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Campbell ZC, Dawson JK, Kirkendall SM, McCaffery KJ, Jansen J, Campbell KL, Lee VW, Webster AC. Interventions for improving health literacy in people with chronic kidney disease. Cochrane Database Syst Rev 2022; 12:CD012026. [PMID: 36472416 PMCID: PMC9724196 DOI: 10.1002/14651858.cd012026.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Low health literacy affects 25% of people with chronic kidney disease (CKD) and is associated with increased morbidity and death. Improving health literacy is a recognised priority, but effective interventions are not clear. OBJECTIVES This review looked the benefits and harms of interventions for improving health literacy in people with CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched MEDLINE (OVID) and EMBASE (OVID) for non-randomised studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies that assessed interventions aimed at improving health literacy in people with CKD. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility and performed risk of bias analysis. We classified studies as either interventions aimed at improving aspects of health literacy or interventions targeting a population of people with poor health literacy. The interventions were further sub-classified in terms of the type of intervention (educational, self-management training, or educational with self-management training). Results were expressed as mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CI for dichotomous outcomes. MAIN RESULTS We identified 120 studies (21,149 participants) which aimed to improve health literacy. There were 107 RCTs and 13 non-randomised studies. No studies targeted low literacy populations. For the RCTs, selection bias was low or unclear in 94% of studies, performance bias was high in 86% of studies, detection bias was high in 86% of studies reporting subjective outcomes and low in 93% of studies reporting objective outcomes. Attrition and other biases were low or unclear in 86% and 78% of studies, respectively. Compared to usual care, low certainty evidence showed educational interventions may increase kidney-related knowledge (14 RCTs, 2632 participants: SMD 0.99, 95% CI 0.69 to 1.32; I² = 94%). Data for self-care, self-efficacy, quality of life (QoL), death, estimated glomerular filtration rate (eGFR) and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed self-management interventions may improve self-efficacy (5 RCTs, 417 participants: SMD 0.58, 95% CI 0.13 to 1.03; I² = 74%) and QoL physical component score (3 RCTs, 131 participants: MD 4.02, 95% CI 1.09 to 6.94; I² = 0%). There was moderate-certainty evidence that self-management interventions probably did not slow the decline in eGFR after one year (3 RCTs, 855 participants: MD 1.53 mL/min/1.73 m², 95% CI -1.41 to 4.46; I² = 33%). Data for knowledge, self-care behaviour, death and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed educational with self-management interventions may increase knowledge (15 RCTs, 2185 participants: SMD 0.65, 95% CI 0.36 to 0.93; I² = 90%), improve self-care behaviour scores (4 RCTs, 913 participants: SMD 0.91, 95% CI 0.00 to 1.82; I² =97%), self-efficacy (8 RCTs, 687 participants: SMD 0.50, 95% CI 0.10 to 0.89; I² = 82%), improve QoL physical component score (3 RCTs, 2771 participants: MD 2.56, 95% CI 1.73 to 3.38; I² = 0%) and may make little or no difference to slowing the decline of eGFR (4 RCTs, 618 participants: MD 4.28 mL/min/1.73 m², 95% CI -0.03 to 8.85; I² = 43%). Moderate-certainty evidence shows educational with self-management interventions probably decreases the risk of death (any cause) (4 RCTs, 2801 participants: RR 0.73, 95% CI 0.53 to 1.02; I² = 0%). Data for hospitalisation could not be pooled. AUTHORS' CONCLUSIONS Interventions to improve aspects of health literacy are a very broad category, including educational interventions, self-management interventions and educational with self-management interventions. Overall, this type of health literacy intervention is probably beneficial in this cohort however, due to methodological limitations and high heterogeneity in interventions and outcomes, the evidence is of low certainty.
