Effectiveness of multidisciplinary care for chronic kidney disease in Taiwan: a 3-year prospective cohort study

Major adverse kidney events in multidisciplinary chronic kidney disease care compared with usual outpatient care: a propensity score matched analysis

BACKGROUND

Chronic kidney disease (CKD) is a public health problem worldwide. Multidisciplinary care has been recommended in clinical practice to delay disease progression and minimize complications. However, the effectiveness of multidisciplinary care on major adverse kidney events in CKD patients is still inconclusive.

METHODS

We conducted a cohort study in patients with CKD stages G3b to 4 who were followed up at Bhumibol Adulyadej Hospital from 2014 to 2020. Propensity score matching by age, sex, CKD staging, Diabetes Mellitus (DM), blood pressure and rate of estimated Glomerular Filtration Rate (eGFR) decline before inclusion between patients in multidisciplinary CKD care (MDC) and usual outpatient care (UOC) was performed. The primary outcome was a composite of cardiovascular or renal mortality, 40% eGFR decline and initiation of long-term kidney replacement therapy.

RESULTS

After 1:1 propensity score matching, 822 patients were included. Mean age was 70.9 years, 64% had diabetes. During the mean follow-up of 3.3 years, rate of reaching the primary endpoint was lower in the multidisciplinary CKD care group than in the usual outpatient care group (24.1% vs. 38.9%; hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.52-0.86; P = 0.002). The multidisciplinary CKD care group benefited more than the usual outpatient care group with regard to 40% eGFR decline (21.7% vs. 35.0%; HR, 0.67; 95%CI 0.52-0.88; P = 0.004), all-cause mortality (8.5% vs. 19.5%; HR, 0.60; 95%CI 0.40-0.90; P = 0.014), non-cardiovascular death (6.1% vs. 15.1%; HR, 0.56; 95%CI 0.35-0.90; P = 0.015) and hospitalizations per year (1.0 ± 1.5 vs. 1.6 ± 2.0; P < 0.001). According to subgroup analysis, diabetes mellitus patients benefited the most from multidisciplinary CKD care.

CONCLUSIONS

In a tertiary care hospital, multidisciplinary CKD care showed benefits over usual outpatient care on kidney outcomes in patients with CKD stages G3b and 4. The benefit was enhanced in DM patients.

Interprofessional Differences in Multidimensional Self-Efficacy Associated With Professional Performance in Nephrology During Case-Based Learning

Introduction

Postgraduate medical education assumes rising importance in the rapidly advancing field of medicine. Case-based learning (CBL), a learner-centered pedagogy employing clinical cases to improve decision-making, is widely embraced in postgraduate medical education, including nephrology. Studies suggest that learning self-efficacy (SE) was closely associated with learning motivation and academic performance; however, very few studies examined this association in postgraduate nephrology education. None evaluated whether there were interprofessional differences concerning such association.

Methods

In 2022, we prospectively enrolled physicians and nurses participating in chronic kidney disease (CKD) care from institutions around Taiwan. They completed the Professional Medical Learning Self-efficacy (PMLS) questionnaire after attending >1 CBL session involving CKD care. We undertook confirmatory factor analysis (CFA), followed by structural equation modeling (SEM) to evaluate associations between 5 dimensions of learning SE (conceptual understanding [CU], higher-order cognitive skills [HC], practical work [PW], everyday application [EA], and medical science communication [MSC]) and their professional SE in nephrology according to participants' medical professions.

Results

A total of 513 healthcare providers were surveyed. The convergent and construct validity of our questionnaire were satisfied after analyses. We found that better perceived professional performance in the form of higher professional SE in nephrology was significantly associated with all 5 dimensions of learning SE among physicians and nurses. Only CU and PW were significantly associated with physicians' professional performance; whereas among nurses, only HC and MSC were significantly associated.

Conclusion

We showed that learning SE was an important determinant of nephrology professional performance. Different medical professions posed influences on major SE dimensions.

Effect of multidisciplinary care on diabetic kidney disease: a retrospective cohort study

BACKGROUND

Diabetic kidney disease (DKD) is the most common disease among patients requiring dialysis for the first time in Japan. Multidisciplinary care (MDC) may prevent the progression of kidney failure. However, the effectiveness and timing of MDC to preserve kidney function in patients with DKD is unclear. Therefore, the aim of this study was to investigate whether MDC for patients with DKD affects the preservation of kidney function as well as the timing of MDC in clinical practice.

METHODS

In this retrospective cohort study, we identified patients with type 2 diabetes mellitus and DKD from April 2012 to January 2020 using a nationwide Japanese healthcare record database. The fee code for medical guidance to prevent dialysis in patients with diabetes was used to distinguish between the MDC and non-MDC groups. The primary outcome was a 40% decline in the estimated glomerular filtration rate, and secondary outcomes were death, hospitalization, permanent dialysis, kidney failure with replacement therapy, and emergency temporary catheterization. Propensity score matching was performed, and Kaplan-Meier and multivariable Cox regression analyses were performed.

RESULTS

Overall, 9,804 eligible patients met the inclusion criteria, of whom 5,614 were matched for the main analysis: 1,039 in the MDC group, and 4,575 in the non-MDC group. The primary outcome did not differ between the groups (hazard ratio: 1.18, [95% confidence interval: 0.99-1.41], P = 0.07). The groups also did not differ in terms of the secondary outcomes. Most patients with DKD received their first MDC guidance within 1 month of diagnosis, but most received guidance only once per year.

CONCLUSIONS

Although we could not demonstrate the effectiveness of MDC on kidney function in patients with DKD, we clarified the characteristics of such patients assigned the fee code for medical guidance to prevent dialysis related to diabetes.

Prevalence and varieties of complementary and alternative medicine usage among individuals with pre-dialysis chronic kidney disease in Taiwan: an investigative cross-sectional analysis

BACKGROUND

Complementary and alternative medicine (CAM) is frequently used in the general population, yet only limited data are available regarding the prevalence of these medications in patients with chronic kidney disease (CKD). Hence, our study aimed to explore the prevalence and types of CAM in Taiwanese patients with CKD.

METHODS

A cross-sectional questionnaire survey was conducted by face-to-face interview of 275 pre-dialysis patients without dialysis treatment or kidney transplant at an outpatient nephrology clinic in Taiwan from March 2021 to June 2023. The study outcomes were the prevalence of CAM, CAM types, reasons for using CAM, and sources of information about CAM.

RESULTS

Overall, 128 patients (46.5%) were using CAM, but no significant differences from non-CAM users in the various CKD stages (p = 0.156) were found. CAM usage was high in the age range of 20-60 years and duration of CKD ≤ 5 years (p < 0.05). The most commonly used type of CAM was nutritional approaches (79.7%), followed by other complementary health approaches (26.6%). The most commonly utilized modalities of CAM were vitamins and minerals (38.3%), and only 27.1% of patients disclosed their CAM use to their physicians. The most common sources of information about CAM were family and friends, cited by 66% of the participants. Health promotion and a proactive attitude were reported by 40% of users as the reasons for using CAM.

CONCLUSIONS

The present study provides data on the CAM usage among CKD patients and adds to the increasing evidence on CAM use. Because some of these practices have safety concerns, better education from healthcare providers on the risks and benefits of CAM therapy is needed by CKD patients.

Ellagic acid ameliorates renal fibrogenesis by blocking epithelial-to-mesenchymal transition

Objectives

Ellagic acid (EA), a kind of polyphenol found in numerous fruits and vegetables, has anti-inflammatory, anti-apoptotic, anti-oxidant, and anti-fibrotic effects against a variety of diseases, but its role in mediating renal fibrogenesis remains unknown.

Materials and Methods

We used an in vivo mouse unilateral ureteral obstruction (UUO) model and an in vitro model with HK-2 cell lines treated with EA and transforming growth factor β1 (TGF-β1). The expression of epithelial-to-mesenchymal transition (EMT)-related proteins of UUO mice was examined using immunohistochemical staining. Liver function and renal function were evaluated using biochemical testing. Western blot analysis was used to determine the proteins related to EMT, and MTT assay was used to determine cell viability.

Results

In UUO mice fed EA, both microscopical examination with immunohistochemical staining and western blotting protein analysis showed reduced expression of fibrotic (α-SMA, fibronectin, and collagen I)- and EMT (vimentin and N-cadherin)-related proteins, compared with sham control. In HK-2 cells treated with TGF-β1, EA decreased motility as well as expression of α-SMA, collagen-I, fibronectin, N-cadherin, and vimentin.

Conclusion

EA reduced the progression of the morphological transformations and concomitantly suppressed the expression of fibrotic- and EMT-related proteins in vitro and in vivo. These findings improved our understanding of the role of EA in suppressing renal fibrogenesis and demonstrated the promising role EA may play in the management of chronic kidney disease.

Alpha-mangostin alleviate renal interstitial fibrosis via suppression of TGF-β1/Smad/ERK signaling axis in vitro and in vivo

α-mangostin (α-MG), a natural derivative of coumarin, exhibits anti-inflammatory, antioxidant and anti-fibrotic effects. This study aimed to determine the effect of α-MG treatment in mediating the process of renal interstitial fibrosis. We found that α-MG could alleviate tubule-interstitial damage and decrease fibrotic (α-smooth muscle actin [α-SMA], fibronectin, and collagen I), and epithelial-mesenchymal transition (EMT) protein (N-cadherin, Snail, Slug, TGF-β1 and vimentin) expression in unilateral ureteral obstruction (UUO) mice with chronic kidney disease. α-MG significantly decreased motility as well as inhibited expression of fibrotic- and EMT-related proteins in TGF-β1-induced HK2 cells. To clarify the molecular mechanisms of α-MG in reducing renal interstitial fibrosis, we used a MEK inhibitor (U0126) or Smad inhibitor (SB431542) cotreatment with α-MG. This is the first study is to demonstrate the antifibrotic effects of α-MG by targeting the TGF-β1/ERK/Smad-mediated EMT signaling pathway, is even more effective against renal interstitial fibrosis.

