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Shrestha S, Haq K, Malhotra D, Patel DM. Care of Adults with Advanced Chronic Kidney Disease. J Clin Med 2024; 13:4378. [PMID: 39124645 PMCID: PMC11313041 DOI: 10.3390/jcm13154378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/23/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024] Open
Abstract
Chronic kidney disease (CKD) impacts over 10% of the global population. Adults with CKD face significant morbidity and mortality. As kidney disease progresses, the risk of adverse outcomes increases. Here, we present an overview of strategies to care for adults with advanced CKD (stage 4-5 CKD, not receiving kidney replacement therapy). We aim to guide clinicians through several aspects of CKD care, ranging from recommended laboratory assessments to interdisciplinary support for patients as they plan for kidney replacement therapy (dialysis, transplantation, or conservative management). We incorporate considerations of health equity and person-centered care, empowering clinicians to deliver high-quality care to people with CKD.
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Affiliation(s)
| | | | | | - Dipal M. Patel
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA (D.M.)
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2
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Piveteau J, Raffray M, Couchoud C, Ayav C, Chatelet V, Vigneau C, Bayat S. Pre-dialysis care trajectory and post-dialysis survival and transplantation access in patients with end-stage kidney disease. J Nephrol 2023; 36:2057-2070. [PMID: 37505404 DOI: 10.1007/s40620-023-01711-y] [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: 12/12/2022] [Accepted: 06/18/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND The pre-dialysis care trajectory impact on post-dialysis outcomes is poorly known. This study assessed survival, access to kidney transplant waiting list and to transplantation after dialysis initiation by taking into account the patients' pre-dialysis care consumption (inpatient and outpatient) and the conditions of dialysis start: initiation context (emergency or planned) and vascular access type (catheter or fistula). METHODS Adults who started dialysis in France in 2015 were included. Clinical data came from the French REIN registry and data on the care trajectory from the French National Health Data system (SNDS). The Cox model was used to assess survival and access to kidney transplantation. RESULTS We included 8856 patients with a mean age of 68 years. Survival was shorter in patients with emergency or planned dialysis initiation with a catheter compared to patients with planned dialysis with a fistula. The risk of death was lower in patients who were seen by a nephrologist more than once in the 6 months before dialysis than in those who were seen only once. The rate of kidney transplant at 1 year post-dialysis was lower for patients with emergency or planned dialysis initiation with a catheter (respectively, HR = 0.5 [0.4; 0.8] and HR = 0.7 [0.5; 0.9]) compared to patients with planned dialysis start with a fistula. Patients who were seen by a nephrologist more than three times between 0 and 6 months before dialysis start were more likely to access the waiting list 1 and 3 years after dialysis start (respectively, HR = 1.3 [1.1; 1.5] and HR = 1.2 [1.1; 1.4]). CONCLUSIONS Nephrological follow-up in the year before dialysis initiation is associated with better survival and higher probability of access to kidney transplantation. These results emphasize the importance of early patient referral to nephrologists by general practitioners.
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Affiliation(s)
- Juliette Piveteau
- Univ Rennes, EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS - U1309, French School of Public Health, 15 Avenue du Professeur Léon Bernard, Rennes, France.
| | - Maxime Raffray
- Univ Rennes, EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS - U1309, French School of Public Health, 15 Avenue du Professeur Léon Bernard, Rennes, France
| | - Cécile Couchoud
- Renal Epidemiology and Information Network (REIN) Registry, Biomedecine Agency, Saint-Denis-La-Plaine, France
| | - Carole Ayav
- CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie Clinique, Nancy, France
| | - Valérie Chatelet
- Centre Universitaire des Maladies Rénales, CHU Caen, Caen, France
- U1086 Inserm, ANTICIPE, Centre de Lutte Contre le Cancer François Baclesse, Caen, France
| | - Cécile Vigneau
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France
| | - Sahar Bayat
- Univ Rennes, EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS - U1309, French School of Public Health, 15 Avenue du Professeur Léon Bernard, Rennes, France
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3
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Kelepouris E, St Peter W, Neumiller JJ, Wright EE. Optimizing Multidisciplinary Care of Patients with Chronic Kidney Disease and Type 2 Diabetes Mellitus. Diabetes Ther 2023:10.1007/s13300-023-01416-2. [PMID: 37209236 DOI: 10.1007/s13300-023-01416-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/19/2023] [Indexed: 05/22/2023] Open
Abstract
Diabetes is the leading cause of chronic kidney disease (CKD), a condition associated with significant morbidity and mortality. As these patients have a high risk of developing cardiovascular disease and end-stage kidney disease, there is a need for early detection and early initiation of appropriate therapeutic interventions that slow disease progression and prevent adverse outcomes. Due to the complex nature of diabetes and CKD management, a holistic, patient-centered, collaborative care approach delivered by a coordinated multidisciplinary team (ideally including a clinical pharmacist as part of a comprehensive medication management program) is needed. In this review, we discuss the barriers to effective care, the current multidisciplinary approach used for CKD prevention and treatment, and the potential ways that the multidisciplinary management of CKD associated with type 2 diabetes mellitus can be refined to improve patient outcomes.
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Affiliation(s)
- Ellie Kelepouris
- Division of Renal Electrolyte and Hypertension, University of Pennsylvania, Philadelphia, PA, USA.
| | - Wendy St Peter
- University of Minnesota, Minneapolis, MN, USA
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
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Engels N, de Graav GN, van der Nat P, van den Dorpel M, Stiggelbout AM, Bos WJ. Shared decision-making in advanced kidney disease: a scoping review. BMJ Open 2022; 12:e055248. [PMID: 36130746 PMCID: PMC9494569 DOI: 10.1136/bmjopen-2021-055248] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To provide a comprehensive overview of interventions that support shared decision-making (SDM) for treatment modality decisions in advanced kidney disease (AKD). To provide summarised information on their content, use and reported results. To provide an overview of interventions currently under development or investigation. DESIGN The JBI methodology for scoping reviews was followed. This review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist. DATA SOURCES MEDLINE, Embase, Web of Science, Cochrane Library, Emcare, PsycINFO, PROSPERO and Academic Search Premier for peer-reviewed literature. Other online databases (eg, clinicaltrials.gov, OpenGrey) for grey literature. ELIGIBILITY FOR INCLUSION Records in English with a study population of patients >18 years of age with an estimated glomerular filtration rate <30 mL/min/1.73 m2. Records had to be on the subject of SDM, or explicitly mention that the intervention reported on could be used to support SDM for treatment modality decisions in AKD. DATA EXTRACTION AND SYNTHESIS Two reviewers independently screened and selected records for data extraction. Interventions were categorised as prognostic tools (PTs), educational programmes (EPs), patient decision aids (PtDAs) or multicomponent initiatives (MIs). Interventions were subsequently categorised based on the decisions they were developed to support. RESULTS One hundred forty-five interventions were identified in a total of 158 included records: 52 PTs, 51 EPs, 29 PtDAs and 13 MIs. Sixteen (n=16, 11%) were novel interventions currently under investigation. Forty-six (n=46, 35.7%) were reported to have been implemented in clinical practice. Sixty-seven (n=67, 51.9%) were evaluated for their effects on outcomes in the intended users. CONCLUSION There is no conclusive evidence on which intervention is the most efficacious in supporting SDM for treatment modality decisions in AKD. There is a lot of variation in selected outcomes, and the body of evidence is largely based on observational research. In addition, the effects of these interventions on SDM are under-reported.