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Affiliation(s)
- Zoe C Campbell
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jessica K Dawson
- Westmead Clinical School, The University of Sydney at Westmead, Westmead, Australia
- Department of Nutrition and Dietetics, St George Hospital, Kogarah, Australia
| | | | - Kirsten J McCaffery
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jesse Jansen
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Family Medicine, School Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
- Faculty of Health Medicine and Life Sciences (FHML), Maastricht University, Maastricht, Netherlands
| | - Katrina L Campbell
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Nathan, Australia
| | - Vincent Ws Lee
- Westmead Clinical School, The University of Sydney at Westmead, Westmead, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Angela C Webster
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Westmead Applied Research Centre, The University of Sydney at Westmead, Westmead, Australia
- Department of Transplant and Renal Medicine, Westmead Hospital, Westmead, Australia
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Smits KPJ, Sidorenkov G, Bilo HJG, Bouma M, Navis GJ, Denig P. Process quality indicators for chronic kidney disease risk management: a systematic literature review. Int J Clin Pract 2016; 70:861-869. [PMID: 27640992 DOI: 10.1111/ijcp.12878] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/22/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Quality indicators (QIs) can be used for measuring the quality of actions of healthcare providers. This systematic review gives an overview of such QIs measuring processes of care for chronic kidney disease (CKD), and identifies the QIs that have content, face, operational and/or predictive validity. METHODS PubMed and Embase were searched using a strategy combining the terms "quality of care," "quality indicators" and "chronic kidney disease". Papers were included if they focused on developing, testing or applying QIs for assessing the quality of care in adult patients with CKD not on renal replacement therapy. RESULTS Two hundred and seventy-three QIs from thirty-one papers were extracted, including QIs on adequate monitoring of kidney function and vascular risk factors, on indicated treatment, drug safety, adherence and referral to a specialist. The QIs that were considered content, face and operational valid focused on monitoring of glomerular filtration rate, albumin-creatinine ratio, lipid levels and blood pressure, the use of non-steroidal anti-inflammatory drugs, nitrofurantoin and biphosphonates in patients with CKD, and QIs on monitoring haemoglobin and treatment with angiotensin-converting-enzyme-inhibitors/angiotensin-receptor-II-blockers in patients with CKD and comorbidities. No QIs were tested for predictive validity. In addition, only two QIs focused on diet and no other QIs focused on lifestyle management. CONCLUSIONS Based on this review, sufficiently validated QIs can be selected for measuring the quality of CKD care. This review provides insight in QIs that need further validation, and in areas of care where QIs are still lacking.
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Affiliation(s)
- Kirsten P J Smits
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Grigory Sidorenkov
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henk J G Bilo
- Diabetes Centre, Isala Clinics, Zwolle, The Netherlands
| | - Margriet Bouma
- Dutch College of General Practitioners (NHG), Utrecht, The Netherlands
| | - Gerjan J Navis
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Moreira TR, Giatti L, Cesar CC, Andrade EIG, Acurcio FDA, Cherchiglia ML. Health self-assessment by hemodialysis patients in the Brazilian Unified Health System. Rev Saude Publica 2016; 50:10. [PMID: 27143610 PMCID: PMC4891181 DOI: 10.1590/s1518-8787.2016050005885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 06/09/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To examine whether the level of complexity of the services structure and sociodemographic and clinical characteristics of patients in hemodialysis are associated with the prevalence of poor health self-assessment. METHODS In this cross-sectional study, we evaluated 1,621 patients with chronic terminal kidney disease on hemodialysis accompanied in 81 dialysis services in the Brazilian Unified Health System in 2007. Sampling was performed by conglomerate in two stages and a structured questionnaire was applied to participants. Multilevel multiple logistic regression was used for data analysis. RESULTS The prevalence of poor health self-assessment was of 54.5%, and in multivariable analysis it was associated with the following variables: increasing age (OR = 1.02; 95%CI 1.01–1.02), separated or divorced marital status (OR = 0.62; 95%CI 0.34–0.88), having 12 years or more of study (OR = 0.51; 95%CI 0.37–0.71), spending more than 60 minutes in commuting between home and the dialysis service (OR = 1.80; 95%CI 1.29–2.51), having three or more self-referred diseases (OR = 2.20; 95%CI 1.33–3.62), and reporting some (OR = 2.17; 95%CI 1.66–2.84) or a lot of (OR = 2.74; 95%CI 2.04–3.68) trouble falling asleep. Individuals in treatment in dialysis services with the highest level of complexity in the structure presented less chance of performing a self-assessment of their health as bad (OR = 0.59; 95%CI 0.42–0.84). CONCLUSIONS We showed poor health self-assessment is associated with age, years of formal education, marital status, home commuting time to the dialysis service, number of self-referred diseases, report of trouble sleeping, and also with the level of complexity of the structure of health services. Acknowledging these factors can contribute to the development of strategies to improve the health of patients in hemodialysis in the Brazilian Unified Health System.
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Affiliation(s)
- Tiago Ricardo Moreira
- Departamento de Medicina e Enfermagem, Universidade Federal de Viçosa, Viçosa, MG, Brasil
| | - Luana Giatti
- Departamento de Nutrição Clínica e Social, Escola de Nutrição, Universidade Federal de Ouro Preto, Ouro Preto, MG, Brasil
| | - Cibele Comini Cesar
- Departamento de Estatística, Instituto de Ciências Exatas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Eli Iola Gurgel Andrade
- Departamento de Medicina Preventiva e Social, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Francisco de Assis Acurcio
- Departamento de Farmácia Social, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Mariângela Leal Cherchiglia
- Departamento de Medicina Preventiva e Social, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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Smits KPJ, Sidorenkov G, Bilo HJG, Bouma M, van Ittersum FJ, Voorham J, Navis G, Denig P. Development and initial validation of prescribing quality indicators for patients with chronic kidney disease. Nephrol Dial Transplant 2016; 31:1876-1886. [PMID: 26743176 DOI: 10.1093/ndt/gfv420] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 11/16/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Quality assessment is a key element for improving the quality of care. Currently, a comprehensive indicator set for measuring the quality of medication treatment in patients with chronic kidney disease (CKD) is lacking. Our aim was to develop and validate a set of prescribing quality indicators (PQIs) for CKD care, and to test the feasibility of applying this set in practice. METHODS Potential indicators were based on clinical practice guidelines and evaluated using the RAND/UCLA Appropriateness Method. This is a structured process in which an expert panel assesses the validity of the indicators. Feasibility was tested in a Dutch primary care database including >4500 diabetes patients with CKD. RESULTS An initial list of 22 PQIs was assessed by 12 experts. After changing 10 PQIs, adding 2 and rejecting 8, a final list of 16 indicators was accepted by the expert panel as valid. These PQIs focused on the treatment of hypertension, albuminuria, mineral and bone disorder, statin prescribing and possible unsafe medication. The indicators were successfully applied to measure treatment quality in the primary care database, but for some indicators the number of eligible patients was too small for reliable calculation. Results showed that there was room for improvement in the treatment quality of this population. CONCLUSIONS We developed a set of 16 PQIs for measuring the quality of treatment in CKD patients, which had sufficient content and face validity as well as operational feasibility. These PQIs can be used to point out priority areas for improvement.
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Affiliation(s)
- Kirsten P J Smits
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Grigory Sidorenkov
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henk J G Bilo
- Diabetes Centre, Isala Clinics, Zwolle, The Netherlands
| | - Margriet Bouma
- Dutch College of General Practitioners (NHG), Utrecht, The Netherlands
| | - Frans J van Ittersum
- Department of Nephrology, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Jaco Voorham
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerjan Navis
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Palmer SC, Navaneethan SD, Craig JC, Johnson DW, Perkovic V, Hegbrant J, Strippoli GFM. HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis. Cochrane Database Syst Rev 2014:CD007784. [PMID: 24880031 DOI: 10.1002/14651858.cd007784.pub2] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the most frequent cause of death in people with early stages of chronic kidney disease (CKD), for whom the absolute risk of cardiovascular events is similar to people who have existing coronary artery disease. This is an update of a review published in 2009, and includes evidence from 27 new studies (25,068 participants) in addition to the 26 studies (20,324 participants) assessed previously; and excludes three previously included studies (107 participants). This updated review includes 50 studies (45,285 participants); of these 38 (37,274 participants) were meta-analysed. OBJECTIVES To evaluate the benefits (such as reductions in all-cause and cardiovascular mortality, major cardiovascular events, MI and stroke; and slow progression of CKD to end-stage kidney disease (ESKD)) and harms (muscle and liver dysfunction, withdrawal, and cancer) of statins compared with placebo, no treatment, standard care or another statin in adults with CKD who were not on dialysis. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 5 June 2012 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care, or other statins, on mortality, cardiovascular events, kidney function, toxicity, and lipid levels in adults with CKD not on dialysis were the focus of our literature searches. DATA COLLECTION AND ANALYSIS Two or more authors independently extracted data and assessed study risk of bias. Treatment effects were expressed as mean difference (MD) for continuous outcomes (lipids, creatinine clearance and proteinuria) and risk ratio (RR) for dichotomous outcomes (major cardiovascular events, all-cause mortality, cardiovascular mortality, fatal or non-fatal myocardial infarction (MI), fatal or non-fatal stroke, ESKD, elevated liver enzymes, rhabdomyolysis, cancer and withdrawal rates) with 95% confidence intervals (CI). MAIN RESULTS We included 50 studies (45,285 participants): 47 studies (39,820 participants) compared statins with placebo or no treatment and three studies (5547 participants) compared two different statin regimens in adults with CKD who were not yet on dialysis. We were able to meta-analyse 38 studies (37,274 participants).The risk of bias in the included studies was high. Seven studies comparing statins with placebo or no treatment had lower risk of bias overall; and were conducted according to published protocols, outcomes were adjudicated by a committee, specified outcomes were reported, and analyses were conducted using intention-to-treat methods. In placebo or no treatment controlled studies, adverse events were reported in 32 studies (68%) and systematically evaluated in 16 studies (34%).Compared with placebo, statin therapy consistently prevented major cardiovascular events (13 studies, 36,033 participants; RR 0.72, 95% CI 0.66 to 0.79), all-cause mortality (10 studies, 28,276 participants; RR 0.79, 95% CI 0.69 to 0.91), cardiovascular death (7 studies, 19,059 participants; RR 0.77, 95% CI 0.69 to 0.87) and MI (8 studies, 9018 participants; RR 0.55, 95% CI 0.42 to 0.72). Statins had uncertain effects on stroke (5 studies, 8658 participants; RR 0.62, 95% CI 0.35 to 1.12).Potential harms from statin therapy were limited by lack of systematic reporting and were uncertain in analyses that had few events: elevated creatine kinase (7 studies, 4514 participants; RR 0.84, 95% CI 0.20 to 3.48), liver function abnormalities (7 studies, RR 0.76, 95% CI 0.39 to 1.50), withdrawal due to adverse events (13 studies, 4219 participants; RR 1.16, 95% CI 0.84 to 1.60), and cancer (2 studies, 5581 participants; RR 1.03, 95% CI 0.82 to 130).Statins had uncertain effects on progression of CKD. Data for relative effects of intensive cholesterol lowering in people with early stages of kidney disease were sparse. Statins clearly reduced risks of death, major cardiovascular events, and MI in people with CKD who did not have CVD at baseline (primary prevention). AUTHORS' CONCLUSIONS Statins consistently lower death and major cardiovascular events by 20% in people with CKD not requiring dialysis. Statin-related effects on stroke and kidney function were found to be uncertain and adverse effects of treatment are incompletely understood. Statins have an important role in primary prevention of cardiovascular events and mortality in people who have CKD.
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Affiliation(s)
- Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, 2 Riccarton Ave, PO Box 4345, Christchurch, New Zealand, 8140
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Hadimeri H, Frisenette-Fich C, Deurell SI, Svensson L, Carlsson-Bjering L, Fernström A, Almroth G, Melander S, Haarhaus M, Andersson PO, Cassel A, Mauritz NJ, Ståhl-Nilsson A, Wilske J, Nordström K, Oruda P, Eriksson M, Larsson AI, Stegmayr B. A fixed protocol for outpatient clinic routines in the care of patients with severe renal failure. Ren Fail 2013; 35:845-54. [DOI: 10.3109/0886022x.2013.794661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Henrik Hadimeri
- Department of Medicine and Nephrology, Kärnsjukhuset, Kärnsjukhuset, Skövde, Sweden.
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Peeters MJ, van Zuilen AD, van den Brand JAJG, Bots ML, Blankestijn PJ, Wetzels JFM. Validation of the kidney failure risk equation in European CKD patients. Nephrol Dial Transplant 2013; 28:1773-9. [PMID: 23645476 DOI: 10.1093/ndt/gft063] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) are at risk for progression to kidney failure. Using data of Canadian CKD patients, Tangri et al. recently developed models to predict the progression of CKD stages 3-5 to kidney failure within 5 years. We validated this kidney failure risk equation (KFRE) in European CKD patients. METHODS We selected non-transplanted patients with CKD stages 3-5 who participated in the MASTERPLAN study, a randomized controlled trial in patients with CKD. Kidney failure was defined as the initiation of chronic dialysis or kidney transplantation within 5 years. Patients who died before kidney failure were censored. Patients followed for <5 years, who did not develop kidney failure and did not die, were excluded. The 5-year kidney failure risk was predicted using three different models developed by Tangri et al. and compared with the actual kidney failure rate in MASTERPLAN. Model performance was evaluated using the area under the receiver operating characteristic curve (ROC-AUC), the net reclassification index (NRI) and by comparing the observed and predicted rates of kidney failure. RESULTS A total of 595 patients were included; 114 developed kidney failure. (Overall observed kidney failure risk in our cohort was 5% lower than in the Canadian validation cohort.) Discrimination of the eight-variable model [including age, sex, estimated glomerular filtration rate (eGFR), albuminuria, calcium, phosphate, bicarbonate, albumin] was similar to that of the four-variable model (including age, sex, eGFR, albuminuria) and the three-variable model (including age, sex, eGFR); ROC-AUCs were 0.89 [95% confidence interval (CI) 0.86-0.92], 0.88 (95% CI 0.85-0.91) and 0.88 (95% CI 0.85-0.92), respectively. Using the NRI, the eight-variable model slightly outperformed the four-variable model (NRI 6.5%) and the three-variable model (NRI 12.4%). The mean differences between the observed and predicted kidney failure risk were -4.0, -7.1 and -7.4% for the eight-, four-, and three-variable model, respectively. CONCLUSIONS The KFRE accurately predicted the progression to kidney failure in European CKD patients. Discrimination of the three models was similar. Calibration of the eight-variable model was slightly better than that of the simpler models. We question whether this outweighs its added complexity.
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Affiliation(s)
- Mieke J Peeters
- Department of Nephrology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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A re-appraisal of volume status and renal function impairment in chronic heart failure: combined effects of pre-renal failure and venous congestion on renal function. Heart Fail Rev 2013; 17:263-70. [PMID: 21365244 PMCID: PMC3310983 DOI: 10.1007/s10741-011-9233-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The association between cardiac failure and renal function impairment has gained wide recognition over the last decade. Both structural damage in the form of systemic atherosclerosis and (patho) physiological hemodynamic changes may explain this association. As regards hemodynamic factors, renal impairment in chronic heart failure is traditionally assumed to be mainly due to a decrease in cardiac output and a subsequent decrease in renal perfusion. This will lead to a decrease in glomerular filtration rate and a compensatory increase in tubular sodium retention. The latter is a physiological renal response aimed at retaining fluids in order to increase cardiac filling pressure and thus renal perfusion. In heart failure, however, larger increases in cardiac filling pressure are needed to restore renal perfusion and thus more volume retention. In this concept, in chronic heart failure, an equilibrium exists where a certain degree of congestion is the price to be paid to maintain adequate renal perfusion and function. Recently, this hypothesis was challenged by new studies, wherein it was found that the association between right-sided cardiac filling pressures and renal function is bimodal, with worse renal function at the highest filling pressures, reflecting a severely congested state. Renal hemodynamic studies suggest that congestion negatively affects renal function in particular in patients in whom renal perfusion is also compromised. Thus, an interplay between cardiac forward failure and backward failure is involved in the renal function impairment in the congestive state, presumably along with other factors. Only few data are available on the impact of intervention in volume status on the cardio-renal interaction. Sparse data in cardiac patients as well as evidence from cohorts with primary renal disease suggest that specific targeting of volume overload may be beneficial for long-term outcome, in spite of a certain further decrease in renal function, at least in the context of current treatment where possible reflex neurohumoral activation is ameliorated by the background treatment by blockers of the renin-angiotensin-aldosterone system.
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Peeters MJ, van Zuilen AD, van den Brand JAJG, Blankestijn PJ, ten Dam MAGJ, Wetzels JFM. Differences between hospitals in attainment of parathyroid hormone treatment targets in chronic kidney disease do not reflect differences in quality of care. BMC Nephrol 2012; 13:82. [PMID: 22867424 PMCID: PMC3467173 DOI: 10.1186/1471-2369-13-82] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 07/27/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transparency in quality of care (QoC) is stimulated and hospitals are compared and judged on the basis of indicators of performance on specific treatment targets. In patients with chronic kidney disease, QoC differed significantly between hospitals. In this analysis we explored additional parameters to explain differences between centers in attainment of parathyroid hormone (PTH) treatment targets. METHODS Using MASTERPLAN baseline data, we selected one of the worst (center A) and one of the best (center B) performing hospitals. Differences between the two centers were analyzed from the year prior to start of the MASTERPLAN study until the baseline evaluation. Determinants of PTH were assessed. RESULTS 101 patients from center A (median PTH 9.9 pmol/l, in 67 patients exceeding recommended levels) and 100 patients from center B (median PTH 6.5 pmol/l, in 34 patients exceeding recommended levels), were included. Analysis of clinical practice did not reveal differences in PTH management between the centers. Notably, hyperparathyroidism resulted in a change in therapy in less than 25% of patients. In multivariate analysis kidney transplant status, MDRD-4, and treatment center were independent predictors of PTH. However, when MDRD-6 (which accounts for serum urea and albumin) was used instead of MDRD-4, the center effect was reduced. Moreover, after calibration of the serum creatinine assays treatment center no longer influenced PTH. CONCLUSIONS We show that differences in PTH control between centers are not explained by differences in treatment, but depend on incomparable patient populations and laboratory techniques. Therefore, results of hospital performance comparisons should be interpreted with great caution.
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Affiliation(s)
- Mieke J Peeters
- Department of Nephrology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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van Zuilen AD, Bots ML, Dulger A, van der Tweel I, van Buren M, Ten Dam MAGJ, Kaasjager KAH, Ligtenberg G, Sijpkens YWJ, Sluiter HE, van de Ven PJG, Vervoort G, Vleming LJ, Blankestijn PJ, Wetzels JFM. Multifactorial intervention with nurse practitioners does not change cardiovascular outcomes in patients with chronic kidney disease. Kidney Int 2012; 82:710-7. [PMID: 22739979 DOI: 10.1038/ki.2012.137] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Strict implementation of guidelines directed at multiple targets reduces vascular risk in diabetic patients. Whether this also applies to patients with chronic kidney disease (CKD) is uncertain. To evaluate this, the MASTERPLAN Study randomized 788 patients with CKD (estimated GFR 20-70 ml/min) to receive additional intensive nurse practitioner support (the intervention group) or nephrologist care (the control group). The primary end point was a composite of myocardial infarction, stroke, or cardiovascular death. During a mean follow-up of 4.62 years, modest but significant decreases were found for blood pressure, LDL cholesterol, anemia, proteinuria along with the increased use of active vitamin D or analogs, aspirin and statins in the intervention group compared to the controls. No differences were found in the rate of smoking cessation, weight reduction, sodium excretion, physical activity, or glycemic control. Intensive control did not reduce the rate of the composite end point (21.3/1000 person-years in the intervention group compared to 23.8/1000 person-years in the controls (hazard ratio 0.90)). No differences were found in the secondary outcomes of vascular interventions, all-cause mortality or end-stage renal disease. Thus, the addition of intensive support by nurse practitioner care in patients with CKD improved some risk factor levels, but did not significantly reduce the rate of the primary or secondary end points.
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Affiliation(s)
- Arjan D van Zuilen
- Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands.
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van den Berg E, Geleijnse JM, Brink EJ, van Baak MA, Homan van der Heide JJ, Gans ROB, Navis G, Bakker SJL. Sodium intake and blood pressure in renal transplant recipients. Nephrol Dial Transplant 2012; 27:3352-9. [PMID: 22499024 DOI: 10.1093/ndt/gfs069] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Hypertension is common among renal transplant recipients (RTR) and a risk factor for graft failure and mortality. Sodium intake is a well-established determinant of blood pressure (BP) in the general population. However, data in RTR are limited. International guidelines recommend a maximum daily sodium intake of 70 mmol. We investigated sodium intake in RTR as compared to healthy controls and its association with BP. METHODS We included 660 RTR (age 53 ± 13 years, 58% male) and 201 healthy controls (age 54 ± 11 years, 46% male). Sodium intake was assessed from 24-h urine collections. The morning after completion of urine collection, BP was measured according to a strict protocol. RESULTS Urinary sodium excretion was 156 ± 62 mmol/24 h in RTR and 195 ± 75 in controls (difference: P < 0.001), and 95% of RTR had a urinary sodium excretion >70 mmol/24 h. Systolic BP (SBP) and diastolic BP (DBP) were 136 ± 18 and 82 ± 11 mmHg, respectively. Sodium intake was positively associated with SBP (β = 0.042 mmHg/mmol/24 h, P = 0.002) and DBP (β = 0.023 mmHg/mmol/24 h, P = 0.007), independent of potential confounders. CONCLUSIONS Although RTR had a lower sodium intake than healthy controls, their intake still exceeded current guidelines. Reduction of sodium intake to recommended amounts could reduce SBP by 4-5 mmHg. Better control of sodium intake may help to prevent graft failure and mortality due to hypertension among RTR.
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Mazairac AHA, Grooteman MPC, Blankestijn PJ, Lars Penne E, van der Weerd NC, den Hoedt CH, van den Dorpel MA, Buskens E, Nubé MJ, ter Wee PM, de Wit GA, Bots ML. Differences in quality of life of hemodialysis patients between dialysis centers. Qual Life Res 2012; 21:299-307. [PMID: 21633878 PMCID: PMC3276757 DOI: 10.1007/s11136-011-9942-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2011] [Indexed: 12/03/2022]
Abstract
PURPOSE Hemodialysis patients undergo frequent and long visits to the clinic to receive adequate dialysis treatment, medical guidance, and support. This may affect health-related quality of life (HRQOL). Although HRQOL is a very important management aspect in hemodialysis patients, there is a paucity of information on the differences in HRQOL between centers. We set out to assess the differences in HRQOL of hemodialysis patients between dialysis centers and explore which modifiable center characteristics could explain possible differences. METHODS This cross-sectional study evaluated 570 hemodialysis patients from 24 Dutch dialysis centers. HRQOL was measured with the Kidney Disease Quality Of Life-Short Form (KDQOL-SF). RESULTS After adjustment for differences in case-mix, three HRQOL domains differed between dialysis centers: the physical composite score (PCS, P = 0.01), quality of social interaction (P = 0.04), and dialysis staff encouragement (P = 0.001). These center differences had a range of 11-21 points on a scale of 0-100, depending on the domain. Two center characteristics showed a clinical relevant relation with patients' HRQOL: dieticians' fulltime-equivalent and the type of dialysis center. CONCLUSION This study showed that clinical relevant differences exist between dialysis centers in multiple HRQOL domains. This is especially remarkable as hemodialysis is a highly standardized therapy.
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Affiliation(s)
- Albert H. A. Mazairac
- Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Muriel P. C. Grooteman
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
- Institute for Cardiovascular Research VU Medical Center (ICaR-VU), VU Medical Center, Amsterdam, The Netherlands
| | - Peter J. Blankestijn
- Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - E. Lars Penne
- Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
| | - Neelke C. van der Weerd
- Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
| | - Claire H. den Hoedt
- Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Erik Buskens
- MTA Unit, Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Menso J. Nubé
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
- Institute for Cardiovascular Research VU Medical Center (ICaR-VU), VU Medical Center, Amsterdam, The Netherlands
| | - Piet M. ter Wee
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
- Institute for Cardiovascular Research VU Medical Center (ICaR-VU), VU Medical Center, Amsterdam, The Netherlands
| | - G. Ardine de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
- National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Current World Literature. Curr Opin Nephrol Hypertens 2011; 20:561-7. [DOI: 10.1097/mnh.0b013e32834a3de5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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