Patient Care Gaps Prior to Maintenance Dialysis Initiation: A Population-Based Retrospective Study

Background

Guidelines in Ontario, Canada, recommend timely referral for multidisciplinary kidney care to facilitate planned dialysis initiation. Many patients do not receive recommended multidisciplinary kidney care prior to dialysis.

Objective

To better understand why this gap in pre-dialysis care exists, we conducted a study to describe the pathways by which patients initiate maintenance dialysis.

Design

A retrospective cohort study.

Setting

Population-based, using health care administrative databases from Ontario, Canada.

Patients

Adults initiating maintenance dialysis from April 2016 to March 2019.

Measurements and methods

Patients were grouped based on whether they received recommended multidisciplinary kidney care prior to dialysis initiation (at least 1 year of care with at least 2 visits). For those who did not receive recommended care, we grouped patients as having no identified care gap or into the following groups: (1) lack of timely chronic kidney disease (CKD) screening, (2) late nephrology referral (<1 year), or (3) late or no referral for multidisciplinary kidney care among patients followed by a nephrologist for at least 1 year.

Results

A total of 9216 patients were included with a mean (standard deviation) age of 66 (15) years, and 61.5% were male. Of the total, 896 (9.7%) patients died, 7671 (83.2%) remained on dialysis at 90 days, and 649 (7.0%) had stopped dialysis due to kidney function recovery within 90 days. Of the 9216 patients, 5434 (59%) had not received recommended multidisciplinary kidney care. Among those without recommended care, there were 2251 (41.4%) patients with no identified care gaps, 1351 (24.9%) patients with a lack of timely CKD screening, 359 (6.6%) patients with late nephrology referral, and 1473 (27.1%) patients with late or no referral for multidisciplinary kidney care.

Limitations

We could not determine if patients were referred but declined multidisciplinary kidney care.

Conclusions

More than half of patients had not received recommended multidisciplinary kidney care. Many patients experienced an acute decline in kidney function, which may not be preventable, but in others, there were missed opportunities for CKD screening or early referral to nephrology, or at the level of nephrology practice for early referral for multidisciplinary care. This work could be used to inform policies aimed at improving increased uptake of multidisciplinary kidney care prior to dialysis.

Change in Liver Fibrosis Associates with Progress of Diabetic Nephropathy in Patients with Nonalcoholic Fatty Liver Disease

Diabetic nephropathy (DN) is a major complication of diabetes. Nonalcoholic fatty liver disease (NAFLD) is common in diabetes, and liver fibrosis is a prognostic risk factor for NAFLD. The interaction between DN and liver fibrosis in NAFLD remains unclear. In 189 patients with DN and NAFLD who received an education course about diabetic nephropathy, liver fibrosis was evaluated using the fibrosis-4 (FIB-4) index. The association between the outcome of DN and changes in liver fibrosis was examined. The FIB-4 index was maintained at the baseline level in patients with improved DN, while it was increased in other patients. The ΔFIB-4 index was positively correlated with changes in albuminuria and proteinuria (ρ = 0.22, p = 0.004). In a multivariate analysis, changes in albuminuria and proteinuria were associated with the ΔFIB-4 index (p = 0.002). Patients with a progressive FIB-4 index category from baseline to 5 years showed a lower event-free survival rate after 5 years than patients with an improved FIB-4 index category (p = 0.037). The outcome of DN is associated with changes in liver fibrosis in patients with diabetes, NAFLD and DN. Developing a preventive and therapeutic approach for these conditions is required.

Inpatient multidisciplinary care can prevent deterioration of renal function in patients with chronic kidney disease: a nationwide cohort study

Background

Multidisciplinary care is necessary to prevent worsening renal function and all-cause mortality in patients with chronic kidney disease (CKD) but has mostly been investigated in the outpatient setting. In this study, we evaluated the outcome of multidisciplinary care for CKD according to whether it was provided in an outpatient or inpatient setting.

Methods

This nationwide, multicenter, retrospective, observational study included 2954 Japanese patients with CKD stage 3-5 who received multidisciplinary care in 2015-2019. Patients were divided into two groups: an inpatient group and an outpatient group, according to the delivery of multidisciplinary care. The primary composite endpoint was the initiation of renal replacement therapy (RRT) and all-cause mortality, and the secondary endpoints were the annual decline in the estimated glomerular filtration rate (ΔeGFR) and the changes in proteinuria between the two groups.

Results

Multidisciplinary care was provided on an inpatient basis in 59.7% and on an outpatient basis in 40.3%. The mean number of health care professionals involved in multidisciplinary care was 4.5 in the inpatient group and 2.6 in the outpatient group (P < 0.0001). After adjustment for confounders, the hazard ratio of the primary composite endpoint was significantly lower in the inpatient group than in the outpatient group (0.71, 95% confidence interval 0.60-0.85, P = 0.0001). In both groups, the mean annual ΔeGFR was significantly improved, and proteinuria significantly decreased 24 months after the initiation of multidisciplinary care.

Conclusion

Multidisciplinary care may significantly slow deterioration of eGFR and reduce proteinuria in patients with CKD and be more effective in terms of reducing initiation of RRT and all-cause mortality when provided on an inpatient basis.

Effectiveness and current status of multidisciplinary care for patients with chronic kidney disease in Japan: a nationwide multicenter cohort study

Background

Multidisciplinary care is well established in clinical practice, but its effectiveness in patients with chronic kidney disease (CKD) remains unclear. The aim of this study was to determine whether multidisciplinary care could help to avoid worsening kidney function in patients with CKD.

Methods

This nationwide study had a multicenter retrospective observational design and included 3015 Japanese patients with CKD stage 3–5 who received multidisciplinary care. We assessed the annual decrease in estimated glomerular filtration rate (ΔeGFR) and urinary protein in the 12 months before and 24 months after the start of multidisciplinary care. All-cause mortality and initiation of renal replacement therapy were investigated according to baseline characteristics.

Results

Most of the patients had CKD stage 3b or higher and a median eGFR of 23.5 mL/min/1.73 m2. The multidisciplinary care teams consisted of health care professionals from an average of four disciplines. ΔeGFR was significantly smaller at 6, 12, and 24 months after initiation of multidisciplinary care (all P < 0.0001), regardless of the primary cause of CKD and its stage when multidisciplinary intervention was started. Urinary protein level also decreased after initiation of multidisciplinary care. After a median follow-up of 2.9 years, 149 patients had died and 727 had started renal replacement therapy.

Conclusion

Multidisciplinary care may significantly slow the decline in eGFR in patients with CKD and might be effective regardless of the primary disease, including in its earlier stages. Multidisciplinary care is recommended for patients with CKD stage 3–5.

Trial registration

UMIN00004999.

Adherence to multidisciplinary care in a prospective chronic kidney disease cohort is associated with better outcomes

INTRODUCTION

The Renal Healthcare Program Uruguay (NRHP-UY) is a national, multidisciplinary program that provides care to chronic kidney disease (CKD) patients. In this study, we report the global results of CKD patient outcomes and a comparison between those treated at the NRHP-UY Units, with those patients who were initially included in the program but did not adhere to follow up.

METHODS

A cohort of not-on dialysis CKD patients included prospectively in the NRHP-UY between October 1st 2004 and September 30th 2017 was followed-up until September 30th 2019. Two groups were compared: a) Nephrocare Group: Patients who had at least one clinic visit during the first year on NRHP-UY (n = 11174) and b) Non-adherent Group: Patients who were informed and accepted to be included but had no subsequent data registered after admission (n = 3485). The study was approved by the Ethics Committee and all patients signed an informed consent. Outcomes were studied with Logistic and Cox´s regression analysis, Fine and Gray competitive risk and propensity-score matching tests.

RESULTS

14659 patients were analyzed, median age 70 (60-77) years, 56.9% male. The Nephrocare Group showed improved achievement of therapeutic goals, ESKD was more frequent (HR 2.081, CI 95%1.722-2.514) as planned kidney replacement therapy (KRT) start (OR 2.494, CI95% 1.591-3.910), but mortality and the combined event (death and ESKD) were less frequent (HR 0.671, CI95% 0.628-0.717 and 0.777, CI95% 0.731-0.827) (p = 0.000) compared to the Non-adherent group. Results were similar in the propensity-matched group: ESKD (HR 2.041, CI95% 1.643-2.534); planned kidney replacement therapy (KRT) start (OR 2.191, CI95% 1.322-3.631) death (HR 0.692, CI95% 0.637-0.753); combined event (HR 0.801, CI95% 0.742-0.865) (p = 0.000).

CONCLUSION

Multidisciplinary care within the NRHP-UY is associated with timely initiation of KRT and lower mortality in single outcomes, combined analysis, and propensity-matched analysis.

Effect of a Pay-for-Performance Program on Renal Outcomes Among Patients With Early-Stage Chronic Kidney Disease in Taiwan

BACKGROUND

With the promising outcomes of the pre-ESRD (end-stage renal disease) pay-for-performance (P4P) program, the National Health Insurance Administration (NHIA) of Taiwan launched a P4P program for patients with early chronic kidney disease (CKD) in 2011, targeting CKD patients at stages 1, 2, and 3a. This study aimed to examine the long-term effect of the early-CKD P4P program on CKD progression.

METHODS

We conducted a matched cohort study using electronic medical records from a large healthcare delivery system in Taiwan. The outcome of interest was CKD progression to estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2 between P4P program enrolees and non-enrolees. The difference in the cumulative incidence of CKD progression between the P4P and non-P4P groups was tested using Gray's test. We adopted a cause-specific (CS) hazard model to estimate the hazard in the P4P group as compared to non-P4P group, adjusting for age, sex, baseline renal function, and comorbidities. A subgroup analysis was further performed in CKD patients with diabetes to evaluate the interactive effects between the early-CKD P4P and diabetes P4P programs.