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Affiliation(s)
- Noel Engels
- Department of Shared Decision-Making and Value-Based Health Care, Santeon, Utrecht, The Netherlands
- Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Internal Medicine, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Paul van der Nat
- Department of Value-Based Health Care, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Anne M Stiggelbout
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Jan Bos
- Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Value-Based Health Care, Sint Antonius Hospital, Nieuwegein, The Netherlands
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5
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Poor perception of chronic kidney diseases and its influencing factors among diabetics patients. Sci Rep 2022; 12:5694. [PMID: 35383215 PMCID: PMC8983655 DOI: 10.1038/s41598-022-09354-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 02/22/2022] [Indexed: 11/08/2022] Open
Abstract
Purpose We aimed to determine predictors of chronic kidney disease (CKD) prevention among patients with diabetes. Method A cross-sectional study was conducted on 1000 selected respondents based on socio-demographic, socio-economic, general CKD perception knowledge, self-monitoring advocacy, preventive behavior, treatment compliance, and psychosocial factors. Using multiple logistic regression, variables and their association with impaired perception of CKD prevention were analyzed. Results Overall, 74% had poor perception regarding CKD prevention (68.7% of men and 31.3% of women). In multivariable analysis, those with weak illness identity fear were two times more likely to have poor perceptions (95% CI 1.563–3.196, p < 0.001). Respondents with weak medical practice (AOR = 2.33, 95% CI 1.609–2.381, p < 0.001) and weak cooperation (AOR = 1.563; 95% CI 1.099–2.224, p < 0.001) were more likely to have poor perceptions on CKD prevention. Concerning poor perception, significant predictors were self-employment, housewives, working in private jobs, weak knowledge on clear glycosuria, sleep problems, print media, digital media, illness identity fear, weak medical practice, and weak co-operation factors. Conclusion Media support is crucial for supporting and improving positive views regarding CKD knowledge. Interventions to reach people with limited awareness on CKD prevention, lower socioeconomic status, and poor social support may improve identification of patients with early-stage CKD. Particular care should be taken to recognize and provide necessary services regarding the early detection of CKD.
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Aloudah SA, Alanazi BA, Alrehaily MA, Alqessayer AN, Alanazi NS, Elhassan E. Chronic Kidney Disease Education Class Improves Rates of Early Access Creation and Peritoneal Dialysis Enrollment. Cureus 2022; 14:e21306. [PMID: 35070580 PMCID: PMC8765590 DOI: 10.7759/cureus.21306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 11/18/2022] Open
Abstract
Background Most patients with end-stage kidney disease begin hemodialysis (HD) in an unplanned fashion at a late stage, necessitating the commencement of HD with a temporary venous catheter, the least favorable option. Alternative modalities of kidney replacement therapy (KRT), peritoneal dialysis (PD), and preemptive transplant offer similar or better outcomes than HD at a lower overall cost, and yet they remain underutilized in Saudi Arabia. Early education may help prepare patients with advanced chronic kidney disease (CKD IV and V) to accept their disease and choose a KRT modality that minimizes complications and matches their lifestyle. The aim of the study is to assess the impact of a pilot educational class on therapy choices and outcomes. Methodology In a cross-sectional study, we conducted phone interviews and reviewed medical records of 81 attendees of the multidisciplinary monthly educational class about KRT that was held at the King Abdulaziz Medical City (KAMC) from January 2017 to October 2021. The interview was conducted at least one year after the participants attended the class. The study proposal, consent, and questionnaire were approved by the King Abdulaziz International Medical Research Center. Patient data was retrieved from KAMC electronic medical record system. Results Volunteer participation in the survey was high (62/81). For the respondents, a preemptive kidney transplant was the most preferred (48/62, 77%) option for KRT. Among the preferred fallback options, HD was the most frequently chosen (29/62, 47%) compared to PD (26/62, 41.9%). At the time of the interview, a great majority of the patients (54/62, 87%) was already on KRT, including about half (26/54, 48%) on HD via a catheter, and the rest about equally divided between those on HD via an arteriovenous (AF) fistula (13/54, 24%) and those on PD (15/54, 28%). Thus, half of the respondents on KRT (28/54, 51%) avoided urgent HD catheter commencement. However, because of an unfortunate shortage of donors, only a small minority (2/62, 3%) of patients received preemptive transplantation. Conclusion The KAMC CKD education class helped boost the fraction of patients, significantly above the national average, who accepted the diagnosis of kidney failure and pursued preemptive native HD access or enrolled in PD.
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7
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Terlizzi V, Sandrini M, Vizzardi V, Tonoli M, Facchini A, Manili L, Zeni L, Cancarini G. Ten-year experience of an outpatient clinic for CKD-5 patients with multidisciplinary team and educational support. Int Urol Nephrol 2021; 54:949-957. [PMID: 34331637 PMCID: PMC8924108 DOI: 10.1007/s11255-021-02963-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 07/07/2021] [Indexed: 10/31/2022]
Abstract
PURPOSE To analyze the results of an outpatient clinic with a multidisciplinary team and educational support for patients with late-stage CKD (lsCKD), to check its possible effect on their outcomes. METHODS Longitudinal cohort study on patients followed up in the MaReA (Malattia Renale Avanzata = CKD5) outpatient clinic at ASST Spedali Civili of Brescia from 2005 to 2015 for at least six months. Trajectory of renal function over time has been evaluated only in those patients with at least four estimations of eGFR before referring to MaReA. RESULTS Seven hundred and six patients were enrolled, their mean age was 72 ± 14 years, 59% were males. At the end of the study, 147 (21%) were still on MaReA, 240 (34%) on dialysis, 92 (13%) on very low-protein diet (VLPDs), 13 (2%) on pre-hemodialysis clinic, 23 (3%) improved renal function, 10 (1%) transplanted, 62 (9%) transferred/lost to follow-up, and 119 (17%) died. Optimal dialysis start (defined as start with definitive dialysis access, as an out-patient and without lsCKD complications) occurred in 180/240 (75%) patients. The results showed a slower eGFR decrease during MaReA follow-up compared to previous renal follow-up: - 2.0 vs. - 4.0 mL/min/1.73 m2 BSA/year (p < 0.05), corresponding to a median delay of 17.7 months in dialysis start in reference to our policy in starting dialysis. The patient cumulative survival was 75% after 24 months and 25% after 70. LIMITATIONS (1) lack of a control group, (2) one-center-study, (3) about all patients were Caucasians. CONCLUSION The follow-up of lsCKD patients on MaReA is associated with an optimal and delayed initiation of dialysis.
