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Cortvrindt C, Van Biesen W, Gambino G, Clause AL. Factors influencing renal replacement therapy modality choice from the nephrologist's perspective. J Nephrol 2024; 37:635-645. [PMID: 38512379 DOI: 10.1007/s40620-024-01915-w] [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: 10/27/2023] [Accepted: 01/24/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Peritoneal dialysis (PD) offers quality of life and empowerment for persons with end-stage kidney disease (ESKD). Nevertheless, the prevalence of PD is low in Belgium and Europe in general. Reimbursement, patient mix and late referral have been quoted as underlying reasons. However, to date no one-size-fits-all solution increasing uptake of PD has been successfully implemented. We aimed to understand the nephrologist's perspective, beliefs, and experiences on dialysis modality selection and to clarify underlying process-level and intrinsic motivations steering final decisions. METHODS Using purposeful sampling, Belgian nephrologists (non-/academic, geographical spread, age, gender) were selected. We conducted semi-structured interviews, and audiotapes were transcribed verbatim. Meaningful units were grouped into (sub-)themes, and a conceptual framework was developed using grounded theory according to Charmaz as guidance. RESULTS Twenty-nine nephrologists were interviewed. We identified four themes: Trust and belief (in PD as a technique; own expertise, knowledge and team; in behavior of patient, family practitioner), feeling of control (paternalism; insecurity; prejudice), vision of care and approach (shared decision making; troubleshooting attitude; flexibility and creativity; complacency), and organizational issues (predialysis; access; financial; and assisted PD). CONCLUSIONS Based on these interviews, it is apparent that next to already identified singular issues such as late referral, predialysis education, patient mix and financial incentives, more intrinsic factors also impact uptake of home-based therapies. These factors intertwine and relate both to process-level topics and to attitudes and culture of the nephrologists within the team.
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Affiliation(s)
| | - Wim Van Biesen
- Renal Division, University Hospital Gent, Gent, Belgium.
- Department of Internal Medicine and Paediatrics, University of Gent, Ghent, Belgium.
| | - Guiseppe Gambino
- Service de Néphrologie dialyse et transplantation, Hôpital Erasme, ULB, Brussels, Belgium
| | - Anne-Lorraine Clause
- Service de Néphrologie dialyse et transplantation, Hôpital Erasme, ULB, Brussels, Belgium
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Shukri A, Mettang T, Scheckel B, Schellartz I, Simic D, Scholten N, Müller M, Stock S. Hemodialysis and Peritoneal Dialysis in Germany from a Health Economic View-A Propensity Score Matched Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14007. [PMID: 36360885 PMCID: PMC9653857 DOI: 10.3390/ijerph192114007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/19/2022] [Accepted: 10/25/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Hemodialysis (HD) and peritoneal dialysis (PD) are deemed medically equivalent for therapy of end-stage renal disease (ESRD) and reimbursed by the German statutory health insurance (SHI). However, although the home dialysis modality PD is associated with higher patient autonomy than HD, for unknown reasons, PD uptake is low in Germany. Hence, we compared HD with PD regarding health economic outcomes, particularly costs, as potentially relevant factors for the predominance of HD. METHODS Claims data from two German health insurance funds were analysed in a retrospective cohort study regarding the prevalence of HD and PD in 2013-2016. Propensity score matching created comparable HD and PD groups (n = 436 each). Direct annual health care costs were compared. A sensitivity analysis included a comparison of different matching techniques and consideration of transportation costs. Additionally, hospitalisation and survival were investigated using Poisson regression and Kaplan-Meier curves. RESULTS Total direct annual average costs were higher for HD (€47,501) than for PD (€46,235), but not significantly (p = 0.557). The additional consideration of transportation costs revealed an annual cost advantage of €7000 for PD. HD and PD differed non-significantly in terms of hospitalisation and survival rates (p = 0.610/p = 0.207). CONCLUSIONS PD has a slight non-significant cost advantage over HD, especially when considering transportation costs.
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Affiliation(s)
- Arim Shukri
- Institute for Health Economics and Clinical Epidemiology (IGKE), Faculty of Medicine, University Hospital Cologne, University of Cologne, 50923 Cologne, Germany
| | | | - Benjamin Scheckel
- Institute for Health Economics and Clinical Epidemiology (IGKE), Faculty of Medicine, University Hospital Cologne, University of Cologne, 50923 Cologne, Germany
| | - Isabell Schellartz
- Institute of Health Care Research, Rhineland State Council, 51109 Cologne, Germany
| | - Dusan Simic
- Institute for Health Economics and Clinical Epidemiology (IGKE), Faculty of Medicine, University Hospital Cologne, University of Cologne, 50923 Cologne, Germany
| | - Nadine Scholten
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), Faculty of Human Sciences and Medicine, University of Cologne, 50923 Cologne, Germany
| | - Martin Müller
- Institute for Health Economics and Clinical Epidemiology (IGKE), Faculty of Medicine, University Hospital Cologne, University of Cologne, 50923 Cologne, Germany
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, 3012 Bern, Switzerland
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology (IGKE), Faculty of Medicine, University Hospital Cologne, University of Cologne, 50923 Cologne, Germany
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Salas-Gama K, Díaz-Gómez JM, Bolíbar Ribas I. Appropriateness of the dialysis modality selection process: A cross-sectional study. Medicine (Baltimore) 2022; 101:e31041. [PMID: 36281100 PMCID: PMC9592345 DOI: 10.1097/md.0000000000031041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Studies that specifically quantify the appropriateness of the process of dialysis modality selection are lacking. Peritoneal dialysis (PD) offers clinical and social advantages over hemodialysis (HD), but may be underused. We aimed to determine the appropriateness of the process of dialysis modality selection and quantify the percentage of patients who could potentially have been PD candidates. We performed a cross-sectional study that included adult patients from a hospital Nephrology Department in Barcelona who started dialysis between 2014 and 2015. We assessed the appropriateness of dialysis modalities selection by defining 3 sequential domains based on 3 critical steps in choosing a dialysis modality: eligibility for either treatment, information about modalities, and shared decision-making. We obtained data using medical records and a patient questionnaire. The dialysis modality selection process was considered appropriate when patients had no contraindications for the selected option, received complete information about both modalities, and voluntarily chose the selected option. A total of 141 patients were included in this study. The median age was 72 years (interquartile range 63-82 years), and 65% of the patients were men. The dialysis modality selection process was potentially inappropriate in 22% of the participants because of problems related to information about dialysis modalities (15%) or shared decision-making (7%). Appropriate PD use can potentially increase from 17% to 38%. Patient age and lack of information regarding dialysis options were independently associated with the potential degree of inappropriate dialysis modality selection. Our findings indicate areas for improvement in the selection of dialysis modalities. With better education and shared decision-making, the number of patients with PD could potentially double. The analysis of appropriateness is a helpful approach for studying renal replacement treatment patterns and identifying strategies to optimize their use.
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Affiliation(s)
- Karla Salas-Gama
- Quality, Process and Innovation Direction, Valld’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Health Services Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- PhD candidate at the Methodology of Biomedical Research and Public Health program, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health-CIBERESP, Barcelona, Spain
- *Correspondence: Karla Salas-Gama, Quality, Process and Innovation Direction, Vall d’Hebron University Hospital, Passeig de la Vall d’Hebron, 119, 08035 Barcelona, Spain ()
| | - Juan-Manuel Díaz-Gómez
- Nephrology Department, Fundación Puigvert, IIB Sant Pau, Barcelona, Spain
- Medicine Department, Universitat de Vic (UVic-UCC), Vic, Spain
| | - Ignasi Bolíbar Ribas
- Consortium for Biomedical Research in Epidemiology and Public Health-CIBERESP, Barcelona, Spain
- Department of Clinical Epidemiology and Public Health, Hospital de la Santa Creu i Sant Pau Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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Hahn Lundström U, Abrahams AC, Allen J, Altabas K, Béchade C, Burkhalter F, Clause AL, Corbett RW, Eden G, François K, de Laforcade L, Lambie M, Martin H, Pajek J, Panuccio V, Ros-Ruiz S, Steubl D, Vega A, Wojtaszek E, Zaloszyc A, Davies SJ, Van Biesen W, Gudmundsdottir H. Barriers and opportunities to increase PD incidence and prevalence: Lessons from a European Survey. Perit Dial Int 2021; 41:542-551. [PMID: 34409901 DOI: 10.1177/08968608211034988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Peritoneal dialysis (PD) remains underutilised and unplanned start of dialysis further diminishes the likelihood of patients starting on PD, although outcomes are equal to haemodialysis (HD). METHODS A survey was sent to members of EuroPD and regional societies presenting a case vignette of a 48-year-old woman not previously known to the nephrology department and who arrives at the emergency department with established end-stage kidney disease (unplanned start), asking which dialysis modality would most likely be chosen at their respective centre. We assessed associations between the modality choices for this case vignette and centre characteristics and PD-related practices. RESULTS Of 575 respondents, 32.8%, 32.2% and 35.0% indicated they would start unplanned PD, unplanned HD or unplanned HD with intention to educate patient on PD later, respectively. Likelihood for unplanned start of PD was only associated with quality of structure of the pre-dialysis program. Structure of pre-dialysis education program, PD program in general, likelihood to provide education on PD to unplanned starters, good collaboration with the PD access team and taking initiatives to enhance home-based therapies increased the likelihood unplanned patients would end up on PD. CONCLUSIONS Well-structured pre-dialysis education on PD as a modality, good connections to dedicated PD catheter placement teams and additional initiatives to enhance home-based therapies are key to grow PD programs. Centres motivated to grow their PD programs seem to find solutions to do so.
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Affiliation(s)
- Ulrika Hahn Lundström
- Division of Renal Medicine, 206106Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, 8124University Medical Center Utrecht, The Netherlands
| | - Jennifer Allen
- Renal and Transplant Unit, 9820Nottingham University NHS Trust, UK
| | - Karmela Altabas
- Division of Nephrology and Dialysis, Clinical Hospital Center Sestre Milosrdnice, Zagreb, Croatia
| | - Clémence Béchade
- Service Néphrologie-Dialyse-Transplantation, Normandie University, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Felix Burkhalter
- Division of Nephrology, University Clinic of Medicine, 367307Kantonsspital Baselland, Liestal, Switzerland
| | | | - Richard W Corbett
- Renal and Transplant Centre, Hammersmith Hospital, 8946Imperial College Healthcare NHS Trust, London, UK
| | - Gabriele Eden
- Medical Clinic V: Nephrology
- Rheumatology
- Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
| | - Karlien François
- Division of Nephrology and Hypertension, Vrije Universiteit Brussel, 60201Universitair Ziekenhuis Brussel, Brussel, Belgium
| | - Louis de Laforcade
- Service d'Endocrinologie-Néphrologie, 377376Centre Hospitalier Pierre Oudot, Bourgoin-Jallieu, France
| | - Mark Lambie
- Institute of Applied Clinical Sciences, Keele University, Stoke on Trent, UK
| | | | - Jernej Pajek
- Department of Nephrology, 37663University Medical Centre Ljubljana, Slovenia and Medical Faculty, University of Ljubljana, Slovenia
| | - Vincenzo Panuccio
- Nephrology, Dialysis and Renal Transplant Unit, Grande Ospedale Metropolitano 'Bianchi Melacrino Morelli', Reggio Calabria, Italy
| | - Silvia Ros-Ruiz
- Department of Nephrology, Elche University General Hospital, Alicante, Spain
| | - Dominik Steubl
- Department of Nephrology, Faculty of Medicine, 27190Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Almudena Vega
- Department of Nephrology, 16483Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ewa Wojtaszek
- Department of Nephrology, Dialysis and Internal Diseases, 37803The Medical University of Warsaw, Poland
| | - Ariane Zaloszyc
- Department of Pediatrics 1, 27083University Hospital of Strasbourg, Strasbourg, France
| | - Simon J Davies
- Faculty of Medicine and Health Science, Keele University, Stoke on Trent, UK
| | - Wim Van Biesen
- Department of Nephrology, 26656Ghent University Hospital, Belgium
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Van Biesen W, Lameire N. Increasing peritoneal dialysis initiation worldwide: ‘there are none so blind as those who will not see’. Nephrol Dial Transplant 2020; 35:1458-1461. [DOI: 10.1093/ndt/gfaa024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 12/28/2019] [Indexed: 01/01/2023] Open
Affiliation(s)
- Wim Van Biesen
- Renal Division, University Hospital Ghent, Ghent, Belgium
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Scholten N, Ohnhaeuser T, Schellartz I, von Gersdorff G, Hellmich M, Karbach U, Pfaff H, Samel C, Stock S, Rascher K, Mettang T. Multidimensional analysis of factors responsible for the low prevalence of ambulatory peritoneal dialysis in Germany (MAU-PD): a cross-sectional Mixed-Methods Study Protocol. BMJ Open 2019; 9:e025451. [PMID: 31005921 PMCID: PMC6500214 DOI: 10.1136/bmjopen-2018-025451] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Patients with end-stage kidney failure can be treated either by transplant or by dialysis, which can be administered as haemodialysis (HD) or peritoneal dialysis (PD). Although they are equivalent therapeutic options in terms of mortality, the percentage of patients in Germany treated with PD is currently very low (∼6%) compared with other countries. The aim of our study is to analyse the factors behind this percentage and their relevance to the choice of dialysis treatment in Germany. This includes analyses of regional disparities in the provision of care for dialysis patients as well as the evaluations of costs and the influence of reimbursement structures. This approach should provide further insights to explain the variation in the usage of PD and HD and will help to define starting points for future interventions. METHODS AND ANALYSIS A mixed-methods approach will be applied to several data sources, including administrative data (ambulatory physicians' claim data, statutory health insurance claim data), quality assurance data from one of the largest German dialysis providers Kuratorium für Dialyse (KfH) and qualitative and quantitative survey data (patients, nephrologists and dialysis nurses). Qualitative data will be analysed content-analytically. Based on the quantitative data, multivariable analyses will be performed and, where possible, hierarchical models will be tested. This multidimensional approach will enable us to account for the different factors influencing the penetration of PD in Germany. ETHICS AND DISSEMINATION Ethics approval (17-299) has been obtained from the Ethics Committee of the Medical Faculty of the University of Cologne on 25 April 2018. National and international dissemination will be accomplished by informing healthcare practitioners, patients and professional organisations and other stakeholders via conferences, scientific and non-scientific publications and seminars. TRIAL REGISTRATION NUMBER DRKS00012555; Pre-Results.
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Affiliation(s)
- Nadine Scholten
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), University of Cologne, Faculty of Human Sciences and Faculty of Medicine, Cologne, Germany
| | - Tim Ohnhaeuser
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), University of Cologne, Faculty of Human Sciences and Faculty of Medicine, Cologne, Germany
| | - Isabell Schellartz
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), University of Cologne, Faculty of Human Sciences and Faculty of Medicine, Cologne, Germany
| | - Gero von Gersdorff
- Department II of Internal Medicine—QiN Group, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology (IMSB), University of Cologne, Cologne, Germany
| | - Ute Karbach
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), University of Cologne, Faculty of Human Sciences and Faculty of Medicine, Cologne, Germany
| | - Holger Pfaff
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), University of Cologne, Faculty of Human Sciences and Faculty of Medicine, Cologne, Germany
| | - Christina Samel
- Institute of Medical Statistics and Computational Biology (IMSB), University of Cologne, Cologne, Germany
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology (IGKE), University of Cologne, Cologne, Germany
| | - Katherine Rascher
- Department II of Internal Medicine—QiN Group, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Thomas Mettang
- Dr Klaus-Ketzler-Zentrum, KfH-Nierenzentrum, Wiesbaden, Germany
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Impact of Intra-Abdominal Adhesion on Dialysis Outcome in Peritoneal Dialysis Patients. BIOMED RESEARCH INTERNATIONAL 2018; 2018:1978765. [PMID: 30356377 PMCID: PMC6176331 DOI: 10.1155/2018/1978765] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 08/22/2018] [Accepted: 09/05/2018] [Indexed: 11/17/2022]
Abstract
Background Peritoneal dialysis (PD) is an increasingly popular therapeutic option for patients with advanced renal failure. However, intra-abdominal adhesions (IAA) represent a major unsolved problem in adequate PD performance. In this study, we investigated the role of previous abdominal surgery on the presence of subsequent IAA as well as outcomes in those patients with PD who had subsequent IAA. Methods Two hundred and two patients who received continuous ambulatory peritoneal dialysis were prospectively enrolled in this study. We compared the PD adequacy indices and outcomes for technical failure in patients with and without subsequent IAA at presentation and a minimum of 2 years of follow-up. Results Subsequent IAA accounted for 19% (38/202) of patients. Patients who had previous abdominal surgery had higher risks of subsequent IAA especially those patients who had higher mean ages (P=0.023). PD adequacy indices including both 24-hour dialysate volume and peritoneal WCcr L/week/1.73 m2 were significantly lower in patients who had, as compared to those who did not have subsequent IAA (P=0.003 and 0.018, respectively). Although patients who had subsequent IAA had decreased PD adequacy, the development of technical failures during PD maintenance did not show significant differences at the 2-year minimum follow-up study. Conclusions Subsequent IAA is not rare, especially in high-risk patients including those with previous abdominal surgery and higher mean ages. Although decreased PD adequacy after IAA was found, the development of technical failures was not significantly different at the 2-year minimum follow-up study.
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Budhram B, Akbari A, Brown P, Biyani M, Knoll G, Zimmerman D, Edwards C, McCormick B, Bugeja A, Sood MM. End-Stage Kidney Disease in Patients With Autosomal Dominant Polycystic Kidney Disease: A 12-Year Study Based on the Canadian Organ Replacement Registry. Can J Kidney Health Dis 2018; 5:2054358118778568. [PMID: 29977583 PMCID: PMC6024346 DOI: 10.1177/2054358118778568] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 03/31/2018] [Indexed: 01/04/2023] Open
Abstract
Background: Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease, with afflicted patients often progressing to end-stage kidney disease (ESKD) requiring renal replacement therapy (RRT). As the timelines to ESKD are predictable over decades, it follows that ADPKD patients should be optimized regarding kidney transplantation, home dialysis therapies, and vascular access. Objectives: To examine the association of kidney transplantation, dialysis modalities, and vascular access in ADPKD patients compared with a matched, non-ADPKD cohort. Setting: Canadian patients from 2001-2012 excluding Quebec. Patients: All adult incident ESKD patients who received dialysis or a kidney transplant. Measurements: ADPKD as defined by the treating physician. Methods: ADPKD and non-ADPKD patients were propensity score (PS) matched (1:4) using demographics, comorbidities, and lab values. Conditional logistic regression and Cox proportional hazards models were used to examine associations with kidney transplantation (preemptive or any), dialysis modality (peritoneal, short daily, home, or in-center hemodialysis [HD]), vascular access (arteriovenous fistula [AVF], permanent or temporary central venous catheter [CVC]), and dialysis survival. Results: We matched 2120 ADPKD (99.9%) with 8283 non-ADPKD with no significant imbalances between the groups. ADPKD was significantly associated with preemptive kidney transplantation (odds ratio [OR] = 7.13, 95% confidence interval [CI] = 5.74-8.87), any kidney transplant (OR = 2.37, 95% CI = 2.14-2.63), and initial therapy of nocturnal daily HD (OR = 2.74, 95% CI = 1.38-5.44), whereas in-center intermittent HD was significantly less likely in the ADPKD population (OR = 0.59, 95% CI = 0.54-0.65). There was no difference in peritoneal dialysis (PD) as initial RRT but lower use of any PD among the ADPKD group (OR = 0.85, 95% CI = 0.77-0.95). ADPKD patients were significantly more likely to have an AVF (OR = 3.25, 95% CI = 2.79-3.79) and less likely to have either a permanent (OR 0.68, 95% CI 0.59-0.78) or temporary (OR = 0.49, 95% CI = 0.41-0.59) CVC as compared with the non-ADPKD cohort. Survival on either in-center HD or PD was better for ADPKD patients (HD: hazard ratio [HR] 0.48, 95% CI 0.44-0.53; PD: HR 0.73, 95% CI 0.60-0.88). Limitations: Conservative care patients were not captured; despite PS matching, the possibility of residual confounding remains. Conclusions: ADPKD patients were more likely to receive a kidney transplant, use home HD, dialyze with an AVF, and have better survival relative to non-ADPKD patients. Conversely, they were less likely to receive PD either as initial therapy or anytime during ESKD. This may be attributed to higher transplantation or clinical decision-making processes susceptible to education and intervention.
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Affiliation(s)
| | | | | | | | - Gregory Knoll
- University of Ottawa, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,The Ottawa Hospital, ON, Canada
| | | | | | | | | | - Manish M Sood
- University of Ottawa, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,The Ottawa Hospital, ON, Canada
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Wallace EL, Rosner MH, Alscher MD, Schmitt CP, Jain A, Tentori F, Firanek C, Rheuban KS, Florez-Arango J, Jha V, Foo M, de Blok K, Marshall MR, Sanabria M, Kudelka T, Sloand JA. Remote Patient Management for Home Dialysis Patients. Kidney Int Rep 2017; 2:1009-1017. [PMID: 29634048 PMCID: PMC5733746 DOI: 10.1016/j.ekir.2017.07.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/09/2017] [Accepted: 07/24/2017] [Indexed: 12/20/2022] Open
Abstract
Remote patient management (RPM) offers renal health care providers and patients with end-stage kidney disease opportunities to embrace home dialysis therapies with greater confidence and the potential to obtain better clinical outcomes. Barriers and evidence required to increase adoption of RPM by the nephrology community need to be clearly defined. Ten health care providers from specialties including nephrology, cardiology, pediatrics, epidemiology, nursing, and health informatics with experience in home dialysis and the use of RPM systems gathered in Vienna, Austria to discuss opportunities for, barriers to, and system requirements of RPM as it applies to the home dialysis patient. Although improved outcomes and cost-effectiveness of RPM have been demonstrated in patients with diabetes mellitus and heart disease, only observational data on RPM have been gathered in patients on dialysis. The current review focused on RPM systems currently in use, on how RPM should be integrated into future care, and on the evidence needed for optimized implementation to improve clinical and economic outcomes. Randomized controlled trials and/or large observational studies could inform the most effective and economical use of RPM in home dialysis. These studies are needed to establish the value of existing and/or future RPM models among patients, policy makers, and health care providers.
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Affiliation(s)
- Eric L. Wallace
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mitchell H. Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mark Dominik Alscher
- Department of Internal Medicine and Nephrology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Claus Peter Schmitt
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Arsh Jain
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | - Francesca Tentori
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Karen S. Rheuban
- Department of Center for Telehealth, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jose Florez-Arango
- Department of Biomedical Informatics, Texas A & M University, College Station, Texas, USA
- Universidad de Pontificia Bolivariana a Escuela de Ciencias de la Salud, Medellin, Columbia
| | - Vivekanand Jha
- George Institute for Global Health, Syndey, New South Wales, Australia
| | - Marjorie Foo
- Department of Renal Medicine, Duke−National University of Singapore Graduate Medical School, Singapore
| | - Koen de Blok
- Department of Nephrology and Dialysis, Flevo Hospital, Almere, Flevoland, Netherlands
| | - Mark R. Marshall
- Baxter Healthcare (Asia) Pte Ltd, Singapore
- Counties Manukau Health, Auckland, New Zealand
| | - Mauricio Sanabria
- Baxter Healthcare Inc, Deerfield, Illinois, USA
- Renal Therapy Services, Bogota, Colombia
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10
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Walker RC, Howard K, Morton RL. Patient Education and Choice of Peritoneal Dialysis. Am J Kidney Dis 2016; 68:341-3. [DOI: 10.1053/j.ajkd.2016.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 06/13/2016] [Indexed: 11/11/2022]
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Addressing Peritoneal Dialysis: In Vitro PD Models, In Vivo Rodent PD Model, Clinical Biobanks, and Underutilization of PD. BIOMED RESEARCH INTERNATIONAL 2016; 2016:4964316. [PMID: 26881221 PMCID: PMC4735936 DOI: 10.1155/2016/4964316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 11/26/2015] [Indexed: 11/17/2022]
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van de Luijtgaarden MWM, Jager KJ, Segelmark M, Pascual J, Collart F, Hemke AC, Remón C, Metcalfe W, Miguel A, Kramar R, Aasarød K, Abu Hanna A, Krediet RT, Schön S, Ravani P, Caskey FJ, Couchoud C, Palsson R, Wanner C, Finne P, Noordzij M. Trends in dialysis modality choice and related patient survival in the ERA-EDTA Registry over a 20-year period. Nephrol Dial Transplant 2015; 31:120-8. [PMID: 26311215 DOI: 10.1093/ndt/gfv295] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 07/09/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although previous studies suggest similar patient survival for peritoneal dialysis (PD) and haemodialysis (HD), PD use has decreased worldwide. We aimed to study trends in the choice of first dialysis modality and relate these to variation in patient and technique survival and kidney transplant rates in Europe over the last 20 years. METHODS We used data from 196 076 patients within the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry who started renal replacement therapy (RRT) between 1993 and 2012. Trends in the incidence rate and prevalence on Day 91 after commencing RRT were quantified with Joinpoint regression. Crude and adjusted hazard ratios (HRs) for 5-year dialysis patient and technique survival were calculated using Cox regression. Analyses were repeated using propensity score matching to control for confounding by indication. RESULTS PD prevalence dropped since 2007 and HD prevalence stabilized since 2009. Incidence rates of PD and HD decreased from 2000 and 2009, respectively, while the incidence of kidney transplantation increased from 1993 onwards. Similar 5-year patient survival for PD versus HD patients was found in 1993-97 [adjusted HR: 1.02, 95% confidence interval (95% CI): 0.98-1.06], while survival was higher for PD patients in 2003-07 (HR: 0.91, 95% CI: 0.88-0.95). Both PD (HR: 0.95, 95% CI: 0.91-1.00) and HD technique survival (HR: 0.93, 95% CI: 0.87-0.99) improved in 2003-07 compared with 1993-97. CONCLUSIONS Although initiating RRT on PD was associated with favourable patient survival when compared with starting on HD treatment, PD was often not selected as initial dialysis modality. Over time, we observed a significant decline in PD use and a stabilization in HD use. These observations were explained by the lower incidence rate of PD and HD and the increase in pre-emptive transplantation.
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Affiliation(s)
- Moniek W M van de Luijtgaarden
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Mårten Segelmark
- Department of Nephrology, Linköping University, Linköping, Sweden Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | | | | | - César Remón
- SICATA (The Information System of the Andalusian Transplant Autonomic Coordination Registry), Andalusia, Spain
| | | | - Alfonso Miguel
- Department of Nephrology, University Clinic Hospital, Valencia, Spain
| | - Reinhard Kramar
- OEDTR, Austrian Dialysis and Transplant Registry, Linz, Austria
| | - Knut Aasarød
- Department of Nephrology, St Olavs Hospital HF, Trondheim, Norway
| | - Ameen Abu Hanna
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Raymond T Krediet
- Division of Nephrology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Pietro Ravani
- Department of Medicine and Community Health Science, University of Calgary, Calgary, Alberta, Canada
| | | | - Cecile Couchoud
- REIN Registry, Biomedicine Agency, La Plaine-Saint Denis, France
| | - Runolfur Palsson
- Division of Nephrology, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Christoph Wanner
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
| | - Patrik Finne
- Finnish Registry for Kidney Diseases, Helsinki, Finland
| | - Marlies Noordzij
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Lee YK, Yang PS, Park KS, Choi KH, Kim BS. Modified Peritoneal Dialysis Catheter Insertion: Comparison with a Conventional Method. Yonsei Med J 2015; 56:981-6. [PMID: 26069120 PMCID: PMC4479866 DOI: 10.3349/ymj.2015.56.4.981] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The conventional trocar and cannula method in peritoneal dialysis (PD) catheter insertion has its limitation in clinical setting. The aim of this study was to compare a modified method for percutaneous PD catheter insertion with the conventional method, and demonstrate advantages of the modified method. MATERIALS AND METHODS Patients at a single center who had percutaneous PD catheters inserted by nephrologists from January 2006 until September 2012, using either a modified method (group M) or the conventional trocar and cannula method (group C), were retrospectively analyzed, in terms of baseline characteristics, complications experienced up to 3 months after the procedure, and the suitability of the procedure for patients. RESULTS Group M included 82 subjects, while group C included 66 cases. The overall early complication rate in group M (1.2%) was significantly lower than that in group C (19.7%) (p<0.001). The catheter revision rate during timeframe for early complications was significantly lower in group M (0%) than in group C (6.1%) (p=0.024). When comparing Procedure time (1 h 3 min±16 min vs. 1 h 36 min±19 min, p<0.01), immediate post-procedural pain (2.43±1.80 vs. 3.14±2.07, p<0.05), and post-procedure days until ambulation (3.95±1.13 days vs. 6.17±1.34 days, p<0.01), group M was significantly lower than group C. There was no significant difference in total hospitalization period (14.71±7.05 days vs. 13.86±3.7 days). CONCLUSION Our modified PD catheter insertion method shows its advantages in early complication rate, early complications revision rate, and the patients' conveniences.
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Affiliation(s)
- Yong Kyu Lee
- Department of Internal Medicine, NHIC, Ilsan Hospital, Goyang, Korea
| | - Pil-Sung Yang
- Division of Nephrology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Kyoung Sook Park
- Division of Nephrology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Kyu Hun Choi
- Division of Nephrology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Beom Seok Kim
- Division of Nephrology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea.
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14
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Ferguson TW, Tangri N, Rigatto C, Komenda P. Cost-effective treatment modalities for reducing morbidity associated with chronic kidney disease. Expert Rev Pharmacoecon Outcomes Res 2015; 15:243-52. [DOI: 10.1586/14737167.2015.1012069] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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Patients' perceptions of information and education for renal replacement therapy: an independent survey by the European Kidney Patients' Federation on information and support on renal replacement therapy. PLoS One 2014; 9:e103914. [PMID: 25079071 PMCID: PMC4117591 DOI: 10.1371/journal.pone.0103914] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 07/03/2014] [Indexed: 11/29/2022] Open
Abstract
Background Selection of an appropriate renal replacement modality is of utmost importance for patients with end stage renal disease. Previous studies showed provision of information to and free modality choice by patients to be suboptimal. Therefore, the European Kidney Patients’ Federation (CEAPIR) explored European patients’ perceptions regarding information, education and involvement on the modality selection process. Methods CEAPIR developed a survey, which was disseminated by the national kidney patient organisations in Europe. Results In total, 3867 patients from 36 countries completed the survey. Respondents were either on in-centre haemodialysis (53%) or had a functioning graft (38%) at the time of survey. The majority (78%) evaluated the general information about kidney disease and treatment as helpful, but 39% did not recall being told about alternative treatment options than their current one. Respondents were more often satisfied with information provided on in-centre haemodialysis (90%) and transplantation (87%) than with information provided on peritoneal dialysis (79%) or home haemodialysis (61%), and were more satisfied with information from health care professionals vs other sources such as social media. Most (75%) felt they had been involved in treatment selection, 29% perceived they had no free choice. Involvement in modality selection was associated with enhanced satisfaction with treatment (OR 3.13; 95% CI 2.72–3.60). Many respondents (64%) could not remember receiving education on how to manage their kidney disease in daily life. Perceptions on information seem to differ between countries. Conclusions Kidney patients reported to be overall satisfied with the information they received on their disease and treatment, although information seemed mostly to have been focused on one modality. Patients involved in modality selection were more satisfied with their treatment. However, in the perception of the patients, the freedom to choose an alternative modality showed room for improvement.
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16
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Nesrallah G, Manns B. Do socioeconomic factors affect dialysis modality selection? Clin J Am Soc Nephrol 2014; 9:837-9. [PMID: 24763869 DOI: 10.2215/cjn.02750314] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Gihad Nesrallah
- Li Ka Shing Knowledge Institute, Keenan Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada;, †Nephrology Program, Humber River Hospital, Toronto, Ontario, Canada;, ‡Ontario Renal Network, Toronto, Ontario, Canada;, §Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada, ‖Libin Cardiovascular Institute and Institute of Population Health, Alberta Foothills Medical Centre, Calgary, Alberta, Canada
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Nesrallah GE, Mendelssohn DC. Reflections on education interventions and optimal dialysis starts. Perit Dial Int 2014; 33:358-61. [PMID: 23843588 DOI: 10.3747/pdi.2013.00077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Osterlund K, Mendelssohn D, Clase C, Guyatt G, Nesrallah G. Identification of Facilitators and Barriers to Home Dialysis Selection by Canadian Adults with ESRD. Semin Dial 2014; 27:160-72. [DOI: 10.1111/sdi.12183] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Katherine Osterlund
- The Lawson Health Research Institute; Western University; London Ontario Canada
| | - David Mendelssohn
- Department of Nephrology; Humber River Hospital; Toronto Ontario Canada
| | - Catherine Clase
- Department of Health Research Methodology; McMaster University; Hamilton Ontario Canada
| | - Gordon Guyatt
- Department of Health Research Methodology; McMaster University; Hamilton Ontario Canada
| | - Gihad Nesrallah
- Department of Nephrology; Humber River Hospital; Toronto Ontario Canada
- The Li Ka Shing Knowledge Institute; Keenan Research Centre; St. Michael's Hospital; Toronto Ontario Canada
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Sood MM, Tangri N, Hiebert B, Kappel J, Dart A, Levin A, Manns B, Molzahn A, Naimark D, Nessim SJ, Rigatto C, Soroka SD, Zappitelli M, Komenda P. Geographic and facility-level variation in the use of peritoneal dialysis in Canada: a cohort study. CMAJ Open 2014; 2:E36-44. [PMID: 25077124 PMCID: PMC3985977 DOI: 10.9778/cmajo.20130050] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Peritoneal dialysis is associated with similar survival and similar improvement in quality of life and is less costly compared with in-centre hemodialysis. We examined facility and geographic variation in the use of peritoneal dialysis in Canada. METHODS We analyzed data from the Canadian Organ Replacement Register for the period January 2001 to December 2010. We identified patients for whom peritoneal dialysis was the primary modality at 90 days after initiation of dialysis. We used multilevel models to evaluate variation in use of peritoneal dialysis by facility and geographic region. RESULTS We analyzed data for 31 778 incident dialysis patients at 56 facilities in 13 geographic regions across Canada. Use of peritoneal dialysis at 90 days varied considerably across geographic regions (range 19.8%-36.1%) and declined over time, from 28.8% in 2001 to 22.5% in 2010. After adjustment for case mix and facility-level quality indicators, 9.3% and 3.4% of the variability was attributable to facility and geographic factors, respectively. In adjusted models, there was a substantial difference between geographic regions with the lowest and highest peritoneal dialysis use (odds ratio for high use 1.51, 95% confidence interval [CI] 1.33-1.73 v. odds ratio for low use 0.69, 95% CI 0.60-0.79). INTERPRETATION In Canada, substantial variability in the use of peritoneal dialysis attributable to facility and geographic region was not explained by differences in patient case mix. An opportunity exists to optimize use of this cost-effective therapy through changes in policy and standardization of criteria for initiation of peritoneal dialysis.
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Affiliation(s)
- Manish M Sood
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ont
| | - Navdeep Tangri
- Seven Oaks Hospital, University of Manitoba, Winnipeg, Man
| | - Brett Hiebert
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Man
| | - Joanne Kappel
- Saskatoon Health Region, University of Saskatchewan, Saskatoon, Sask
| | - Allison Dart
- Health Sciences Centre, University of Manitoba, Winnipeg, Man
| | - Adeera Levin
- St Paul's Hospital, University of British Columbia, Vancouver, BC
| | - Braden Manns
- Foothills Hospital, University of Calgary, Calgary, Alta
| | - Anita Molzahn
- Faculty of Nursing, University of Alberta, Edmonton, Alta
| | - David Naimark
- Sunnybrook Hospital, University of Toronto, Toronto, Ont
| | | | | | | | | | - Paul Komenda
- Seven Oaks Hospital, University of Manitoba, Winnipeg, Man
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20
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Li PKT, Chow KM. Peritoneal Dialysis–First Policy Made Successful: Perspectives and Actions. Am J Kidney Dis 2013; 62:993-1005. [DOI: 10.1053/j.ajkd.2013.03.038] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 03/19/2013] [Indexed: 12/31/2022]
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21
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Abdelsalam MS, Althaf MM, Albaqumi MN, Alfurayh O, Korbi L, Ul Haq N. Peritoneal dialysis catheter placement with peritoneoscopic technique and successful initiation of peritoneal dialysis in a patient with diastasis recti. Semin Dial 2013; 27:E1-3. [PMID: 24028085 DOI: 10.1111/sdi.12139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Preserved anatomical integrity of the anterior abdominal wall is considered important in the presurgical evaluation of a patient who is being considered for placement of a peritoneal dialysis (PD) catheter. Diastasis recti abdominis (DRA) is the excessive widening or separation between the two bellies of the rectus abdominis muscle. The separation can occur anywhere along the linea alba and at times has been found to span the entire length from the xiphosternal angle to the pubic bone. Presence of DRA can pose a surgical challenge in the peritoneoscopic placement of peritoneal dialysis catheter. In this report, we discuss a case of successful placement of peritoneal dialysis catheter with peritoneoscope technique and successful initiation of peritoneal dialysis in a chronic kidney disease patient with DRA.
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Affiliation(s)
- Mohamed Said Abdelsalam
- Department of Medicine, Section of Nephrology, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia; Department of Internal Medicine, Alexandria University, Alexandria, Egypt
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22
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Puttinger H. [Peritoneal dialysis--an ideal initial dialysis mode]. Wien Med Wochenschr 2013; 163:271-9. [PMID: 23817731 DOI: 10.1007/s10354-013-0200-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 03/26/2013] [Indexed: 11/25/2022]
Abstract
Peritoneal dialysis (PD) has become an established dialysis modality besides hemodialysis (HD). Although PD is an equal form of dialysis compared to HD, patients numbers on PD remain low worldwide. There are several reasons for this fact. The medical staff in some centers is not used to PD, so there is not enough information about the different dialysis methods available for the patients and the staff doesn't get the training that would be necessary to get familiar with PD. There are some concerns about offering PD to certain groups of patients despite excellent results as to quality of dialysis, good preservation of residual renal function, low costs compared to HD and better quality of life than on HD. However, PD should be offered to all patients requiring dialysis with very few exeptions as an ideal initial dialysis method. This includes patients with diabetes, patients with kidney transplant failure, patients with congestive heart failure and older patients.
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Affiliation(s)
- Heidi Puttinger
- Klinische Abteilung für Nephrologie und Dialyse, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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