RESULTS

The incidence per 100 person-months of disease progression was significantly lower in the P4P group than in the non-P4P group (0.44 vs. 0.69, P<.0001), and the CS hazard ratio (CS-HR) for P4P program enrolees compared with non-enrolees was 0.61 (95% CI: 0.58-0.64, P<.0001). The results of the subgroup analysis further revealed an additive effect of the diabetes P4P program on CKD progression; compared to none of both P4P enrolees, the CS-HR for CKD disease progression was 0.60 (95% CI: 0.54-0.67, P<.0001) for patients who were enrolled in both early-CKD P4P and diabetes P4P programs.

CONCLUSION

The present study results suggest that the early-CKD P4P program is superior to usual care to decelerate CKD progression in patients with early-stage CKD.

Impact of integrated health care on elderly population: A systematic review of Taiwan's experience

BACKGROUND

Care fragmentation in the elderly population prompted the need for integrated health care systems. However, evidence regarding the impact of the integrated care system in Taiwan is unclear. We aimed to conduct a systematic review to evaluate the impact of Taiwan's integrated health care programs on geriatric population.

METHODS

We searched bibliographic databases MEDLINE, Embase, Web of Science, and Airiti Library for relevant publications throughout May 2022. Studies investigating the effectiveness of Taiwan's integrated care programs were included. We used the critical appraisal skills programme (CASP) checklist, to assess the risk of bias of included studies.

RESULTS

Thirty-four studies, with a total of 838,026 study subjects, were assessed. The systematic review on 11 subthemes (diabetes mellitus, chronic kidney disease, hepatitis C virus, fractures, cancer, dementia, atrial fibrillation, chronic obstructive pulmonary disease, mechanical ventilation, terminal illness, outpatients and community-dwelling patients), demonstrated that the implementation of integrated health care could not only provide benefits on survival, self-care ability, health quality, physical, and functional rehabilitation outcomes, but also significantly reduce medical utilization and expenditures.

CONCLUSION

The integrated health care system for multiple morbidities benefits the Taiwanese geriatric population in physical and functional outcomes. The thematic synthesis provides references for future rigorous clinical trials.

CKD Care Programs and Incident Kidney Failure: A Study of a National Disease Management Program in Taiwan

Rationale & Objective

Taiwan implemented national pay-for-performance programs for chronic kidney disease (CKD) care in 2006 and 2011; however, it is unknown whether this affected trends in maintenance dialysis. This study assessed the temporal trends in the incidence, prevalence, and mortality of individuals treated with maintenance dialysis from 2002-2016 in Taiwan.

Study Design

Follow-up study using Taiwan Renal Disease System Databases.

Setting & Participants

Participants who received dialysis for ≥90 days.

Predictors

Age, sex, and calendar year.

Outcomes

Incidence, prevalence of maintenance dialysis, or death, ascertained using the National Death Registry database.

Analytical Approach

The estimated annual percentage change was assessed by a generalized linear model, and the association of the programs with changes in the incidence of maintenance dialysis was evaluated using an age-period-cohort model.

Results

A total of 144,258 incident cases with a follow-up of 346 million person-years were analyzed during the observed periods. The estimated annual percentage change of the expected crude incidence rate was slightly reduced by 0.41% (95% CI, −1.06 to 0.24) and was more obvious in women and patients aged greater than 70 years; whereas, it was significantly increased in those aged greater than 75 years. After disentangling age and cohort effects, the implementation of the care programs was associated with an overall net drift of −1.09% (95% CI, −1.65 to −0.52) per year and a significant linear reduction in the period rate ratio from 1.06 (95% CI, 1.02-1.09) in the years 2002-2006 to 0.95 (95% CI, 0.92-0.98) in 2012-2016, using years 2007-2011 as reference.

Limitations

The findings of the study may have limited inferences to other countries with different health care systems.

Conclusions

The implementation of universal CKD care programs in Taiwan has significantly reduced the long-term trends in the incidence of maintenance dialysis; hence, devoting governmental resources to CKD care and prevention is advocated.

Impact of inpatient educational programs on mortality after the start of dialysis therapy

BACKGROUND

Although inpatient educational programs (IEPs) for non-dialysis-dependent chronic kidney disease (CKD) have been reported to slow disease progression, their legacy effect on prognosis after the start of dialysis therapy is unclear.

METHODS

Consecutive patients who started dialysis therapy between January 1, 2011 and December 31, 2018 were included in a single-center, retrospective, observational study. The patients were divided into two groups according to whether or not they participated in IEPs before dialysis introduction, and their background characteristics were compared. The survival rate for each group was calculated using the Kaplan-Meier method and compared by the log-rank test. Furthermore, the hazard ratio (HR) of IEP participation adjusted for confounding factors associated with mortality was calculated using Cox regression analysis.

RESULTS

Of the 490 subjects (median age 69 years, 71.0% male), 129 patients (26.3%) participated in the IEP. At the start of dialysis, the IEP group had higher serum albumin (3.5 vs. 3.3 g/dL, p < 0.001) and lower serum total cholesterol levels (151 vs. 166 mg/dL, p = 0.0076) and the proportion of patients with independence in their daily living activities was high (p = 0.034). The median observation period was 3.4 years, during which 153 patients (31.2%) died. The 5-year survival rates were 81.0 and 61.5% in the IEP and non-IEP groups, respectively (p = 0.0038). Cox regression analysis revealed a HR for IEP of 0.57 (95% Confidence interval 0.37-0.88, p = 0.011).

CONCLUSION

IEPs for CKD patients are associated with a more favorable prognosis after the start of dialysis.

Update on Existing Care Models for Chronic Kidney Disease in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Approximately 78% of chronic kidney disease (CKD) cases reside in low- and middle-income countries (LMICs). However, little is known about the care models for CKD in LMICs.

OBJECTIVE

Our objective was to update a prior systematic review on CKD care models in LMICs and summarize information on multidisciplinary care and management of CKD complications.

DESIGN

We searched MEDLINE, EMBASE, and Global Health databases in September 2020, for papers published between January 1, 2017, and September 14, 2020. We used a combination of search terms, which were different iterations of CKD, care models, and LMICs. The World Bank definition (2019) was used to identify LMICs.

SETTING

Our review included studies published in LMICs across 4 continents: Africa, Asia, North America (Mexico), and Europe (Ukraine). The study settings included tertiary hospitals (n = 6), multidisciplinary clinics (n = 1), primary health centers (n = 2), referral centers (n = 2), district hospitals (n = 1), teaching hospitals (n = 1), regional hospital (n = 1), and an urban medical center (n = 1).

PATIENTS

Eighteen studies met inclusion criteria, and encompassed 4679 patients, of which 4665 were adults. Only 9 studies reported mean eGFR which ranged from 7 to 45.90 ml/min/1.73 m2.

MEASUREMENTS

We retrieved the following details about CKD care: funding, urban or rural location, types of health care staff, and type of care provided, as defined by Kidney Disease Improving Global Outcomes (KDIGO) guidelines for CKD care.

METHODS

We included studies which met the following criteria: (1) population was largely adults, defined as age 18 years and older; (2) most of the study population had CKD, and not end-stage kidney disease (ESKD); (3) population resided in an LMIC as defined by the World Bank; (4) manuscript described in some detail a clinical care model for CKD; (5) manuscript was in either English or French. Animal studies, case reports, comments, and editorials were excluded.

RESULTS

Eighteen studies (24 care models with 4665 patients) met inclusion criteria. Out of 24 care models, 20 involved interdisciplinary health care teams. Twenty models incorporated international guidelines for CKD management. However, conservative kidney management (management of kidney failure without dialysis or renal transplant) was in a minority of models (11 of 24). Although there were similarities between all the clinical care models, there was variation in services provided and in funding arrangement; the latter ranged from comprehensive government funding (eg, Sri Lanka, Thailand), to out-of-pocket payments (eg, Benin, Togo).

LIMITATIONS

These include (1) lack of detail on CKD care in many of the studies, (2) small number of included studies, (3) using a different definition of care model from the original Stanifer et al paper, and (4) using the KDIGO Guidelines as the standard for defining a CKD care model.

CONCLUSIONS

Most of the CKD models of care include the key elements of CKD care. However, access to such care depends on the funding mechanism available. In addition, few models included conservative kidney management, which should be a priority for future investment.

TRIAL REGISTRATION

Not applicable.

Effect of a 3-Year Lifestyle Intervention in Patients with Chronic Kidney Disease: A Randomized Clinical Trial

BACKGROUND

Supervised lifestyle interventions have the potential to significantly improve physical activity and fitness in patients with CKD.

METHODS

To assess the efficacy of a lifestyle intervention in patients with CKD to improve cardiorespiratory fitness and exercise capacity over 36 months, we conducted a randomized clinical trial, enrolling 160 patients with stage 3-4 CKD, with 81 randomized to usual care and 79 to a 3-year lifestyle intervention. The lifestyle intervention comprised care from a multidisciplinary team, including a nephrologist, nurse practitioner, exercise physiologist, dietitian, diabetes educator, psychologist, and social worker. The exercise training component consisted of an 8-week individualized and supervised gym-based exercise intervention followed by 34 months of a predominantly home-based program. Self-reported physical activity (metabolic equivalent of tasks [METs] minutes per week), cardiorespiratory fitness (peak O₂ consumption [VO_2peak]), exercise capacity (maximum METs and 6-minute walk distance) and neuromuscular fitness (grip strength and get-up-and-go test time) were evaluated at 12, 24, and 36 months.

RESULTS

The intervention increased the percentage of patients meeting physical activity guideline targets of 500 MET min/wk from 29% at baseline to 63% at 3 years. At 12 months, both VO_2peak and METs increased significantly in the lifestyle intervention group by 9.7% and 30%, respectively, without change in the usual care group. Thereafter, VO_2peak declined to near baseline levels, whereas METs remained elevated in the lifestyle intervention group at 24 and 36 months. After 3 years, the intervention had increased the 6-minute walk distance and blunted declines in the get-up-and-go test time.

CONCLUSIONS

A 3-year lifestyle intervention doubled the percentage of CKD patients meeting physical activity guidelines, improved exercise capacity, and ameliorated losses in neuromuscular and cardiorespiratory fitness.

C-C Motif Chemokine Ligand-17 as a Novel Biomarker and Regulator of Epithelial Mesenchymal Transition in Renal Fibrogenesis

CCL17, a chemotactic cytokine produced by macrophages, is known to promote inflammatory and fibrotic effects in multiple organs, but its role in mediating renal fibrosis is unclear. In our study cohort of 234 chronic kidney disease (CKD) patients and 65 healthy controls, human cytokine array analysis revealed elevated CCL17 expression in CKD that correlated negatively with renal function. The area under the receiver operating characteristic curve of CCL17 to predict the development of CKD stages 3b–5 was 0.644 (p < 0.001), with the optimal cut-off value of 415.3 ng/mL. In vitro over-expression of CCL17 in HK2 cells had no effect on cell viability, but increased cell motility and the expression of α-SMA, vimentin and collagen I, as shown by western blot analysis. In a unilateral ureteral obstruction (UUO) mouse model, we observed significantly increased interstitial fibrosis and renal tubule dilatation by Masson’s Trichrome and H&E staining, and markedly increased expression of CCL17, vimentin, collagen I, and α-SMA by IHC stain, qRTPCR, and western blotting. CCL17 induced renal fibrosis by promoting the epithelial-mesenchymal transition, resulting in ECM accumulation. CCL17 may be a useful biomarker for predicting the development of advanced CKD.

Association of pre-ESRD care education with patient outcomes in a 10-year longitudinal study of patients with CKD stages 3-5 in Taiwan

There is little comprehensive education for people with end-stage renal disease (ESRD) progress. We investigated the differences in terms of outcomes between patients with CKD stages 3-5 who enrolled and did not enroll in the pre-ESRD care education in Taiwan. This retrospective cohort study was conducted using data from the National Health Insurance Research Database (NHIRD). All patients diagnosed with CKD stages 3-5 who received the pre-ESRD care education through the pay for performance (P4P) program were enrolled. Based on whether or not they participated in the program, they were categorized into P4P or non-P4P groups. All analyses were performed from January 2006 through December 2015. Study outcomes were risk of hemodialysis dependency, hospitalization, and all-cause mortality. In this study of 29,337 patients, those with CKD stages 3-5 in the P4P group had lower events of hemodialysis, hospitalization, and all-cause mortality compared to patients in the non-P4P group. This study suggested that pre-ESRD care education is associated with increased patient outcomes, resulting in lower hemodialysis and hospitalization events and a higher overall survival rate in patients with CKD stages 3-5. Patient education could raise opportunities to improve pre-ESRD care by reaching patients outside the traditional health care setting.

Ten-year experience of an outpatient clinic for CKD-5 patients with multidisciplinary team and educational support

PURPOSE

To analyze the results of an outpatient clinic with a multidisciplinary team and educational support for patients with late-stage CKD (lsCKD), to check its possible effect on their outcomes.

METHODS

Longitudinal cohort study on patients followed up in the MaReA (Malattia Renale Avanzata = CKD5) outpatient clinic at ASST Spedali Civili of Brescia from 2005 to 2015 for at least six months. Trajectory of renal function over time has been evaluated only in those patients with at least four estimations of eGFR before referring to MaReA.

RESULTS

Seven hundred and six patients were enrolled, their mean age was 72 ± 14 years, 59% were males. At the end of the study, 147 (21%) were still on MaReA, 240 (34%) on dialysis, 92 (13%) on very low-protein diet (VLPDs), 13 (2%) on pre-hemodialysis clinic, 23 (3%) improved renal function, 10 (1%) transplanted, 62 (9%) transferred/lost to follow-up, and 119 (17%) died. Optimal dialysis start (defined as start with definitive dialysis access, as an out-patient and without lsCKD complications) occurred in 180/240 (75%) patients. The results showed a slower eGFR decrease during MaReA follow-up compared to previous renal follow-up: - 2.0 vs. - 4.0 mL/min/1.73 m² BSA/year (p < 0.05), corresponding to a median delay of 17.7 months in dialysis start in reference to our policy in starting dialysis. The patient cumulative survival was 75% after 24 months and 25% after 70.

LIMITATIONS

(1) lack of a control group, (2) one-center-study, (3) about all patients were Caucasians.

CONCLUSION

The follow-up of lsCKD patients on MaReA is associated with an optimal and delayed initiation of dialysis.

A co-designed integrated kidney and diabetes model of care improves mortality, glycaemic control and self-care

BACKGROUND

Current health-care models are ill-equipped for managing people with diabetes and chronic kidney disease (CKD). We evaluated the impact of a new diabetes and kidney disease service (DKS) on hospitalisation, mortality, clinical and patient relevant outcomes.

METHODS

Longitudinal analyses of adult patients with diabetes and CKD (stages 3a to 5) were performed using outpatient and hospitalisation data from January 2015 to October 2018. Data was handled according to whether patients received the DKS intervention (n = 196) or standard care (n = 7511). The DKS provided patient-centered, coordinated multi-disciplinary assessment and management of patients. Primary analyses examined hospitalisation and mortality rates between the two groups. Secondary analyses evaluated the impact of the DKS on clinical target attainment, changes in eGFR, HbA1c, self-care and patient activation at 12 months.

RESULTS

Patients who received the intervention had a higher hospitalisation rate (incidence rate ratio (IRR), 1.20; 95% CI, 1.13 to 1.30; P < 0.0001), shorter median length of stay (2 days [interquartile range (IQR), 6-1] versus 4 days [IQR 9-1]; P < 0.0001) and lower all-cause mortality rate (IRR 0.4; 95% CI, 0.29 to 0.64; P < 0.0001) than those who received standard care. Improvements in overall self-care (MD 2.26, 95% CI 0.83, 3.69; P < 0.001) and in statin use, foot and eye examination were observed. Mean eGFR did not significantly change after 12 months (MD 1.30, 95% CI -4.17, 1.67; P = 0.40) mls/min per 1.73 m2. HbA1c levels significantly decreased by 0.40, 0.35, 0.34 and 0.23% at 3, 6, 9 and 12 months follow-up respectively.

CONCLUSIONS

A co-designed, person-centred integrated model of care improved all-cause mortality, kidney function, glycaemic control and self-care for patients with diabetes and CKD.

In Vitro and In Vivo Antifibrotic Effects of Fraxetin on Renal Interstitial Fibrosis via the ERK Signaling Pathway

Fraxetin, a natural derivative of coumarin, is known to have anti-inflammatory, anti-oxidant, and hepatoprotective effects in multiple diseases and in liver fibrosis. Whether fraxetin exerts similar effects against renal fibrosis is unknown. In a Unilateral Ureteral Obstruction (UUO) mouse model of renal fibrosis, fraxetin decreased UUO-induced renal dysfunction with a marked reduction in renal interstitial collagen fibers as detected by Masson’s Trichrome staining. Fraxetin treatment also inhibited the expression of α-SMA, Collagen I, Collagen IV, fibronectin, N-cadherin, vimentin, phosphorylated-ERK, and increased the expression of E-cadherin in UUO mice, as shown by immunohistochemical staining and western blot analysis. In vitro studies showed that fraxetin and indoxyl sulfate had no cytotoxic effects on MES13 kidney cells, but that fraxetin significantly decreased IS-induced cell motility and decreased protein expression of α-SMA, N-cadherin, vimentin, and Collagen IV via the ERK-mediated signaling pathway. These findings provide insight into the mechanism underlying fraxetin-induced inhibition of fibrogenesis in renal tissue and suggest that fraxetin treatment may be beneficial for slowing CKD progression.

Prediction of non-responsiveness to pre-dialysis care program in patients with chronic kidney disease: a retrospective cohort analysis

The responsiveness of patients with chronic kidney disease (CKD) to nephrologists’ care is unpredictable. We defined the longitudinal stages (LSs) 1–5 of estimated glomerular filtration rate (eGFR) by group-based trajectory modeling for repeated eGFR measurements of 7135 patients with CKD aged 20–90 years from a 13-year pre-end-stage renal disease (ESRD) care registry. Patients were considered nonresponsive to the pre-dialysis care if they had a more advanced eGFR LS compared with the baseline. Conversely, those with improved or stable eGFR LS were considered responsive. The proportion of patients with CKD stage progression increased with the increase in the baseline CKD stage (stages 1–2: 29.2%; stage 4: 45.8%). The adjusted times to ESRD and all-cause mortality in patients with eGFR LS-5 were 92% (95% confidence interval [CI] 86–96%) and 57% (95% CI 48–65%) shorter, respectively, than in patients with eGFR LS-3A. Among patients with baseline CKD stages 3 and 4, the adjusted times to ESRD and all-cause death in the nonresponsive patients were 39% (95% CI 33–44%) and 20% (95% CI 14–26%) shorter, respectively, than in the responsive patients. Our proposed Renal Care Responsiveness Prediction (RCRP) model performed significantly better than the conventional Kidney Failure Risk Equation in discrimination, calibration, and net benefit according to decision curve analysis. Non-responsiveness to nephrologists’ care is associated with rapid progression to ESRD and all-cause mortality. The RCRP model improves early identification of responsiveness based on variables collected during enrollment in a pre-ESRD program. Urgent attention should be given to characterize the underlying heterogeneous responsiveness to pre-dialysis care.

Association of glomerular filtration rate slope with timely creation of vascular access in incident hemodialysis

The factors associated with the timely creation of distal vascular access for hemodialysis initiation are unclear. We aimed to explore the association between the slope of estimated glomerular filtration rate (eGFR) and the successful usage of vascular access upon hemodialysis initiation. This single center retrospective cohort study enrolled chronic kidney disease patients who undertook a multidisciplinary care program from 2003 to 2016. Using eGFR slope as predictor, we evaluated the vascular access created timely upon hemodialysis initiation. Among the 987 patients, vascular access was created at a median eGFR of 5.8 min/ml/1.73 m², with a median duration of 3.1 months before hemodialysis. The proportions of vascular access created timely, created not timely (vascular access immature), and not created were 68.5%, 8.8%, and 22.7%, respectively. There was a significant negative association of eGFR upon vascular access creation with eGFR slope (r = − 0.182, P < 0.001). The fastest eGFR slope patients (the first quartile or < − 10 min/ml/1.73 m²/year) had the lowest percentage of vascular access created timely. In the multivariable logistic regression analysis, only higher eGFR upon vascular access creation (P = 0.001) and eGFR slope (P = 0.009) were significantly associated with vascular access created timely. The adjusted odds ratios of each quartile of eGFR slopes for vascular access created timely were 0.46 (95% confidence interval 0.27–0.86), 1.30 (0.62, 2.72), 1.00 (reference), and 0.95 (0.48–1.87), respectively. eGFR slope is associated with the timely creation of vascular access for the initiation of hemodialysis in a reverse-J-shaped pattern and may help determine the time of vascular access creation.

Effects of ketoanalogues on skeletal muscle mass in patients with advanced chronic kidney disease: real-world evidence

OBJECTIVE

Ketoanalogue (KA) supplementation in patients with chronic kidney disease (CKD) on a restricted protein diet has been shown to maintain their nutritional status in clinical trials. However, a gap existed between the findings of the clinical trials and the real-world practice. The aim of this prospective observational study was to evaluate the KA effect on skeletal muscle mass in patients with stage 4-5 CKD.

METHODS

Among 170 patients with CKD screened, 148 were recruited. Patients were defined as KA or non-KA users. During a 12-mo follow-up, skeletal muscle and body fat mass were measured via bioelectrical impedance analysis at baseline, 6 mo (n = 108), and 12 mo (n = 85).

RESULTS

Among the patients (mean age, 66.5 ± 12.9 y), KA users tended to maintain skeletal muscle and body fat mass, whereas non-KA users had a significantly reduced muscle mass (P = 0.011) and body fat gain (P = 0.004). Stratified by median age, in patients ≥68 y of age, non-KA users yielded the most significant muscle mass reduction and fat mass gain, whereas KA users revealed no changes in skeletal muscle and fat mass.

CONCLUSION

In real-world practice, we concluded that KA supplementation favorably prevents skeletal muscle mass loss and fat mass gain in elderly patients with stage 4-5 CKD.

Health Care Delivery, Patient Resources, and Community Reintegration

When providing health care services, clinicians should provide patient-centered and family-centered care. When providing care for medically complex patients, it is important to think about how health care teams are working together to care for patients. Health care providers need to think about how they can guide their patients to become more independent, have an improved quality of life, and have improved access to their homes and community environments when possible. Clinicians need to recognize the importance of caregivers and the burdens that are put on caregivers. Clinicians should provide support to caregivers whenever possible.

Suboptimal dialysis initiation is associated with comorbidities and uraemia progression rate but not with estimated glomerular filtration rate

BACKGROUND

Despite early referral of uraemic patients to nephrological care, suboptimal dialysis initiation (SDI) remains a common problem associated with increased morbimortality. We hypothesized that SDI is related to pre-dialysis care.

METHODS

In the 'Peridialysis' study, time and reasons for dialysis initiation (DI), clinical and biochemical data and centre characteristics were registered during the pre- and peri-dialytic period for 1583 end-stage kidney disease patients starting dialysis over a 3-year period at 15 nephrology departments in the Nordic and Baltic countries to identify factors associated with SDI.

RESULTS

SDI occurred in 42%. Risk factors for SDI were late referral, cachexia, comorbidity (particularly cardiovascular), hypoalbuminaemia and rapid uraemia progression. Patients with polycystic renal disease had a lower incidence of SDI. High urea and C-reactive protein levels, acidosis and other electrolyte disorders were markers of SDI, independently of estimated glomerular filtration rate (eGFR). SDI patients had higher eGFR than non-SDI patients during the pre-dialysis period, but lower eGFR at DI. eGFR as such did not predict SDI. Patients with comorbidities had higher eGFR at DI. Centre practice and policy did not associate with the incidence of SDI.

CONCLUSIONS

SDI occurred in 42% of all DIs. SDI was associated with hypoalbuminaemia, comorbidity and rate of eGFR loss, but not with the degree of renal failure as assessed by eGFR.

Inpatient educational program delays the need for dialysis in patients with chronic kidney disease stage G5

BACKGROUND

Inpatient educational programs (IEPs) for patients with chronic kidney disease (CKD) decrease CKD progression. However, patients with end-stage kidney disease who started dialysis during the observation period were excluded from previous studies.

METHODS

After adjusting for age, sex, baseline estimated glomerular filtration rate, hemoglobin level, and the presence of diabetes mellitus using 1:1 propensity score matching (caliper width of 0.008) in the groups that did and did not receive an IEP, we compared the time period from the beginning of CKD stage G5 to the start of dialysis and patient characteristics at the start of dialysis.

RESULTS

Prior to matching, 41 patients received an IEP and 260 did not. After propensity score matching, the 41 patients who received an IEP had a longer period from the beginning of stage G5 to the start of dialysis (344 vs. 257 days, P = 0.011), shorter hospitalization period upon the start of dialysis (14 vs. 18 days, P = 0.015) compared with the 41 patients who did not receive an IEP. In addition, the proportion of patients with a planned start of dialysis tended to be higher in the IEP group (95.1 vs. 83.0%, P = 0.077).

CONCLUSION

An IEP may delay the start of dialysis in patients with end-stage kidney disease, contribute to better preparation of vascular access placement and the smoother start of dialysis.

Gender Differences in the Association Between Obesity Indices and Chronic Kidney Disease Among Middle-Aged and Elderly Taiwanese Population: A Community-Based Cross-Sectional Study

BACKGROUND

Traditional risk factors for chronic kidney disease (CKD) include diabetes mellitus (DM), hypertension (HTN), and metabolic syndrome, which are health conditions related to obesity. We aimed to investigate which of the three obesity indices has the strongest association with CKD and to explore whether there are gender differences in these relationships in the middle-aged and elderly Taiwanese population.

METHODS

This was a cross-sectional, community-based study. It included 400 residents (141 males and 259 females, age 50-90 years) residing in a community in northern Taiwan. Each participant was asked to fill a questionnaire that collected personal information, medical history, medication use, and anthropometric measurements. The laboratory data were obtained by testing the blood and urine samples. The baseline characteristics were compared, and the obesity indices included body mass index (BMI), waist circumference (WC), and visceral adiposity index (VAI). CKD was defined as the presence of renal dysfunction (urine albumin-creatinine ratio ≥ 30 mg/g) or estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m². We used a multiple logistic regression model to evaluate the association between each obesity index and CKD for both genders. Further, we used the area under the receiver operating characteristic (ROC) curve (AUC) to examine the best obesity indices to predict CKD in different genders.

RESULTS

The average age of the subjects was 64.47 ± 8.45 years, and men were significantly older. CKD was found in 31 (22.0%) males and 50 (19.3%) females. In men, there was no significant difference between the CKD and non-CKD groups among the three obesity indices. However, in women, only VAI was significantly higher in subjects with CKD (1.9 [1.1, 3.4]) than in subjects without CKD (1.5 [1.0, 2.2]) (p-value = 0.03). The multivariate logistic regression revealed that even after adjusting for possible confounding factors, VAI was found to be an independent risk factor for CKD in women (OR: 1.32, 95% CI: 1.04-1.69, p = 0.02), but not in men (OR: 1.20, 95% CI: 0.85-1.69, p = 0.30). The AUC of VAI had a significant ability to predict CKD in women but not in men.

CONCLUSION

Our results showed that among the three obesity indices, VAI had the strongest association with CKD compared to BMI and WC in women. In addition, VAI in women should be given more importance in the screening for CKD among the middle-aged and elderly Taiwanese population.

Continuity of care: evaluating a multidisciplinary care model for people with early CKD via a nationwide population-based longitudinal study

OBJECTIVES

To control and prevent the burdens associated with chronic kidney disease (CKD), Taiwan's National Health Insurance Administration (NHIA) launched the 'early-CKD programme' in 2011 to extend care and education to patients with CKD. This study aims to evaluate the effectiveness of the early-CKD programme in terms of continuity of care (COC).

DESIGN AND PARTICIPANTS

This study used secondary data from 2010 to 2014 provided by the NHIA to identify 86 581 participants each for the intervention and control groups. Patients with CKD who participated in the early-CKD programme between 2011 and 2013 were defined as the intervention group. For the control group, propensity score matching was used to select patients with CKD who did not participate in the programme, but were seen by the same group of physicians.

INTERVENTION

A multidisciplinary care model for patients with early CKD launched in 2011.

PRIMARY OUTCOME MEASURES

Outcome variables included the continuity of care index (COCI), which measures a physician's COC; number of essential examinations; and resource utilisation. To better identify the difference between groups, we separated COCI into two groups based on mean: high (above mean) and low (below mean). A generalised estimating equation model was used to examine the effects of the early-CKD programme.

RESULTS

The programme significantly increased the number of essential examinations/tests administered to patients (β=0.61, p<0.001) and improved COCI between physicians and patients (OR=4.18, p<0.001). Medical expenses (β=1.03, p<0.001) and medication expenses (β=0.23, p<0.001) significantly increased after the programme was implemented, but patients' kidney-related hospitalisations and emergency department visits decreased (β=-0.13, p<0.001).

CONCLUSION

From the COC viewpoint, the programme in Taiwan showed a positive effect on COCI, number of essential examinations and resource utilisation.

Effectiveness of Multidisciplinary Care for Chronic Kidney Disease: A Systematic Review

BACKGROUND

Chronic kidney disease (CKD) is a common chronic disease. As this disease is extremely complex, multidisciplinary care (MDC) is needed to provide complete and continuous care.

AIM

A systematic literature review was performed to examine the constituents of MDC, the content of MDC interventions, and the health outcomes in CKD patients receiving MDC.

METHODS

Searches of five Chinese and English databases for studies of CKD patients who had received MDC from 2007 to 2019 revealed 11 studies, which comprised 16,066 CKD patients. The Physiotherapy Evidence Database scale (Physiotherapy Evidence Database, 2017) was used to appraise study quality for randomized controlled trials, and the Joanna Briggs Institute Critical Appraisal tools (Joanna Briggs Institute, 2017) were for cohort studies.

RESULTS

The MDC teams that provided comprehensive medical care for these patients included nephrologists, nurses, surgeons, general practitioners, pharmacists, psychotherapists, social workers, nutritionists, and other specialists. The literature review revealed that MDC for CKD slows the decline in estimated glomerular filtration rate and decreases patient mortality, the risk of renal replacement therapy, the need for emergent dialysis, and annual medical costs. Analyses of biochemical markers in the CKD patients showed that MDC improves control of serum levels of calcium and phosphate, improves control of parathyroid hormone, and reduces proteinuria and fasting blood glucose values. However, further studies are needed to determine the effects of MDC on all-cause mortality, blood pressure control, hospitalization rate, hospitalization for cardiovascular or infection events, medications use, and other biochemical markers in CKD patients.

LINKING EVIDENCE TO ACTION

Cross-disciplinary collaboration of healthcare professionals is needed to ensure that patients undergo regular follow-up and periodic assessment of clinical status, in addition to ensuring that relevant resources and assistance are provided in a timely manner. A follow-up period of at least 2 years is also needed to ensure sufficient time to observe MDC results.

Correlation of sociodemographic profiles with psychological problems among hospitalized patients receiving unplanned hemodialysis

Purpose

In this prospective study, we aimed to examine the sociodemographic factors and clinical factors associated with psychological disorders in chronic kidney disease (CKD) patients receiving unplanned hemodialysis (HD).

Methods

We prospectively enrolled 187 CKD stage 5 patients receiving unplanned HD at a tertiary hospital from January 2015 to December 2016. We used structured questionnaires to gather data about participants’ anxiety, depression, and sleep disturbance. Generalized linear regression analysis was used to examine the relationships between sociodemographic and laboratory parameters, and severity of psychological distress.

Results

The mean age of the participants was 60 years, and the number of men and women was 97 and 90, respectively. We did not find a significant association between anxiety, depression, and sleep disturbance scores and gender, age, marital status, religion status, education levels, and employment status and number of comorbidities. Generalized linear regression analysis showed that a multidisciplinary CKD care program in outpatient clinic disclosed a significant negative association with psychological disorders in participants.

Conclusions

CKD patients exhibited psychological distress when receiving unplanned HD, not closely associated with sociodemographic profiles.

Arecoline induces epithelial mesenchymal transition in HK2 cells by upregulating the ERK-mediated signaling pathway

Arecoline, a component of betel nuts, is a known carcinogen that causes oral cancers among those who chew betel nuts. Betel nut chewing is also associated with an increased risk of chronic kidney disease (CKD), but the role of arecoline in this association is unclear. This in vitro study investigates the effects of arecoline on cultured human kidney (HK2) cells. We observed that arecoline had no effect on cell viability but increased cell migration in a dose-dependent manner. Western blot analysis showed that arecoline treatment caused a dose-dependent decrease in E-cadherin expression and dose-dependent increases in N-cadherin, vimentin, α-SMA, and collagen expression; reverse transcriptase-polymerase chain reaction analysis revealed dose-dependent increases in α-SMA and collagen mRNA. Arecoline treatment upregulated the expression of phosphorylated extracellular signal-regulated kinase through epithelial mesenchymal transition and renal fibrosis in HK2 cells. These findings demonstrate that arecoline plays a role in inducing the epithelial mesenchymal transition and fibrogenesis in renal tubule cells and suggest that arecoline promotes the progression of CKD.

The role of pharmacists in the renal multidisciplinary team at a tertiary hospital in South Africa: Strategies to increase participation of pharmacists

Background

Pharmacists are often marginalised from participating fully in a Multidisciplinary Team (MDT). Pharmacists can contribute in the renal MDT by minimising drug-related problems and optimising therapy.

Aim

The study aimed to explore the current role of pharmacists in renal care at a tertiary hospital in South Africa, and to recommend strategies to improve their participation in the renal MDT.

Method

An exploratory descriptive qualitative study was conducted using semi-structured interviews. The participants were selected using purposive sampling. The audiotaped interviews were transcribed exactly as spoken and analysed using thematic content analysis.

Results

Three themes emerged from the analysis: pharmacist’s current scope of practice within the renal MDT, potential future roles of pharmacists, and perceived barriers to participation of pharmacists within the renal MDT. Furthermore, participants provided recommendations to increase pharmacist’s participation in the renal MDT: that is standardisation of practice, skills development of both pharmacist and pharmacist assistants and recognition of pharmacist services in the wards.

Conclusion

The role of pharmacists at Pietersburg Hospital is the official name of the hospital is confined to stock management and dispensing. Efforts should be made to improve the participation of pharmacists in the MDTs with the intention to standardise the practice of pharmacists in the wards, equip both pharmacists and pharmacist assistants with the necessary skills and recognise pharmacist’s services in the wards.

Importance of non-medical reasons for dropout in patients on peritoneal dialysis

BACKGROUND

To describe the associated factors for non-medical reasons for dropout in peritoneal dialysis (PD) patients.

METHODS

A retrospective cohort study was performed using registry data of adult patients commencing PD as their initial renal replacement therapy in one hospital-facilitated PD center in Taiwan between 2014 and 2018. The collected data included socio-demographics and relevant medical and PD-related parameters. Kaplan-Meier analysis was used to determine the impact of non-medical reasons and medical reasons on PD dropout.

RESULTS

The analysis included 224 PD patients, of whom 37 dropped out for non-medical reasons and 187 for medical reasons during the study period. There was significant difference between the two cohorts in age (62.3 years vs. 56.1 years, P = 0.010) and PD vintage (median 3.4 years vs. 4.8 years, P = 0.001). Diabetes was more predominant in the cohort for non-medical reasons than in the one for medical reasons (54.1% vs. 27.3% respectively, P = 0.001). In non-medical reason cohort, two leading reasons given for dropping out were lacking of caregivers (n = 12) and losing confidence (n = 10), whereas PD-related peritonitis (n = 101) was the main medical reason for PD dropout. Using Kaplan-Meier curve analysis, patients in the non-medical reason cohort demonstrated higher cumulative dropout rate compared to patients in the medical reason cohort during a 10-year period (P < 0.001).

CONCLUSIONS

The main characteristics of PD dropout patients for non-medical reasons are age, diabetes, patients' perception and caregiver support.

Impact of superimposed nephrological care to guidelines-directed management by primary care physicians of patients with stable chronic kidney disease: a randomized controlled trial

BACKGROUND

Optimal clinical care of patients with chronic kidney disease (CKD) requires collaboration between primary care physicians (PCPs) and nephrologists. We undertook a randomised trial to determine the impact of superimposed nephrologist care compared to guidelines-directed management by PCPs in CKD patients after hospital discharge.

METHODS

Stage 3b-4 CKD patients were enrolled during a hospitalization and randomised in two arms: Co-management by PCPs and nephrologists (interventional arm) versus management by PCPs with written instructions and consultations by nephrologists on demand (standard care). Our primary outcome was death or rehospitalisation within the 2 years post-randomisation. Secondary outcomes were: urgent renal replacement therapy (RRT), decline of renal function and decrease of quality of life at 2 years.

RESULTS

From November 2009 to the end of June 2013, we randomised 242 patients. Mean follow-up was 51 + 20 months. Survival without rehospitalisation, GFR decline and elective dialysis initiation did not differ between the two arms. Quality of life was also similar in both groups. Compared to randomised patients, those who either declined to participate in the study or were previously known by nephrologists had a worse survival.

CONCLUSION

These results do not demonstrate a benefit of a regular renal care compared to guided PCPs care in terms of survival or dialysis initiation in CKD patients. Increased awareness of renal disease management among PCPs may be as effective as a co-management by PCPs and nephrologists in order to improve the prognosis of moderate-to-severe CKD.

TRIAL REGISTRATION

This study was registered on June 29, 2009 in clinicaltrials.gov (NCT00929760) and adheres to CONSORT 2010 guidelines.

Global case studies for chronic kidney disease/end-stage kidney disease care

The prevalence of chronic kidney disease and its risk factors is increasing worldwide, and the rapid rise in global need for end-stage kidney disease care is a major challenge for health systems, particularly in low- and middle-income countries. Countries are responding to the challenge of end-stage kidney disease in different ways, with variable provision of the components of a kidney care strategy, including effective prevention, detection, conservative care, kidney transplantation, and an appropriate mix of dialysis modalities. This collection of case studies is from 15 countries from around the world and offers valuable learning examples from a variety of contexts. The variability in approaches may be explained by country differences in burden of disease, available human or financial resources, income status, and cost structures. In addition, cultural considerations, political context, and competing interests from other stakeholders must be considered. Although the approaches taken have often varied substantially, a common theme is the potential benefits of multistakeholder engagement aimed at improving the availability and scope of integrated kidney care.

Health-related quality of life among patients with comorbid diabetes and kidney disease attending a codesigned integrated model of care: a longitudinal study

OBJECTIVE

To evaluate the impact of an integrated diabetes and kidney disease model of care on health-related quality of life (HRQOL) of patients with comorbid diabetes and chronic kidney disease (CKD).

RESEARCH DESIGN AND METHODS

A longitudinal study of adult patients (over 18 years) with comorbid diabetes and CKD (stage 3a or worse) who attended a new diabetes kidney disease service was conducted at a tertiary hospital. A questionnaire consisting of demographics, clinical data, and the Kidney Disease Quality of Life (KDQOL-36) was administered at baseline and after 12 months. Paired t-tests were used to compare baseline and 12-month scores. A subgroup analysis examined the effects by patient gender. Multiple regression analysis examined the factors associated with changes in scores.

RESULTS

179 patients, 36% of whom were female, with baseline mean±SD age of 65.9±11.3 years, were studied. Across all subscales, HRQOL did not significantly change over time (p value for all mean differences >0.05). However, on subgroup analysis, symptom problem list and physical composite summary scores increased among women (MD=9.0, 95% CI 1.25 to 16.67; p=0.02 and MD=4.5, 95% CI 0.57 to 8.42; p=0.03 respectively) and physical composite scores decreased among men (MD=-3.35, 95% CI -6.26 to -0.44; p=0.03).

CONCLUSION

The HRQOL of patients with comorbid diabetes and CKD attending a new codesigned, integrated diabetes and kidney disease model of care was maintained over 12 months. Given that HRQOL is known to deteriorate over time in this high-risk population, the impact of these findings on clinical outcomes warrants further investigation.

Associations of Waist Circumference, Socioeconomic, Environmental, and Behavioral Factors with Chronic Kidney Disease in Normal Weight, Overweight, and Obese People

Background: Chronic kidney disease (CKD) places a heavy burden on the healthcare system worldwide. The risk factors may vary by body adiposity. We aimed to investigate the associations of socioeconomic, environmental, and behavioral factors with CKD in different groups of body mass indexes (BMI). Methods: A case-control study was conducted in 3280 participants (1048 CKD and 2232 non-CKD) from seven hospitals and nearby communities from May 2012 to August 2015. Personal characteristics, anthropometrics, environmental exposures, and health-related behaviors were assessed using a structured questionnaire. The logistic regression models were utilized for analysis. Results: Older age (odd ratio, OR = 2.85; p < 0.001), being men (OR = 4.23; p < 0.001), smoking (OR = 3.36; p < 0.001), stable income (OR = 0.33; p < 0.001), higher education (OR = 0.37~0.38; p < 0.001), and daily adequate water intake (OR = 0.64; p = 0.010) were associated with CKD in normal weight people. Older age (OR = 2.49; p < 0.001), being men (OR = 3.36; p < 0.001), education (OR = 0.44, p = 0.004), hypertension (OR = 2.93; p<0.001), diabetes (OR = 1.83; p = 0.004), and using traditional Chinese medicine (OR = 2.03, p = 0.014) were associated with CKD in overweight people. Older age (OR = 2.71; p < 0.001), being men (OR = 2.69; p < 0.001), hypertension (OR = 2.93; p < 0.001), diabetes (OR = 1.94; p = 0.001) were associated with CKD in obese people. Conclusions: The associated factors of CKD varied by different groups of BMI. These findings may help to develop potential interventions to manage CKD.

Old age is a positive modifier of renal outcome in Taiwanese patients with stages 3-5 chronic kidney disease

BACKGROUND

The incidence of end-stage renal disease (ESRD) is increasing in elderly patients with chronic kidney disease (CKD). This contradicts the general notion that elderly people are more likely to die than to ever reach ESRD. And racial disparity in relation to age on kidney disease outcomes has always been a subject of research interest.

AIMS

We investigated the effect of age on outcome in a cohort with stages 3-5 CKD patients by age category.

METHODS

A total of 430 patients with a mean age of 65.6 years were enrolled and followed till death, ESRD, or end of 2015. Multivariable Cox regression was used to identify predictors of all-cause mortality. Competing risk-adjusted Cox regression was used to identify determinants of ESRD. The median follow-up was 7.3 (interquartile range 8.8) years.

RESULTS

Cox regression showed old age and low mean arterial pressure were predictors of mortality before and after onset of ESRD. Competing risk analysis revealed patients aged 20-39 years and 40-64 years exhibited greater risks of ESRD, compared to those aged over 75 years. These effects of age on outcomes occurred independently of traditional risk factors such as low estimated glomerular filtration rate and high proteinuria.

CONCLUSIONS

Age over 75 years is associated with decreased risk for ESRD even after adjustment for competing mortality. Given the global trends in population aging, there is a need to develop age-specific strategies, on top of the existing stage-based measures, to optimize the management of CKD in the elderly.

Patient and provider factors associated with enrolment in the pre-end-stage renal disease pay-for-performance programme in Taiwan: a cross-sectional study

OBJECTIVE

The incidence and prevalence of end-stage renal disease (ESRD) in Taiwan have been ranked the highest worldwide. Therefore, the National Health Insurance Administration has implemented the pre-ESRD pay-for-performance (P4P) programme since November 2006, which had significantly reduced the incidence of dialysis and all-cause mortality. This study aimed to identify the factors associated with the enrolment in the pre-ESRD P4P programme.

DESIGN

Cross-sectional study.

SETTING

The National Health Insurance research database 2007-2012 in Taiwan.

PARTICIPANTS

Patients with prevalent pre-ESRD aged more than 18 years between January 2007 and December 2012 were enrolled. Patient demographics and hospital characteristics between P4P and non-P4P groups were compared. A logistic regression model was used to analyse the factors associated with P4P enrolment, and a generalised estimating equation was used to verify the results.

PRIMARY OUTCOME MEASURE

Enrolment in the pre-ESRD P4P programme.

RESULTS

In total, 82 991 patients were enrolled in the programme, with a 45.6% participation rate. Patients who were males (adjusted OR (AOR)=0.89, 95% CI=0.86 to 0.91) and employed (AOR=0.95, 95% CI=0.92 to 0.97) had a significantly lower probability to be enrolled in the programme. Older patients (66-75 years old, AOR=1.23, 95% CI=1.14 to 1.33) and those with higher Charlson Comorbidities Index (CCI 5+, AOR=4.01, 95% CI=3.55 to 4.53) tended to be enrolled in the programme, while those in the 76+ years age group were not (AOR=1.03, 95% CI=0.95 to 1.13). Hospitals located in the central (AOR=1.48, 95% CI=1.05 to 2.08) and Kao-Ping regions (AOR=1.62, 95% CI=1.18 to 2.22) also tended to enrol patients in the pre-ESRD P4P programme. Enrolment rates increased over time.

CONCLUSION

Pre-ESRD patients of the female gender, greater age and more comorbidities were more likely to be enrolled in the pre-ESRD P4P programme. Healthcare providers and health authorities should focus attention on patients who are male, younger and with less comorbidities to improve the healthcare quality and equality for all pre-ESRD patients.

Comparing the Effect of Folic Acid and Pentoxifylline on Delaying Dialysis Initiation in Patients with Advanced Chronic Kidney Disease

Background: We hypothesized that the nutrient loss and chronic inflammation status may stimulate progression in advanced chronic kidney disease. Therefore, we aimed to generate a study to state the influence of combined nutritional and anti-inflammatory interventions. Methods: The registry from the National Health Insurance Research Database in Taiwan was searched for 20–90 years individuals who had certified end-stage renal disease. From January 2005 through December 2010, the diagnosis code ICD-9 585 (chronic kidney disease, CKD) plus erythropoiesis-stimulating agent (ESA) use was defined as entering advanced chronic kidney disease. The ESA starting date was defined as the first index date, whereas the initiation day of maintenance dialysis was defined as the second index date. The duration between the index dates was analyzed in different medical treatments. Results: There were 10,954 patients analyzed. The combination therapy resulted in the longest duration (n = 2184, median 145 days, p < 0.001) before the dialysis initiation compared with folic acid (n = 5073, median 111 days), pentoxifylline (n = 1119, median 102 days, p = 0.654), and no drug group (control, n = 2578, median 89 days, p < 0.001). Lacking eGFR data and the retrospective nature are important limitations. Conclusions: In patients with advanced CKD on the ESA treatment, the combination of folic acid and pentoxifylline was associated with delayed initiation of hemodialysis.

Effect of nephrology referrals and multidisciplinary care programs on renal replacement and medical costs on patients with advanced chronic kidney disease: A retrospective cohort study

Evidence-based studies have revealed outcomes in patients with chronic kidney disease that differed depending on the design of care delivery. This study compared the effects of 3 types of nephrology care: multidisciplinary care (MDC), nephrology care, and non-nephrology care. We studied their effects on the risks of requiring dialysis and the differences between these methods had on long-term medical resource utilization and costs.We conducted a retrospective cohort study involving patients with an estimated glomerular filtration rate of (eGFR) ≤45 mL/min/1.73 m from 2005 to 2007. Patients were divided into MDC, non-MDC, and non-nephrology referral groups. Between-group differences with regard to the risk of requiring dialysis and annual medical utilization and costs were evaluated using a 5-year follow-up period.In total, 661 patients were included. After other covariates and the competing risk of death were taken into account, we observed a significant (56%) reduction in the incidence of dialysis in both the MDC and non-MDC groups relative to the non-nephrology referral group. Costs were markedly lower in the MDC group relative to the other groups (average savings: US$ 830 per year; 95% confidence interval: 367-1295; P < .001).For patients without nephrology referrals, MDC can substantially reduce their risk of developing end-stage renal disease and lower their medical costs. We therefore strongly advocate that all patients with an eGFR of ≤45 mL/min/1.73 m should be referred to a nephrologist and receive MDC.

The effects of a participatory structured group educational program on the development of CKD: a population-based study

BACKGROUND

The type of lifestyle guidance that is effective for preventing development of chronic kidney disease (CKD) is unknown. Here, we aim to investigate the effects of a participatory structured group education (SGE) program on the development of CKD in a population-based study.

METHODS

We retrospectively analyzed 1060 adult special health check-up examinees with CKD. Examinees with an estimated glomerular filtration rate (eGFR) from 50 to 60 mL/min/1.73 m² and/or proteinuria 1+ were encouraged to attend an SGE program. The SGE program included participatory small group discussions on the attendees' remaining risk factors. The primary outcome of this study was the change in eGFR per year.

RESULTS

The changes in eGFR in examinees who attended the SGE program (n = 209, + 2.9 mL/min/1.73 m² [95% confidence interval (CI) + 1.9 to  + 3.9]) significantly improved compared with control (n = 383, + 1.2 mL/min/1.73 m² [95% CI + 0.5 to + 1.9], p = 0.006). Attending an SGE program was independently and positively related to the changes in eGFR at 1 year after attendance, after adjusting for classical covariates (β = 1.55 [95% CI 0.37-2.73], p = 0.01). Attending an SGE program was effective for the examinees with a lower eGFR compared with those with only proteinuria.

CONCLUSIONS

Our SGE program showed the beneficial effects of preventing the development of CKD, independent of classical factors. The type of SGE program that is more effective for preventing development of CKD should be investigated in a long-term analysis.

A Primer on Quality Assurance and Performance Improvement for Interprofessional Chronic Kidney Disease Care: A Path to Joint Commission Certification

Interprofessional care for chronic kidney disease facilitates the delivery of high quality, comprehensive care to a complex, at-risk population. Interprofessional care is resource intensive and requires a value proposition. Joint Commission certification is a voluntary process that improves patient outcomes, provides external validity to hospital administration and enhances visibility to patients and referring providers. This is a single-center, retrospective study describing quality assurance and performance improvement in chronic kidney disease, Joint Commission certification and quality outcomes. A total of 440 patients were included in the analysis. Thirteen quality indicators consisting of clinical and process of care indicators were developed and measured for a period of two years from 2009–2017. Significant improvements or at least persistently high performance were noted for key quality indicators such as blood pressure control (85%), estimation of cardiovascular risk (100%), measurement of hemoglobin A1c (98%), vaccination (93%), referrals for vascular access and transplantation (100%), placement of permanent dialysis access (61%), discussion of advanced directives (94%), online patient education (71%) and completion of office visit documentation (100%). High patient satisfaction scores (94–96%) are consistent with excellent quality of care provided.

Cardiovascular and Renal Outcomes in an Excellent Chronic Kidney Disease Clinic Compared with an Outpatient Clinic in a Primary Care Setting: A Retrospective Cohort Study

Background

Chronic kidney disease (CKD) is associated with increased cardiovascular morbidity and mortality. In standard care, the physician attempts to control all known risk factors, but treatment goals are achieved with difficulty. Assistance by a multidisciplinary care team may improve outcomes.

Objective

To compare the cardiovascular and renal endpoints between patients with CKD receiving care from excellent CKD and outpatient clinics.

Methods

A retrospective cohort study was conducted in a primary care setting in Thailand. Patients with CKD stages 3 and 4 in excellent CKD (n = 96) and outpatient clinics (n = 192) were matched in a 1: 2 ratio with the propensity score. We collected data from electronic medical records concerning the incidences of primary composite outcomes including rapid renal progression, end-stage renal disease, myocardial infarction, congestive heart failure, stroke, and mortality. Multidisciplinary team care in the excellent CKD clinic consisted of physician, nurse, pharmacist, dietitian, physical therapist, and applied Thai traditional physician. The outpatient clinic consisted of physician care only.

Results

Subjects' mean age was 64.54 ± 10.96 years, and 52.1% were female. During an average 49.63 ± 8.36 months of follow-up, 74 events occurred including 35 (47.30%) patients who experienced renal events, 29 (39.19%) who experienced cardiovascular events, and 10 (13.51%) who experienced loss of life. The Kaplan-Meier curve indicated a higher percentage of subjects without primary composite outcomes in the excellent CKD clinic than those in the outpatient clinic (66.85%; 95% CI 0.48-0.80 vs. 44.71%; 95% CI 0.29-0.60; p = 0.005). From multivariate analysis, the excellent CKD clinic group had a 64% lower risk for primary composite outcomes compared with those in the outpatient clinic (adjusted HR 0.36; 95% CI 0.18-0.74; p = 0.005).

Conclusion

A multidisciplinary care system can reduce composition outcomes including cardiovascular and renal outcomes for the growing CKD population. The optimal outcomes arise from the medical personnel's teamwork, not from one physician alone.

Mapping the UK renal psychosocial workforce: the first comprehensive workforce survey

Background

Emerging evidence of psychosocial problems in CKD patients has led to an acceptance that a focus on the emotional wellbeing of the patient should be included in the provision of comprehensive CKD care. It is unclear if an increased attention for psychosocial needs in guidelines and policy documents has led to a rise in psychosocial staffing levels or change in composition of staff since the last workforce mapping in 2002. This paper offers a critical analysis and in-depth discussion of findings and their implications, in addition to providing an international perspective and exposing gaps in current knowledge.

Methods

Data on psychosocial staffing levels was taken from a survey based on the Scottish Renal Association’s (SRA) staffing survey that was sent to all units in England, Wales and Northern-Ireland in 2016. In addition, data from a psychosocial staffing survey designed by and distributed via psychosocial professional groups was used. This data was then completed with Freedom of Information (FOI) requests and collated to describe the current renal psychosocial workforce in all 84 UK renal units. This was compared to results from the last renal workforce mapping in 2002.

Results

The results from this mapping show great variability in models of service provision, significant exceeding of benchmarks for staffing levels, and a change in staffing patterns over the past 15 years. Adult psychology services have increased in number, but provision remains low due to increased patient numbers, whereas adult social work and paediatric services have decreased.

Conclusion

A lack in the provision of renal psychosocial services has been identified, together with the absence of a general service provision model. These findings provide a valuable benchmark for units, a context from which to review and monitor provision alongside patient need. Along with recommendations, this paper forms a foundation for future research and workforce planning. Research into best practice models of service provision and the psychosocial needs of CKD patients lies at the heart of the answers to many identified questions.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1287-0) contains supplementary material, which is available to authorized users.

Multidisciplinary clinics reduce treatment costs and improve patient outcomes in diabetic foot disease

OBJECTIVE

Diabetic foot disease poses a significant and rising financial burden on health care systems worldwide. This study investigated the effect of a new multidisciplinary diabetic foot clinic (MDDFC) in a large tertiary hospital on patient outcomes and treatment cost.

METHODS

Patients' records were retrospectively reviewed to identify all patients who had been managed in a new MDDFC between July 2014 and July 2017. The wound episode-the period from initial presentation to the achievement of a final wound outcome-was identified, and all relevant inpatient and outpatient costs were extracted using a fully absorbed activity-based costing methodology. Risk factor, treatment, outcome, and costing data for this cohort were compared with a group of patients with diabetic foot wounds who had been managed in the same hospital before the advent of the MDDFC using a generalized linear mixed model.

RESULTS

The MDDFC and pre-MDDFC cohorts included 73 patients with 80 wound episodes and 225 patients with 265 wound episodes, respectively. Compared with the pre-MDDFC cohort, the MDDFC group had fewer inpatient admissions (1.56 vs 2.64; P ≤ .001). MDDFC patients had a lower major amputation rate (3.8% vs 27.5%; P ≤ .001), a lower mortality rate (7.5% vs 19.2%; P ≤ .05), and a higher rate of minor amputation (53.8% vs 31.7%; P ≤ .01). No statistically significant difference was noted in the rate of excisional débridement, skin graft, and open or endovascular revascularization. In the MDDFC cohort, the median total cost, inpatient cost, and outpatient cost per wound episode was New Zealand dollars (NZD) 22,407.465 (U.S. dollars [USD] 17,253.74), NZD 21,638.93 (USD 16,661.97), and NZD 691.915 (USD 532.77), respectively. The MDDFC to pre-MDDFC wound episode total cost ratio was 0.7586 (P < .001).

CONCLUSIONS

This study is the first to compare the cost and treatment outcomes of diabetic foot patients treated in a large tertiary hospital before and after the introduction of an MDDFC. The results show that an MDDFC improves patient outcomes and reduces the cost of treatment. MDDFCs should be adopted as the standard of care for diabetic foot patients.

Proton pump inhibitors use and risk of chronic kidney disease in diabetic patients

AIMS

Chronic kidney disease consumes a huge amount of medical resources and proton pump inhibitors may be a potential factor for the increasing prevalence. This population-based cohort study investigates the risk of chronic kidney disease in a diabetic population using proton pump inhibitors in Taiwan.

METHODS

This study is based on a specific diabetic database obtained from the National Health Insurance Research Database. Individuals with a new diagnosis of diabetes from 2002 to 2013 were enrolled. "Exposure" to proton pump inhibitors was defined as at least one prescription and dosage over 180 DDD (defined daily dose) in one year after the index date. A multivariable Cox proportional hazard model and competing-risk regression model were applied.

RESULTS

There were 5994 patients in the final cohort of proton pump inhibitor users and 23,976 patients in the matched controlled cohort based on 1:4 propensity score matching. Compared with no exposure users, PPIs exposure group had more anemia prevalence, anti-hypertension medication and NSAIDs prescriptions. The multivariable Cox proportional hazard model showed that the adjusted hazard ratio of chronic kidney disease was 1.52 (95% CI 1.40-1.65) in diabetic individuals with PPIs exposure, compared with no exposure users.

CONCLUSIONS

Proton pump inhibitors use is associated with 1.52-fold increased risk of chronic kidney disease in diabetic patients when the dosage is over 180 DDD in one year in Taiwan.