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Affiliation(s)
- Vincenzo Terlizzi
- Operative Unit of Nephrology, ASST Spedali Civili Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - Massimo Sandrini
- Operative Unit of Nephrology, ASST Spedali Civili Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - Valerio Vizzardi
- Operative Unit of Nephrology, ASST Spedali Civili Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy.
| | - Mattia Tonoli
- Postgraduate School in Nephrology, University of Brescia, Brescia, Italy
| | - Annalisa Facchini
- Postgraduate School in Nephrology, University of Brescia, Brescia, Italy
| | - Luigi Manili
- Operative Unit of Nephrology, ASST Spedali Civili Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - Letizia Zeni
- Operative Unit of Nephrology, ASST Spedali Civili Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - Giovanni Cancarini
- Operative Unit of Nephrology, ASST Spedali Civili Brescia, Piazzale Spedali Civili, 1, 25123, Brescia, Italy.,Postgraduate School in Nephrology, University of Brescia, Brescia, Italy
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8
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Multidisciplinary education and lifestyle camps for CKD patients and their closest family members: effects on disease progression, self-management and psychosocial condition-a retrospective cohort study. Int Urol Nephrol 2021; 54:851-860. [PMID: 34268674 DOI: 10.1007/s11255-021-02948-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 07/07/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Multidisciplinary education including psychosocial care (MDE) may alleviate high burden of chronic kidney disease (CKD). Family support also has utmost importance, yet, MDE has rarely been provided jointly for patients and their relatives. METHODS We organized intensive, 1-week-long boarding MDE and lifestyle camps for CKD stage III-V patients and their relatives and assessed the rate of CKD progression, proportion of participants' home-based dialysis choice, transplant activity, and improvement of their coping and attitude evaluated by written narratives. Outcome was compared to 40 controls with similarly advanced CKD, under standard of care on our outpatient clinic. RESULTS In 60 predialysis patients, serum creatinine 12 months before participation was 281 [IQR 122] µmol/l, right before MDE 356 [IQR 141] µmol/l, 12 months after MDE 388 [IQR 284] µmol/l, eGFR decreased from 18.5 [IQR 10] ml/min to 14.0 [IQR 7] ml/min and 13.0 [IQR 8] ml/min, respectively. Twelve months' changes before and after MDE differed significantly (p = 0.005 for creatinine; p = 0.003 for eGFR). Decreased progression was found in comparison to controls (p = 0.004; 0.016, respectively) as well. During follow-up, MDE patients compared to controls chose PD as dialysis modality more often (p = 0.004), and were more active in renal transplantation (p = 0.026). Based on narratives, MDE enhanced participants' disease-specific knowledge and ability for coping. It also improved sympathy, helpfulness, and the mutual responsibilities of family members. CONCLUSIONS Our unique MDE programme with participation of the closest relatives enhanced the effectiveness of education and strengthened family support, which contributed to favorable CKD outcome, increased activity in home-based dialysis selection and transplant activity.
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King EK, Hsieh MH, Chang DR, Lu CT, Ting IW, Wang CCN, Chen PS, Yeh HC, Chiang HY, Kuo CC. Prediction of non-responsiveness to pre-dialysis care program in patients with chronic kidney disease: a retrospective cohort analysis. Sci Rep 2021; 11:13938. [PMID: 34230524 PMCID: PMC8260802 DOI: 10.1038/s41598-021-93254-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 06/16/2021] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Emily K King
- Department of Medical Media Design and Application, Interpedia Incorporated, Taichung, Taiwan.,Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, 2, Yude Rd., North Dist., Taichung City, 404, Taiwan
| | - Ming-Han Hsieh
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - David R Chang
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Cheng-Ting Lu
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - I-Wen Ting
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan.,Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, 2, Yude Rd., North Dist., Taichung City, 404, Taiwan
| | - Charles C N Wang
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan.,Center for Artificial Intelligence and Precision Medicine Research, Asia University, Taichung, Taiwan
| | - Pei-Shan Chen
- Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, 2, Yude Rd., North Dist., Taichung City, 404, Taiwan
| | - Hung-Chieh Yeh
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan.,Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, 2, Yude Rd., North Dist., Taichung City, 404, Taiwan.,AKI-CARE (Clinical Advancement, Research and Education) Center, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Hsiu-Yin Chiang
- Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, 2, Yude Rd., North Dist., Taichung City, 404, Taiwan
| | - Chin-Chi Kuo
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan. .,Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, 2, Yude Rd., North Dist., Taichung City, 404, Taiwan. .,AKI-CARE (Clinical Advancement, Research and Education) Center, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan.
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10
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Kang M, Kim YL, Kang E, Ryu H, Kim YC, Kim DK, Lee H, Han SS, Joo KW, Kim YS, Ahn C, Oh KH. Evolving outcomes of peritoneal dialysis: secular trends at a single large center over three decades. Kidney Res Clin Pract 2021; 40:472-483. [PMID: 34233441 PMCID: PMC8476299 DOI: 10.23876/j.krcp.21.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/24/2021] [Indexed: 11/24/2022] Open
Abstract
Background Peritoneal dialysis (PD) is improving as a renal replacement therapy for end-stage renal disease (ESRD) patients. We analyzed the main outcomes of PD over the last three decades at a single large-scale PD center with an established high-quality care system. Methods As a retrospective cohort study, we included participants (n = 1,203) who began PD between 1990 and 2019. Major PD-related outcomes were compared among the three 10-year cohorts. Results The 1,203 participants were 58.3% male with a mean age of 47.9 ± 13.8 years. The median PD treatment duration was 45 months (interquartile range, 19–77 months); 362 patients (30.1%) transferred to hemodialysis, 289 (24.0%) received kidney transplants, and 224 (18.6%) died. Overall, the 5- and 8-year adjust patient survival rates were 64% and 49%, respectively. Common causes of death included infection (n = 55), cardiac (n = 38), and cerebrovascular (n = 17) events. The 5- and 8-year technique survival rates were 77% and 62%, respectively, with common causes of technique failure being infection (42.3%) and solute/water clearance problems (22.7%). The 5-year patient survival significantly improved over time (64% for the 1990–1999 cohort vs. 93% for the 2010–2019 cohort). The peritonitis rate also substantially decreased over time, from 0.278 episodes/patient-year (2000–2004) to 0.162 episodes/patient-year (2015–2019). Conclusion PD is an effective treatment option for ESRD patients. There was a substantial improvement in the patient survival and peritonitis rates over time. Establishing adequate infrastructure and an effective system for high-quality PD therapy may be warranted to improve PD outcomes.
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Affiliation(s)
- Minjung Kang
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yae Lim Kim
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Eunjeong Kang
- Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Hyunjin Ryu
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yong Chul Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong Ki Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hajeong Lee
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Seok Han
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kwon-Wook Joo
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yon Su Kim
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Curie Ahn
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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11
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Ino J, Kasama E, Kodama M, Sato K, Eizumi H, Kawashima Y, Sekiguchi M, Fujiwara T, Yamazaki A, Suzuki C, Ina S, Okuma A, Nitta K. Multidisciplinary Team Care Delays the Initiation of Renal Replacement Therapy in Diabetes: A Five-year Prospective, Single-center Study. Intern Med 2021; 60:2017-2026. [PMID: 33518556 PMCID: PMC8313920 DOI: 10.2169/internalmedicine.4927-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective Although recent reports have highlighted the benefits of multidisciplinary team care (MTC) for chronic kidney disease (CKD) in slowing the progress of renal insufficiency, its long-term effects have not been evaluated for patients with diabetes mellitus (DM). We compared the renal survival rate between MTC and conservative care (CC). Methods In this five-year, single-center, prospective, observational study, we examined 24 patients (mean age 65.5±12.1 years old, men/women 18/6) with DM-induced CKD stage ≥3 in an MTC clinic. The control group included 24 random patients with DM (mean age 61.0±12.8 years old, men/women 22/2) who received CC. MTC was provided by a nephrologist and medical staff, and CC was provided by a nephrologist. Results In total, 10 MTC and 20 CC patients experienced renal events [creatinine doubling, initiation of renal replacement therapy (RRT), or death due to end-stage CKD]. During the five-year observation period, there were significantly fewer renal events in the MTC group than in the CC group according to the cumulative incidence method (p=0.006). Compared to CC, MTC significantly reduced the need for urgent initiation of hemodialysis (relative risk reduction 0.79, 95% confidence interval [CI] 0.107-0.964). On a multivariate analysis, MTC (hazard ratio [HR], 0.434, 95% CI 0.200-0.939) and the slope of the estimated glomerular filtration rate during the first year (HR, 0.429 per 1 mL/min/m2/year, 95% CI 0.279-0.661) were negatively associated with renal events. Conclusion MTC for DM-induced CKD is an effective strategy for delaying RRT. Long-term MTC can demonstrate reno-protective effects.
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Affiliation(s)
- Jun Ino
- Department of Nephrology, Kidney Center, Toda Central General Hospital, Japan
| | - Eri Kasama
- Department of Nephrology, Kidney Center, Toda Central General Hospital, Japan
| | - Mio Kodama
- Department of Nephrology, Kidney Center, Toda Central General Hospital, Japan
| | - Keitaro Sato
- Department of Nephrology, Kidney Center, Toda Central General Hospital, Japan
| | - Hitoshi Eizumi
- Department of Nephrology, Kidney Center, Toda Central General Hospital, Japan
| | - Youichiro Kawashima
- Department of Nephrology, Kidney Center, Toda Central General Hospital, Japan
| | - Maki Sekiguchi
- Department of Nursing, Kidney Center, Toda Central General Hospital, Japan
| | - Tomoko Fujiwara
- Department of Nutrition, Toda Central General Hospital, Japan
| | - Aya Yamazaki
- Department of Nutrition, Toda Central General Hospital, Japan
| | - Chie Suzuki
- Department of Pharmacy, Toda Central General Hospital, Japan
| | - Shuji Ina
- Department of Pharmacy, Toda Central General Hospital, Japan
| | - Astushi Okuma
- Department of Rehabilitation, Toda Central General Hospital, Japan
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, Japan
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12
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Collier ZK, Leite WL, Karpyn A. Neural Networks to Estimate Generalized Propensity Scores for Continuous Treatment Doses. EVALUATION REVIEW 2021:193841X21992199. [PMID: 33653165 PMCID: PMC9344588 DOI: 10.1177/0193841x21992199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND The generalized propensity score (GPS) addresses selection bias due to observed confounding variables and provides a means to demonstrate causality of continuous treatment doses with propensity score analyses. Estimating the GPS with parametric models obliges researchers to meet improbable conditions such as correct model specification, normal distribution of variables, and large sample sizes. OBJECTIVES The purpose of this Monte Carlo simulation study is to examine the performance of neural networks as compared to full factorial regression models to estimate GPS in the presence of Gaussian and skewed treatment doses and small to moderate sample sizes. RESEARCH DESIGN A detailed conceptual introduction of neural networks is provided, as well as an illustration of selection of hyperparameters to estimate GPS. An example from public health and nutrition literature uses residential distance as a treatment variable to illustrate how neural networks can be used in a propensity score analysis to estimate a dose-response function of grocery spending behaviors. RESULTS We found substantially higher correlations and lower mean squared error values after comparing true GPS with the scores estimated by neural networks. The implication is that more selection bias was removed using GPS estimated with neural networks than using GPS estimated with classical regression. CONCLUSIONS This study proposes a new methodological procedure, neural networks, to estimate GPS. Neural networks are not sensitive to the assumptions of linear regression and other parametric models and have been shown to be a contender against parametric approaches to estimate propensity scores for continuous treatments.
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Imamura Y, Takahashi Y, Uchida S, Iwamoto M, Nakamura R, Yamauchi M, Ogawara Y, Goto M, Takeba K, Yaguchi N, Joki N. Effect of multidisciplinary care of dialysis initiation for outpatients with chronic kidney disease. Int Urol Nephrol 2021; 53:1435-1444. [PMID: 33590452 DOI: 10.1007/s11255-021-02787-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/19/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of comprehensive multidisciplinary care (MDC) by the chronic kidney disease (CKD) team is not only to prevent worsening renal function, but also provide education on the selection of renal replacement therapy (RRT) by shared decision making (SDM). The purpose of this study was to examine the effects of MDC for predialysis outpatients on dialysis therapy, especially with regard to peritoneal dialysis (PD). METHODS This study evaluated 112 CKD patients who underwent dialysis at our hospital starting from 2012, with 53 outpatients receiving MDC from the CKD team and 59 outpatients not receiving MDC. Annual decreases in the estimated glomerular filtration rates (ΔeGFR), the duration from the time of intervention to dialysis initiation, the urgent dialysis rate using a temporary catheter, and the PD selection rate were compared and examined between the two groups. The ΔeGFR, the duration from intervention to PD initiation, and the PD retention rate were compared between 18 PD patients in the MDC group and 10 PD patients in the non-MDC group. RESULTS The MDC group had a significantly lower ΔeGFR, significantly longer duration, and a significantly lower urgent dialysis initiation rate versus the non-MDC group. Moreover, there was a significantly higher PD selection rate, significantly prolonged duration, and significantly higher PD retention rate. CONCLUSIONS Multidisciplinary CKD team care for outpatients is effective in delaying the progression of CKD and avoiding the initiation of urgent dialysis; contributing to improved PD selectivity and continuity by SDM.
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Affiliation(s)
- Yoshihiko Imamura
- Department of Nephrology, Nissan Tamagawa Hospital, 4-8-1 Seta Setagaya-ku, Tokyo, 158-0095, Japan.
| | - Yasunori Takahashi
- Department of Nephrology, Nissan Tamagawa Hospital, 4-8-1 Seta Setagaya-ku, Tokyo, 158-0095, Japan
| | - Satoru Uchida
- Department of Diabetes, Nissan Tamagawa Hospital, 4-8-1 Seta Setagaya-ku, Tokyo, 158-0095, Japan
| | - Masateru Iwamoto
- Department of Diabetes, Nissan Tamagawa Hospital, 4-8-1 Seta Setagaya-ku, Tokyo, 158-0095, Japan
| | - Rie Nakamura
- Division of Nursing, Nissan Tamagawa Hospital, 4-8-1 Seta Setagaya-ku, Tokyo, 158-0095, Japan
| | - Miki Yamauchi
- Division of Nursing, Nissan Tamagawa Hospital, 4-8-1 Seta Setagaya-ku, Tokyo, 158-0095, Japan
| | - Yuka Ogawara
- Division of Pharmacy, Nissan Tamagawa Hospital, 4-8-1 Seta Setagaya-ku, Tokyo, 158-0095, Japan
| | - Mikiko Goto
- Division of Pharmacy, Nissan Tamagawa Hospital, 4-8-1 Seta Setagaya-ku, Tokyo, 158-0095, Japan
| | - Kazuyo Takeba
- Division of Pharmacy, Nissan Tamagawa Hospital, 4-8-1 Seta Setagaya-ku, Tokyo, 158-0095, Japan
| | - Naomi Yaguchi
- Division of Nutrition Management, Nissan Tamagawa Hospital, 4-8-1 Seta Setagaya-ku, Tokyo, 158-0095, Japan
| | - Nobuhiko Joki
- Division of Nephrology, Toho University Medical Center Ohashi Hospital, 2-22-36 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan
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Hahn Lundström U, Hedin U, Gasparini A, Caskey FJ, Carrero JJ, Evans M. Arteriovenous access placement and renal function decline. Nephrol Dial Transplant 2021; 36:275-280. [PMID: 31665436 DOI: 10.1093/ndt/gfz221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/02/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND There is controversial evidence on whether arteriovenous access (AVA) placement may protect renal function and hence should be considered in the timing of access placement. This study aimed to investigate the association between AVA placement and estimated glomerular filtration rate (eGFR) decline as compared with the placement of a peritoneal dialysis catheter (PDC) at a similar time point. METHODS We studied a cohort of 744 pre-dialysis patients in Stockholm, Sweden, who underwent surgery for AVA or PDC between 2006 and 2012. Data on comorbidity, medication and laboratory measures were collected 100 days before and after surgery. Patients were followed until dialysis start, death or 100 days, whichever came first. The primary outcome was difference in eGFR decline after AVA surgery compared with PDC. Decline in eGFR was estimated through linear mixed models with random intercept and slope, before and after surgery. RESULTS There were 435 AVA and 309 PDC patients. The AVA patients had higher eGFR (8.1 mL/min/1.73 m2 versus 7.0 mL/min/1.73 m2) and less rapid eGFR decline before surgery (-5.6 mL/min/1.73 m2/year compared with -6.7 mL/min/1.73 m2/year for PDC). We found no difference in eGFR decline after surgery in AVA patients compared with PDC patients [AVA progressed 0.26 (95% confidence interval -0.88 to 0.35) mL/min/1.73 m2/year faster after surgery compared with PDC]. CONCLUSIONS There was no significant difference in eGFR decline after placement of an AVA compared with a PDC. Both forms of access were associated with reduced eGFR decline in our population. The need for dialysis remains the main determinant for timing of access surgery.
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Affiliation(s)
| | - Ulf Hedin
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | | | - Fergus J Caskey
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Juan-Jesus Carrero
- Karolinska Institutet, Department of Medical Epidemiology and Biostatistics, Stockholm, Sweden
| | - Marie Evans
- Karolinska Institutet, Division of Renal Medicine, Clintec, Stockholm, Sweden
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Takagi WH, Osako K, Machida S, Koitabashi K, Shibagaki Y, Sakurada T. Inpatient educational program delays the need for dialysis in patients with chronic kidney disease stage G5. Clin Exp Nephrol 2020; 25:166-172. [PMID: 33040245 DOI: 10.1007/s10157-020-01979-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/23/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Wei Han Takagi
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kiyomi Osako
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Shinji Machida
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kenichiro Koitabashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Tsutomu Sakurada
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.
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16
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Chan CT, Collins K, Ditschman EP, Koester-Wiedemann L, Saffer TL, Wallace E, Rocco MV. Overcoming Barriers for Uptake and Continued Use of Home Dialysis: An NKF-KDOQI Conference Report. Am J Kidney Dis 2020; 75:926-934. [DOI: 10.1053/j.ajkd.2019.11.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/19/2019] [Indexed: 12/24/2022]
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17
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Hassan R, Akbari A, Brown PA, Hiremath S, Brimble KS, Molnar AO. Risk Factors for Unplanned Dialysis Initiation: A Systematic Review of the Literature. Can J Kidney Health Dis 2019; 6:2054358119831684. [PMID: 30899532 PMCID: PMC6419254 DOI: 10.1177/2054358119831684] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/14/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Unplanned dialysis initiation is common in patients with chronic kidney disease (CKD). Objective: To determine common definitions and patient risk factors for unplanned dialysis. Design: Systematic review. Setting: MEDLINE, EMBASE, and the Cochrane Library were searched from inception to February 2018. Patients: Studies that included incident chronic dialysis patients or patients with CKD that cited a definition or examined risk factors for unplanned dialysis were included. Measurements: Definitions and criteria for unplanned dialysis reported across studies. Patient characteristics associated with unplanned dialysis. Methods: Two reviewers independently extracted data using a standardized data abstraction form and assessed study quality using a modified New Castle Ottawa Scale. Results: From 2797 citations, 48 met eligibility criteria. Reported definitions for unplanned dialysis were variable. Most publications cited dialysis initiation under emergency conditions and/or with a central venous catheter. The association of patient characteristics with unplanned dialysis was reported in 26 studies, 18 were retrospective and 21 included incident dialysis patients. The most common risk factors in univariate analyses were (number of studies) increased age (n = 7), cause of kidney disease (n = 6), presence of cardiovascular disease (n = 7), lower serum hemoglobin (n = 9), lower serum albumin (n = 10), higher serum phosphate (n = 6), higher serum creatinine or lower estimated glomerular filtration rate (eGFR) at dialysis initiation (n = 7), late referral (n = 5), lack of dialysis education (n = 6), and lack of follow-up in a predialysis clinic prior to dialysis initiation (n = 5). A minority of studies performed multivariable analyses (n = 10); the most common risk factors were increased age (n = 4), increased comorbidity score (n = 3), late referral (n = 5), and lower eGFR at dialysis initiation (n = 3). Limitations: Comparison of results across studies was limited by inconsistent definitions for unplanned dialysis. High-quality data on patient risk factors for unplanned dialysis are lacking. Conclusions: Well-designed prospective studies to determine modifiable risk factors are needed. The lack of a consensus definition for unplanned dialysis makes research and quality improvement initiatives in this area more challenging.
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18
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Dubin R, Rubinsky A. A Digital Modality Decision Program for Patients With Advanced Chronic Kidney Disease. JMIR Form Res 2019; 3:e12528. [PMID: 30724735 PMCID: PMC6381409 DOI: 10.2196/12528] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Patient education regarding end-stage renal disease (ESRD) has the potential to reduce adverse outcomes and increase the use of in-home renal replacement therapies. OBJECTIVE This study aimed to investigate whether an online, easily scalable education program can improve patient knowledge and facilitate decision making regarding renal replacement therapy options. METHODS We developed a 4-week online, digital educational program that included written information, short videos, and social networking features. Topics included kidney transplant, conservative management, peritoneal dialysis, in-home hemodialysis, and in-center hemodialysis. We recruited patients with advanced chronic kidney disease (stage IV and V) to enroll in the online program, and we evaluated the feasibility and potential impact of the digital program by conducting pre- and postintervention surveys in areas of knowledge, self-efficacy, and choice of ESRD care. RESULTS Of the 98 individuals found to be eligible for the study, 28 enrolled and signed the consent form and 25 completed the study. The average age of participants was 65 (SD 15) years, and the average estimated glomerular filtration rate was 21 (SD 6) ml/min/1.73 m2. Before the intervention, 32% of patients (8/25) were unable to make an ESRD treatment choice; after the intervention, all 25 participants made a choice. The proportion of persons who selected kidney transplant as the first choice increased from 48% (12/25) at intake to 84% (21/25) after program completion (P=.01). Among modality options, peritoneal dialysis increased as the first choice for 4/25 (16%) patients at intake to 13/25 (52%) after program completion (P=.004). We also observed significant increases in knowledge score (from 65 [SD 56] to 83 [SD 14]; P<.001) and self-efficacy score (from 3.7 [SD 0.7] to 4.3 [SD 0.5]; P<.001). CONCLUSIONS Implementation of a digital ESRD education program is feasible and may facilitate patients' decisions about renal replacement therapies. Larger studies are necessary to understand whether the program affects clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT02976220; https://clinicaltrials.gov/ct2/show/NCT02976220.
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Affiliation(s)
- Ruth Dubin
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States.,University California San Francisco, San Francisco, CA, United States
| | - Anna Rubinsky
- Kidney Health Research Collaborative, University of California San Francisco / San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
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19
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Usefulness of multidisciplinary care to prevent worsening renal function in chronic kidney disease. Clin Exp Nephrol 2018; 23:484-492. [PMID: 30341572 DOI: 10.1007/s10157-018-1658-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/06/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Comprehensive education about lifestyle, nutrition, medications and other types of treatment is important to prevent renal dysfunction in patients with chronic kidney disease (CKD). However, the effectiveness of multidisciplinary care on CKD progression has not been evaluated in detail. We aimed to determine whether multidisciplinary care at our hospital could help prevent worsening renal function associated with CKD. METHODS A total of 150 pre-dialysis CKD outpatients accompanied (n = 68) or not (n = 82) with diabetes mellitus (DM) were enrolled into this study. We assessed annual decreases in estimated glomerular filtration rates (ΔeGFR), and measured systolic blood pressure (SBP), diastolic blood pressure (DBP), hemoglobin (Hb), uric acid (UA), low-density lipoprotein cholesterol (LDL), hemoglobin A1c (HbA1c) values and urinary protein to creatinine ratios (UPCR) 12 months before and after multidisciplinary care. In addition, changes in the number of medications and prescription ratio before and after multidisciplinary care were assessed in 90 patients with CKD who could confirm their prescribed medications. RESULTS The ΔeGFR significantly improved between before and after multidisciplinary care from - 5.46 to - 0.56 mL/min/1.73 m2/year, respectively. The number of medications and prescription ratio showed no significant changes before and after multidisciplinary care. The ratios of improved ΔeGFR were found in 66.7% of all patients, comprising 63.1% of males and 76.9% of females, 64.8% without DM and 69.4% with DM. Values for UA, LDL, and HbA1c were significantly reduced among patients with improved ΔeGFR. CONCLUSION Comprehensive multidisciplinary care of outpatients might help prevent worsening renal function among patients with CKD.
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20
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Hsu CK, Lee CC, Chen YT, Ting MK, Sun CY, Chen CY, Hsu HJ, Chen YC, Wu IW. Multidisciplinary predialysis education reduces incidence of peritonitis and subsequent death in peritoneal dialysis patients: 5-year cohort study. PLoS One 2018; 13:e0202781. [PMID: 30138478 PMCID: PMC6107258 DOI: 10.1371/journal.pone.0202781] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/08/2018] [Indexed: 12/04/2022] Open
Abstract
Background Technique failure secondary to peritonitis is a grave impediment to remain in peritoneal dialysis (PD) therapy leading to high mortality. Multidisciplinary predialysis education (MPE) has shown improvement in outcomes of chronic kidney disease (CKD) patients. However, the legacy effects of MPE in PD patients remain unclear. Methods All patients who started PD at single hospital in 2007–16 were enrolled. The incidences of peritonitis and peritonitis-related mortality were compared between MPE recipients and non-recipients. The content of the MPE was standardized in accordance with the NKF/DOQI guidelines. Kaplan-Meier analysis and Cox proportional hazards model were applied to identify the prognostic factors associated with peritonitis-free survival. Results Of 398 PD patients, 169 patients had received MPE before starting PD. The patients of MPE group had a lower peritonitis rate [median (IQR) 0 (0.29) versus 0.11 (0.69) episodes/person-year, P< 0.001] and a lower percentage of peritonitis-related deaths (3.6% versus 8.7%, P = 0.04) compared with the non-MPE group. The median time to the first episode of peritonitis in the non-MPE and MPE groups was 33.9 months and 46.7 months, respectively (Cox-Mantel log rank test, P = 0.003). Cox regression analysis revealed that MPE assignment (HR: 0.594; 95% CI: 0.434–0.813, P< 0.001) were significant independent predictors for peritonitis-free survival. Conclusions An efficient standardized MPE program may prolong the time to the first episode of peritonitis and reduce peritonitis rate, independent of age, gender, diabetes, hypertension, educational status and PD modality. Subsequently, decreased peritonitis-related death.
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Affiliation(s)
- Cheng-Kai Hsu
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chin-Chan Lee
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yih-Ting Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ming-Kuo Ting
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chiao-Yin Sun
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chun-Yu Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Heng-Jung Hsu
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yung-Chang Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - I-Wen Wu
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- * E-mail:
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21
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Hsieh HM, Lin MY, Chiu YW, Wu PH, Cheng LJ, Jian FS, Hsu CC, Hwang SJ. Economic evaluation of a pre-ESRD pay-for-performance programme in advanced chronic kidney disease patients. Nephrol Dial Transplant 2018; 32:1184-1194. [PMID: 28486670 DOI: 10.1093/ndt/gfw372] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/25/2016] [Indexed: 12/13/2022] Open
Abstract
Background The National Health Insurance Administration in Taiwan initiated a nationwide pre-end-stage renal disease (ESRD) pay-for-performance (P4P) programme at the end of 2006 to improve quality of care for chronic kidney disease (CKD) patients. This study aimed to examine this programme's effect on patients' clinical outcomes and its cost-effectiveness among advanced CKD patients. Methods We conducted a longitudinal observational matched cohort study using two nationwide population-based datasets. The major outcomes of interests were incidence of dialysis, all-cause mortality, direct medical costs, life years (LYs) and incremental cost-effectiveness ratio comparing matched P4P and non-P4P advanced CKD patients. Competing-risk analysis, general linear regression and bootstrapping statistical methods were used for the analysis. Results Subdistribution hazard ratio (95% confidence intervals) for advanced CKD patients enrolled in the P4P programme, compared with those who did not enrol, were 0.845 (0.779-0.916) for incidence of dialysis and 0.792 (0.673-0.932) for all-cause mortality. LYs for P4P and non-P4P patients who initiated dialysis were 2.83 and 2.74, respectively. The adjusted incremental CKD-related costs and other-cause-related costs were NT$114 704 (US$3823) and NT$32 420 (US$1080) for P4P and non-P4P patients who initiated dialysis, respectively, and NT$-3434 (US$114) and NT$45 836 (US$1572) for P4P and non-P4P patients who did not initiate dialysis, respectively, during the 3-year follow-up period. Conclusions P4P patients had lower risks of both incidence of dialysis initiation and death. In addition, our empirical findings suggest that the P4P pre-ESRD programme in Taiwan provided a long-term cost-effective use of resources and cost savings for advanced CKD patients.
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Affiliation(s)
- Hui-Min Hsieh
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Yen Lin
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Wen Chiu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ping-Hsun Wu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Jeng Cheng
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Feng-Shiuan Jian
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan.,Department of Health Services Administration, China Medical University, Taichung City, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shang-Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Institute of Population Sciences, National Health Research Institutes, Miaoli, Taiwan
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Lin E, Chertow GM, Yan B, Malcolm E, Goldhaber-Fiebert JD. Cost-effectiveness of multidisciplinary care in mild to moderate chronic kidney disease in the United States: A modeling study. PLoS Med 2018; 15:e1002532. [PMID: 29584720 PMCID: PMC5870947 DOI: 10.1371/journal.pmed.1002532] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 02/14/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Multidisciplinary care (MDC) programs have been proposed as a way to alleviate the cost and morbidity associated with chronic kidney disease (CKD) in the US. METHODS AND FINDINGS We assessed the cost-effectiveness of a theoretical Medicare-based MDC program for CKD compared to usual CKD care in Medicare beneficiaries with stage 3 and 4 CKD between 45 and 84 years old in the US. The program used nephrologists, advanced practitioners, educators, dieticians, and social workers. From Medicare claims and published literature, we developed a novel deterministic Markov model for CKD progression and calibrated it to long-term risks of mortality and progression to end-stage renal disease. We then used the model to project accrued discounted costs and quality-adjusted life years (QALYs) over patients' remaining lifetime. We estimated the incremental cost-effectiveness ratio (ICER) of MDC, or the cost of the intervention per QALY gained. MDC added 0.23 (95% CI: 0.08, 0.42) QALYs over usual care, costing $51,285 per QALY gained (net monetary benefit of $23,100 at a threshold of $150,000 per QALY gained; 95% CI: $6,252, $44,323). In all subpopulations analyzed, ICERs ranged from $42,663 to $72,432 per QALY gained. MDC was generally more cost-effective in patients with higher urine albumin excretion. Although ICERs were higher in younger patients, MDC could yield greater improvements in health in younger than older patients. MDC remained cost-effective when we decreased its effectiveness to 25% of the base case or increased the cost 5-fold. The program costed less than $70,000 per QALY in 95% of probabilistic sensitivity analyses and less than $87,500 per QALY in 99% of analyses. Limitations of our study include its theoretical nature and being less generalizable to populations at low risk for progression to ESRD. We did not study the potential impact of MDC on hospitalization (cardiovascular or other). CONCLUSIONS Our model estimates that a Medicare-funded MDC program could reduce the need for dialysis, prolong life expectancy, and meet conventional cost-effectiveness thresholds in middle-aged to elderly patients with mild to moderate CKD.
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Affiliation(s)
- Eugene Lin
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America.,Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Brandon Yan
- Duke University, Durham, North Carolina, United States of America
| | - Elizabeth Malcolm
- Division of General Medical Disciplines, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Jeremy D Goldhaber-Fiebert
- Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Palo Alto, California, United States of America
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Abstract
: The burden of chronic kidney disease (CKD) is rising both in this country and worldwide. An estimated 10% to 15% of U.S. adults are currently living with CKD. Reducing the CKD burden requires a systematic, interdisciplinary approach to care. The greatest opportunities to reduce the impact of CKD arise early, when most patients are being followed in primary care; yet many clinicians are inadequately educated on this disease. Nurses are well positioned to facilitate the implementation of collaborative care. This two-part article aims to provide nurses with the basic information necessary to assess and manage patients with CKD. Part 1 offers an overview of the disease, describes identification and etiology, and discusses ways to slow disease progression. Part 2, which will appear next month, addresses disease complications and treatment of kidney failure.
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Changsirikulchai S, Sangthawan P, Janma J, Sripaiboonkij N, Rattanamongkolgul S, Thinkhamrop B. National survey: Evaluation of cardiovascular risk factors in Thai patients with type 2 diabetes and chronic kidney disease after the development of cardiovascular disease. Nephrology (Carlton) 2017; 23:53-59. [DOI: 10.1111/nep.12922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 09/06/2016] [Accepted: 09/07/2016] [Indexed: 01/04/2023]
Affiliation(s)
- Siribha Changsirikulchai
- Renal Division, Department of Medicine, Faculty of Medicine; Srinakharinwirot University; Thailand
| | - Pornpen Sangthawan
- Renal Division, Department of Medicine, Faculty of Medicine; Prince of Songkla University; Thailand
| | - Jirayut Janma
- Renal Division, Department of Medicine, Faculty of Medicine; Srinakharinwirot University; Thailand
| | - Nintita Sripaiboonkij
- Ramathibodi Comprehensive Cancer Center, Faculty of Medicine; Ramathibodi Hospital; Thailand
| | - Suthee Rattanamongkolgul
- Department of Preventive and Social Medicine, Faculty of Medicine; Srinakharinwirot University; Thailand
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Schanz M, Ketteler M, Heck M, Dippon J, Alscher MD, Kimmel M. Impact of an in-Hospital Patient Education Program on Choice of Renal Replacement Modality in Unplanned Dialysis Initiation. Kidney Blood Press Res 2017; 42:865-876. [PMID: 29161686 DOI: 10.1159/000484531] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 09/21/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Up to 50% patients requiring dialysis receive an urgent, unplanned start (UPS) to renal replacement therapy (RRT). Most of these are initiated with an intravenous catheter and commenced and maintained on hemodialysis (HD). Although peritoneal dialysis (PD) could be an equipotent initial modality for RRT, it is used less frequently as long-term RRT in UPS patients. This multicenter-study aimed to evaluate the impact of a structured, in-hospital education program and factors influencing PD rates, especially in UPS patients. METHODS Three German nephrology departments collaborated to implement an in-hospital education program. Retrospective analysis included 336 subjects and compared the rates of HD and PD in consecutive patients who started RRT 12 months prior (two centers) and for 12 months after (three centers) implementing the education program. RESULTS PD rates increased significantly (p < 0.05) by 66% in all planned and unplanned dialysis starts after implementation of a structured, patient-centered education program. A highly significant (p < 0.0001) rise in utilization of PD was found, especially in UPS patients. In logistic regression analysis, PD modality choice was significantly influenced by age (p < 0.0001) and gender (p = 0.006). CONCLUSIONS A structured, patient-centered in-hospital education program increases the frequency of PD in patients needing unplanned RRT. PD modality choice is significantly higher in young (p < 0.0001) and male (p = 0.006) patients.
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Affiliation(s)
- Moritz Schanz
- Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany
| | | | - Markus Heck
- Nephrological Center Emsland, Lingen, Germany
| | - Juergen Dippon
- Department of Mathematics, University of Stuttgart, Stuttgart, Germany
| | - Mark Dominik Alscher
- Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany
| | - Martin Kimmel
- Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Robert-Bosch Hospital, Stuttgart, Germany
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26
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Shi Y, Xiong J, Chen Y, Deng J, Peng H, Zhao J, He J. The effectiveness of multidisciplinary care models for patients with chronic kidney disease: a systematic review and meta-analysis. Int Urol Nephrol 2017; 50:301-312. [PMID: 28856498 PMCID: PMC5811573 DOI: 10.1007/s11255-017-1679-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/14/2017] [Indexed: 01/12/2023]
Abstract
Aim To assess the efficacy of the multidisciplinary care (MDC) model for patients with chronic kidney disease (CKD). Background The MDC model has been used in clinical practice for years, but the effectiveness of the MDC model for patients with CKD remains controversial. Methods Embase, PubMed, Medline, the Cochrane Library, and China National Knowledge Infrastructure databases were used to search for relevant articles. Only randomized controlled trials and cohort studies were pooled. Two independent authors assessed all articles and extracted the data. The efficacy was estimated from the odds ratios and corresponding 95% confidence intervals. A random effects model was used according to the heterogeneity. Results Twenty-one studies including 10,284 participants were analyzed. Compared with the non-MDC group, MDC was associated with a lower risk of all-cause mortality and lower hospitalization rates for patients with CKD. In addition, MDC also resulted in a slower eGFR decline and reduced temporary catheterization for patients receiving dialysis. However, according to the subgroup analysis, the lower rates of all-cause mortality in the MDC group were observed only in patients in stage 4–5 and when the staff of the MDC consisted of nephrologists, nurse specialists and professionals from other fields. The most prominent effect of reducing the hospitalization rates was also observed in patients with stage 4–5 but not in patients with stage 4–5 CKD. Conclusions MDC can lower the all-cause mortality of patients with CKD, reduce temporary catheterization for patients receiving dialysis, decrease the hospitalization rate, and slow the eGFR decline. Moreover, the reduction in all-cause mortality crucially depends on the professionals comprising the MDC staff and the stage of CKD in patients. In addition, the CKD stage influences the hospitalization rates.
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Affiliation(s)
- Yu Shi
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Jiachuan Xiong
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Yan Chen
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Junna Deng
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Hongmei Peng
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Jinghong Zhao
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Jing He
- Institute of Nephrology of Chongqing and Kidney Center of PLA, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
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Lower Education Level Is a Risk Factor for Peritonitis and Technique Failure but Not a Risk for Overall Mortality in Peritoneal Dialysis under Comprehensive Training System. PLoS One 2017; 12:e0169063. [PMID: 28056058 PMCID: PMC5215932 DOI: 10.1371/journal.pone.0169063] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 05/29/2016] [Indexed: 11/21/2022] Open
Abstract
Background Lower education level could be a risk factor for higher peritoneal dialysis (PD)-associated peritonitis, potentially resulting in technique failure. This study evaluated the influence of lower education level on the development of peritonitis, technique failure, and overall mortality. Methods Patients over 18 years of age who started PD at Seoul National University Hospital between 2000 and 2012 with information on the academic background were enrolled. Patients were divided into three groups: middle school or lower (academic year≤9, n = 102), high school (9<academic year≤12, n = 229), and higher than high school (academic year>12, n = 324). Outcomes were analyzed using Cox proportional hazards models and competing risk regression. Results A total of 655 incident PD patients (60.9% male, age 48.4±14.1 years) were analyzed. During follow-up for 41 (interquartile range, 20–65) months, 255 patients (38.9%) experienced more than one episode of peritonitis, 138 patients (21.1%) underwent technique failure, and 78 patients (11.9%) died. After adjustment, middle school or lower education group was an independent risk factor for peritonitis (adjusted hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.10–2.36; P = 0.015) and technique failure (adjusted HR, 1.87; 95% CI, 1.10–3.18; P = 0.038), compared with higher than high school education group. However, lower education was not associated with increased mortality either by as-treated (adjusted HR, 1.11; 95% CI, 0.53–2.33; P = 0.788) or intent-to-treat analysis (P = 0.726). Conclusions Although lower education was a significant risk factor for peritonitis and technique failure, it was not associated with increased mortality in PD patients. Comprehensive training and multidisciplinary education may overcome the lower education level in PD.
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Narva AS, Norton JM, Boulware LE. Educating Patients about CKD: The Path to Self-Management and Patient-Centered Care. Clin J Am Soc Nephrol 2015; 11:694-703. [PMID: 26536899 DOI: 10.2215/cjn.07680715] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Patient education is associated with better patient outcomes and supported by international guidelines and organizations, but a range of barriers prevent widespread implementation of comprehensive education for people with progressive kidney disease, especially in the United States. Among United States patients, obstacles to education include the complex nature of kidney disease information, low baseline awareness, limited health literacy and numeracy, limited availability of CKD information, and lack of readiness to learn. For providers, lack of time and clinical confidence combine with competing education priorities and confusion about diagnosing CKD to limit educational efforts. At the system level, lack of provider incentives, limited availability of practical decision support tools, and lack of established interdisciplinary care models inhibit patient education. Despite these barriers, innovative education approaches for people with CKD exist, including self-management support, shared decision making, use of digital media, and engaging families and communities. Education efficiency may be increased by focusing on people with progressive disease, establishing interdisciplinary care management including community health workers, and providing education in group settings. New educational approaches are being developed through research and quality improvement efforts, but challenges to evaluating public awareness and patient education programs inhibit identification of successful strategies for broader implementation. However, growing interest in improving patient-centered outcomes may provide new approaches to effective education of people with CKD.
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Affiliation(s)
- Andrew S Narva
- Division of Kidney, Urologic, and Hematologic Diseases, National Kidney Disease Education Program, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland; and
| | - Jenna M Norton
- Division of Kidney, Urologic, and Hematologic Diseases, National Kidney Disease Education Program, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland; and
| | - L Ebony Boulware
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
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29
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Cowan D, Smith L, Chow J. CARE OF A PATIENT'S VASCULAR ACCESS FOR HAEMODIALYSIS: A NARRATIVE LITERATURE REVIEW. J Ren Care 2015; 42:93-100. [PMID: 26420385 DOI: 10.1111/jorc.12139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients requiring haemodialysis have diverse clinical needs impacting on the longevity of their vascular access and their quality of life. A clinical practice scenario is presented that raises the potential of unsafe cannulation of a patient's vascular access as a result of minimal patient empowerment. Vascular access care is the responsibility of everyone, including the patient and carer. AIM The aim of this narrative literature review (1997-2014) is to explore the current understanding of what factors influence the care of vascular access for haemodialysis. METHOD A narrative literature review allows the synthesis of the known literature pertinent to the research question into a succinct model or unique order to enable new understandings to emerge. The bio-ecological model was used to guide the thematic analysis of the literature. RESULTS The narrative literature review revealed five themes related to care of vascular access: patient experience; relationships-empowerment and shared decision making; environment of healthcare; time; and quality of life as the outcome of care. CONCLUSION The management of vascular access is complicated. Current available literature predominantly concentrates on bio-medical aspects of vascular access care. Contextualised vascular access care in the complex ecology of the patient and carer's lives has the potential to enhance nursing practice and patient outcomes.
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Affiliation(s)
- Debi Cowan
- University of Tasmania, Launceston, Tasmania, Australia.,Central Coast Local Health District, Gosford, New South Wales, Australia
| | - Lindsay Smith
- University of Tasmania, Launceston, Tasmania, Australia
| | - Josephine Chow
- University of Tasmania, Launceston, Tasmania, Australia.,South Western Sydney Local Health District, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
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30
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Wang SM, Hsiao LC, Ting IW, Yu TM, Liang CC, Kuo HL, Chang CT, Liu JH, Chou CY, Huang CC. Multidisciplinary care in patients with chronic kidney disease: A systematic review and meta-analysis. Eur J Intern Med 2015; 26:640-5. [PMID: 26186813 DOI: 10.1016/j.ejim.2015.07.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 07/01/2015] [Accepted: 07/02/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Multidisciplinary care (MDC) was widely used in multiple chronic illnesses but the effectiveness of MDC in patients with chronic kidney disease (CKD) was inconclusive. The aim of this meta-analysis is to estimate the effectiveness of MDC for CKD. METHODS We searched PubMed, Web of Science, Google Scholar, Cochrane Library, and China Journal Full-text Database for relevant articles published in English or Chinese. Studies investigating MDC and non-MDC in patients with CKD were included. Random effect model was used to compare all-cause mortality, dialysis, risk of temporal catheterization, and hospitalization in the two treatment entities. RESULTS We analyzed 8853 patients of 18 studies in patients with CKD stages 3-5, aged 63±12 years. MDC was associated with lower risk of all-cause mortality with an odds ratio (OR) of 0.52 [95% confidence interval (CI): 0.44-0.88, p=0.01], mainly in cohort studies. MDC was associated with a lower risk of starting dialysis (p=0.02) and lower risk of temporal catheterization for dialysis (p<0.01). MDC was not associated with a higher chance of choosing peritoneal dialysis (p=0.18) or a lower chance of hospitalization for dialysis (p=0.13). CONCLUSIONS Limited evidence from randomized controlled trials is currently available to support the benefit of MDC in patients with CKD. MDC is associated with lower all-cause mortality, lower risk of starting dialysis, and lower risk of temporal catheterization for dialysis in cohort studies. MDC is not associated with a higher chance of choosing peritoneal dialysis or a lower chance of hospitalization for dialysis. More studies are needed to determine the optimal professional that should be included in MDC.
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Affiliation(s)
- Su-Ming Wang
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Lien-Cheng Hsiao
- College of Medicine, China Medical University, Taichung, Taiwan; Division of Cardiology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - I-Wen Ting
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Tung-Min Yu
- College of Medicine, China Medical University, Taichung, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taiwan
| | - Chih-Chia Liang
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Huey-Liang Kuo
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Chiz-Tzung Chang
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Jiung-Hsiun Liu
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Che-Yi Chou
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan.
| | - