, Abd ElHafeez S, Tonelli M, Ravani P. Association between Duration of Predialysis Care and Mortality after Dialysis Start. Clin J Am Soc Nephrol 2018; 13:893-899. [PMID: 29507006 PMCID: PMC5989670 DOI: 10.2215/cjn.11951017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/27/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Early nephrology referral is recommended for people with CKD on the basis of observational studies showing that longer nephrology care before dialysis start (predialysis care) is associated with lower mortality after dialysis start. This association may be observed because predialysis care truly reduces mortality or because healthier people with an uncomplicated course of disease will have both longer predialysis care and lower risk for death. We examined whether the survival benefit of longer predialysis care exists after accounting for the potential confounding effect of disease course that may also be affected by predialysis care. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a retrospective cohort study and used data from 3152 adults with end stage kidney failure starting dialysis between 2004 and 2014 in five Canadian dialysis programs. We obtained duration of predialysis care from the earliest nephrology outpatient visit to dialysis start; markers of disease course, including inpatient or outpatient dialysis start and residual kidney function around dialysis start; and all-cause mortality after dialysis start. RESULTS The percentages of participants with 0, 1-119, 120-364, and ≥365 days of predialysis care were 23%, 8%, 10%, and 59%, respectively. When we ignored markers of disease course as in previous studies, longer predialysis care was associated with lower mortality (hazard ratio120-364 versus 0-119 days, 0.60; 95% confidence interval, 0.46 to 0.78]; hazard ratio≥365 versus 0-119 days, 0.60; 95% confidence interval, 0.51 to 0.71; standard Cox model adjusted for demographics and laboratory and clinical characteristics). When we additionally accounted for markers of disease course using the inverse probability of treatment weighted Cox model, this association was weaker and no longer significant (hazard ratio120-364 versus 0-119 days, 0.84; 95% confidence interval, 0.60 to 1.18; hazard ratio≥365 versus 0-119 days, 0.88; 95% confidence interval, 0.69 to 1.13). CONCLUSIONS The association between longer predialysis care and lower mortality after dialysis start is weaker and imprecise after accounting for patients' course of disease.
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Affiliation(s)
- Ping Liu
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Robert R. Quinn
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Matthew J. Oliver
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul E. Ronksley
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Hude Quan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Swapnil Hiremath
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Aminu K. Bello
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Peter G. Blake
- Division of Nephrology, Western University, London, Ontario, Canada
| | - Amit X. Garg
- Departments of Medicine, Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - John Johnson
- London Health Sciences Centre, London, Ontario, Canada
| | - Mauro Verrelli
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James M. Zacharias
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Samar Abd ElHafeez
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Epidemiology Department, High Institute of Public Health, Alexandria University, Egypt
| | - Marcello Tonelli
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Lee MS, Ray KN, Mehrotra A, Giboney P, Yee HF, Barnett ML. Primary Care Practitioners' Perceptions of Electronic Consult Systems: A Qualitative Analysis. JAMA Intern Med 2018; 178:782-789. [PMID: 29801079 PMCID: PMC6145753 DOI: 10.1001/jamainternmed.2018.0738] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Safety-net health systems across the country are implementing electronic consult (eConsult) systems in which primary care practitioners (PCPs) submit all requests for specialty assistance electronically to be reviewed and discussed with specialists. Evidence suggests that eConsult systems can make significant improvements in specialty access, but the outcomes of these systems for frontline PCPs is poorly understood. OBJECTIVE To understand PCP perceptions of the results of eConsult initiation on PCP workflow, specialist access, and patient care. DESIGN, SETTING, AND PARTICIPANTS Qualitative interviews were conducted from December 1, 2016, to April 15, 2017, with 40 safety-net PCPs in Los Angeles County who use the Los Angeles County Department of Health Services (DHS) eConsult system. Interviewees were recruited to include diversity in PCP type, practice setting, and employer (DHS employed vs DHS affiliated). Participants were interviewed about their perceptions of clinical workflow, access to specialists, relationships with specialists, and referral decision making. MAIN OUTCOMES AND MEASURES Perceptions of the results of eConsult, including positive and negative themes and remaining perceived gaps in specialty care. RESULTS Of the 40 participants, 27 (68%) were women; 24 (60%) PCPs performed 5 or more eConsults per week. Primary care practitioners' perceptions of eConsult clustered around 4 main themes: access and timeliness of specialty care, shift of work to PCPs, relationships with specialists, and eConsult interface issues. Many PCPs praised the improved timeliness of specialist input with eConsult, as well as the added clinical and educational value of dialogue with specialists, particularly compared with the limitations of the prior referral process. However, PCPs also consistently perceived that eConsult shifted some of the work of specialty care to them. Many PCPs believed that this extra burden was worth the effort given the benefits of eConsult, such as improved timeliness of care and ability to manage specialty conditions. In contrast, others were frustrated by the increased administrative burden, broadened clinical responsibility, and restructuring of specialty care delivery. CONCLUSIONS AND RELEVANCE While associated with improved specialty care access, eConsult systems simultaneously created new challenges for PCPs, such as an increased burden of work in providing specialty care. Primary care practitioners varied in their enthusiasm for these workflow changes with diverging perceptions of the same processes. Our findings provide insights on challenges future primary care transformation efforts may face.
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Affiliation(s)
- Michelle S Lee
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Paul Giboney
- Los Angeles County Department of Health Services, Los Angeles, California
| | - Hal F Yee
- Los Angeles County Department of Health Services, Los Angeles, California
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Lin MY, Cheng LJ, Chiu YW, Hsieh HM, Wu PH, Lin YT, Wang SL, Jian FX, Hsu CC, Yang SA, Lee HL, Hwang SJ. Effect of national pre-ESRD care program on expenditures and mortality in incident dialysis patients: A population-based study. PLoS One 2018; 13:e0198387. [PMID: 29856821 PMCID: PMC5983494 DOI: 10.1371/journal.pone.0198387] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/17/2018] [Indexed: 12/01/2022] Open
Abstract
Inadequate care of chronic kidney disease (CKD) is common and may be associated with adverse outcomes after dialysis. The nationwide pre-end-stage renal disease pay for performance program (P4P) has been implemented in Taiwan to improve quality of CKD care. However, the effectiveness of the P4P program in improving the outcomes of pre-dialysis care and dialysis is uncertain. We conducted a longitudinal cohort study. Patients who newly underwent long-term dialysis (≥3 mo) between 2007 and 2009 were identified from the Taiwan National Health Insurance Research Database. Based on the patient enrolment of the P4P program, they were categorized into P4P or non-P4P groups. We analysed pre-dialysis care, healthcare expenditures, and mortality between two groups. Among the 26 588 patients, 25.5% participated in the P4P program. The P4P group received significantly better quality of care, including a higher frequency of glomerular filtration rate measurement and CKD complications survey, a higher rate of vascular access preparation, and more frequent use of arteriovenous fistulas than the non-P4P group did. The P4P group had a 68.4% reduction of the 4-year total healthcare expenditure (excluding dialysis fee), which is equivalent to US$345.7 million, and a significant 22% reduction in three-year mortality after dialysis (hazard ratio 0.78, 95% confidence interval: 0.75–0.82, P < 0.001) compared with the non-P4P group. P4P program improves quality of pre-dialysis CKD care, and provide survival benefit and a long-term cost saving for dialysis patients.
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Affiliation(s)
- Ming-Yen Lin
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Jen Cheng
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Wen Chiu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hui-Min Hsieh
- Department of Public Health, College of Health Science, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ping-Hsun Wu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Ting Lin
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Li Wang
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Xuan Jian
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
- Department of Health Services Administration, China Medical University, Taichung City, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shu-An Yang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Huei-Lan Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shang-Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
- * E-mail:
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Okazaki M, Inaguma D, Imaizumi T, Kada A, Yaomura T, Tsuboi N, Maruyama S. Unfavorable effects of history of volume overload and late referral to a nephrologist on mortality in patients initiating dialysis: a multicenter prospective cohort study in Japan. BMC Nephrol 2018. [PMID: 29540158 PMCID: PMC5853026 DOI: 10.1186/s12882-018-0859-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Patients with late referral and positive history of volume overload may have a poor prognosis after initiating dialysis due to insufficient and/or inadequate management of complications of renal failure and the lack of better dialysis preparation. Little is known about the influence of the relationship between history of volume overload and late referral on prognosis. METHODS We analyzed 1475 patients who had initiated dialysis for the first time from October 2011 to September 2013. late referral was defined as referral to a nephrologist < 3 months before dialysis initiation. The major outcomes were all-cause death and deaths due to cardiovascular diseases (CVD). The impact of late referral and history of volume overload on all-cause mortality was assessed by Cox proportional hazards models. RESULTS Among 1475 patients, the mean patient age was 67.5 years. During the median follow-up of 2.2 years, 260 deaths occurred; 99 were due to CVD. Cox proportional hazards models demonstrated that late referral (adjusted hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.00-1.82) and history of volume overload (adjusted HR, 1.39; 95% CI, 1.06-1.81) were risk factors for all-cause mortality. Furthermore, late referral coexisting was associated with a history of volume overload increased mortality (adjusted HR, 2.10; 95% CI, 1.39-3.16 versus absence of late referral without history of volume overload) after adjusting for age, sex, diabetes, atherosclerotic disease, and laboratory values. CONCLUSIONS Both late referral and history of volume overload were associated with increased risks of all-cause mortality. TRIAL REGISTRATION University Hospital Medical Information Network (UMIN000007096). Registered 18 January 2012, retrospectively registered. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000008349 .
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Affiliation(s)
- Masaki Okazaki
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.,Department of Clinical Trials and Research, Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Daijo Inaguma
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Takahiro Imaizumi
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Akiko Kada
- Department of Clinical Trials and Research, Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Takaaki Yaomura
- Department of Nephrology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Naotake Tsuboi
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
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Iimori S, Naito S, Noda Y, Sato H, Nomura N, Sohara E, Okado T, Sasaki S, Uchida S, Rai T. Prognosis of chronic kidney disease with normal-range proteinuria: The CKD-ROUTE study. PLoS One 2018; 13:e0190493. [PMID: 29342207 PMCID: PMC5771558 DOI: 10.1371/journal.pone.0190493] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 12/17/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although lower estimated glomerular filtration rate (eGFR) and higher proteinuria are high risks for mortality and kidney outcomes, the prognosis of chronic kidney disease (CKD) in patients with normal-range proteinuria remains unclear. METHODS In this prospective cohort study, 1138 newly visiting stage G2-G5 CKD patients were stratified into normal-range and abnormal-range proteinuria groups. Study endpoints were CKD progression (>50% eGFR loss or initiation of dialysis), cardiovascular events, and all-cause death. RESULTS In total, 927 patients who were followed for >6 months were included in the analysis. The mean age was 67 years, and 70.2% were male. During a median follow-up of 35 months, CKD progression, cardiovascular events, and mortality were observed in 223, 110, and 55 patients, respectively. Patients with normal-range proteinuria had a significantly lower risk for CKD progression (hazard ratio, 0.20; 95% confidence interval, 0.10-0.38) than those with abnormal-proteinuria by multivariate Cox proportional hazard analysis. We also analyzed patients with normal-range proteinuria (n = 351). Nephrosclerosis was the most frequent cause of CKD among all patients with normal-range proteinuria (59.7%). During a median follow-up of 36 months, CKD progression, cardiovascular events, and mortality were observed in 10, 28, and 18 patients, respectively. The Kaplan-Meyer analysis demonstrated that the risks of CKD progression and cardiovascular events were not significantly different among CKD stages, whereas the risk of death was significantly higher in patients with advanced-stage CKD. Multivariate Cox proportional hazard analysis showed that the risk of three endpoints did not significantly differ among CKD stages. CONCLUSION Newly visiting CKD patients with normal-range proteinuria, who tend to be overlooked during health checkups did not exhibit a decrease in kidney function even in advanced CKD stages under specialized nephrology care.
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Affiliation(s)
- Soichiro Iimori
- Department of Nephrology, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Shotaro Naito
- Department of Nephrology, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Yumi Noda
- Department of Nephrology, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano-ku, Tokyo, Japan
| | - Hidehiko Sato
- Department of Nephrology, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano-ku, Tokyo, Japan
| | - Naohiro Nomura
- Department of Nephrology, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Eisei Sohara
- Department of Nephrology, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Tomokazu Okado
- Department of Nephrology, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Sei Sasaki
- Department of Nephrology, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Shinichi Uchida
- Department of Nephrology, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Tatemitsu Rai
- Department of Nephrology, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
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Schanz M, Ketteler M, Heck M, Dippon J, Alscher MD, Kimmel M. Impact of an in-Hospital Patient Education Program on Choice of Renal Replacement Modality in Unplanned Dialysis Initiation. Kidney Blood Press Res 2017; 42:865-876. [PMID: 29161686 DOI: 10.1159/000484531] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 09/21/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Up to 50% patients requiring dialysis receive an urgent, unplanned start (UPS) to renal replacement therapy (RRT). Most of these are initiated with an intravenous catheter and commenced and maintained on hemodialysis (HD). Although peritoneal dialysis (PD) could be an equipotent initial modality for RRT, it is used less frequently as long-term RRT in UPS patients. This multicenter-study aimed to evaluate the impact of a structured, in-hospital education program and factors influencing PD rates, especially in UPS patients. METHODS Three German nephrology departments collaborated to implement an in-hospital education program. Retrospective analysis included 336 subjects and compared the rates of HD and PD in consecutive patients who started RRT 12 months prior (two centers) and for 12 months after (three centers) implementing the education program. RESULTS PD rates increased significantly (p < 0.05) by 66% in all planned and unplanned dialysis starts after implementation of a structured, patient-centered education program. A highly significant (p < 0.0001) rise in utilization of PD was found, especially in UPS patients. In logistic regression analysis, PD modality choice was significantly influenced by age (p < 0.0001) and gender (p = 0.006). CONCLUSIONS A structured, patient-centered in-hospital education program increases the frequency of PD in patients needing unplanned RRT. PD modality choice is significantly higher in young (p < 0.0001) and male (p = 0.006) patients.
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Affiliation(s)
- Moritz Schanz
- Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany
| | | | - Markus Heck
- Nephrological Center Emsland, Lingen, Germany
| | - Juergen Dippon
- Department of Mathematics, University of Stuttgart, Stuttgart, Germany
| | - Mark Dominik Alscher
- Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany
| | - Martin Kimmel
- Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany
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Long B, Koyfman A, Lee CM. Emergency medicine evaluation and management of the end stage renal disease patient. Am J Emerg Med 2017; 35:1946-1955. [PMID: 28893450 DOI: 10.1016/j.ajem.2017.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 09/02/2017] [Accepted: 09/03/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND End stage renal disease (ESRD) is increasing in the U.S., and these patients demonstrate greater all-cause mortality, cardiovascular events, and hospitalization rates when compared to those with normal renal function. These patients may experience significant complications associated with loss of renal function and dialysis. OBJECTIVE This review evaluates complications of ESRD including cardiopulmonary, neurologic, infectious disease, vascular, and access site complications, as well as medication use in this population. DISCUSSION ESRD incidence is rapidly increasing, and patients commonly require renal replacement therapy including hemodialysis (HDS) or peritoneal dialysis (PD), each type with specific features. These patients possess greater risk of neurologic complications, cardiopulmonary pathology, infection, and access site complications. Focused history and physical examination are essential. Neurologic issues include uremic encephalopathy, cerebrovascular pathology, and several others. Cardiopulmonary complications include pericarditis, pericardial effusion/tamponade, acute coronary syndrome, sudden cardiac death, electrolyte abnormalities, pulmonary edema, and air embolism. Infections are common, with patients more commonly presenting in atypical fashion. Access site infections and metastatic infections must be treated aggressively. Access site complications include bleeding, aneurysm/pseudoaneurysm, thrombosis/stenosis, and arterial steal syndrome. Specific medication considerations are required for analgesics, sedatives, neuromuscular blocking agents, antimicrobials, and anticoagulants. CONCLUSIONS Consideration of renal physiology with complications in ESRD can assist emergency providers in the evaluation and management of these patients. ESRD affects many organ systems, and specific pharmacologic considerations are required.
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Affiliation(s)
- Brit Long
- San Antonio Military Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Courtney M Lee
- Joint Base Elmendorf Richardson Medical Center, Department of Emergency Medicine, 5955 Zeamer Ave, JBER, AK, 99506, United States
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Singh K, Waikar SS, Samal L. Evaluating the feasibility of the KDIGO CKD referral recommendations. BMC Nephrol 2017; 18:223. [PMID: 28687072 PMCID: PMC5501411 DOI: 10.1186/s12882-017-0646-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 06/28/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND In 2012, the international nephrology organization Kidney Disease Improving Global Outcomes (KDIGO) released recommendations for nephrology referral for chronic kidney disease (CKD) patients. The feasibility of adhering to these recommendations is unknown. METHODS We conducted a retrospective analysis of the primary care population at Brigham and Women's Hospital (BWH). We translated referral recommendations based upon serum creatinine, estimated glomerular filtration rate (eGFR), and albuminuria into a set of computable criteria in order to project referral volume if the KDIGO referral recommendations were to be implemented. Using electronic health record data, we evaluated each patient using the computable criteria at the times that the patient made clinic visits in 2013. We then compared the projected referral volume with baseline nephrology clinic volume. RESULTS Out of 56,461 primary care patients at BWH, we identified 5593 (9.9%) who had CKD based on albuminuria or estimated GFR. Referring patients identified by the computable criteria would have resulted in 2240 additional referrals to nephrology. In 2013, this would represent a 38.0% (2240/5892) increase in total nephrology patient volume and 67.3% (2240/3326) increase in new referral volume. CONCLUSIONS This is the first study to examine the projected impact of implementing the 2012 KDIGO referral recommendations. Given the large increase in the number of referrals, this study is suggestive that implementing the KDIGO referral guidelines may not be feasible under current practice models due to a supply-demand mismatch. We need to consider new strategies on how to deliver optimal care to CKD patients using the available workforce in the U.S. health care system.
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Affiliation(s)
- Karandeep Singh
- Division of Learning and Knowledge Systems, Department of Learning Health Sciences, University of Michigan Medical School, 1161H NIB, 300 N. Ingalls St, Ann Arbor, MI, 48109-5403, USA. .,Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, 1161H NIB, 300 N. Ingalls St, Ann Arbor, MI, 48109-5403, USA.
| | - Sushrut S Waikar
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis St, MRB4, Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Lipika Samal
- Division of General Medicine, Brigham and Women's Hospital, 1620 Tremont St Suite 03-02V, Boston, MA, 02120, USA.,Harvard Medical School, Boston, MA, USA
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Gulla J, Neri PM, Bates DW, Samal L. User Requirements for a Chronic Kidney Disease Clinical Decision Support Tool to Promote Timely Referral. Int J Med Inform 2017; 101:50-57. [PMID: 28347447 PMCID: PMC5497591 DOI: 10.1016/j.ijmedinf.2017.01.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 01/09/2017] [Accepted: 01/29/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Timely referral of patients with CKD has been associated with cost and mortality benefits, but referrals are often done too late in the course of the disease. Clinical decision support (CDS) offers a potential solution, but interventions have failed because they were not designed to support the physician workflow. We sought to identify user requirements for a chronic kidney disease (CKD) CDS system to promote timely referral. METHODS We interviewed primary care physicians (PCPs) to identify data needs for a CKD CDS system that would encourage timely referral and also gathered information about workflow to assess risk factors for progression of CKD. Interviewees were general internists recruited from a network of 14 primary care clinics affiliated with Brigham and Women's Hospital (BWH). We then performed a qualitative analysis to identify user requirements and system attributes for a CKD CDS system. RESULTS Of the 12 participants, 25% were women, the mean age was 53 (range 37-82), mean years in clinical practice was 27 (range 11-58). We identified 21 user requirements. Seven of these user requirements were related to support for the referral process workflow, including access to pertinent information and support for longitudinal co-management. Six user requirements were relevant to PCP management of CKD, including management of risk factors for progression, interpretation of biomarkers of CKD severity, and diagnosis of the cause of CKD. Finally, eight user requirements addressed user-centered design of CDS, including the need for actionable information, links to guidelines and reference materials, and visualization of trends. CONCLUSION These 21 user requirements can be used to design an intuitive and usable CDS system with the attributes necessary to promote timely referral.
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Affiliation(s)
- Joy Gulla
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
| | - Pamela M Neri
- Clinical and Quality Analysis, Partners HealthCare System, Wellesley, MA, USA
| | - David W Bates
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA; Clinical and Quality Analysis, Partners HealthCare System, Wellesley, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lipika Samal
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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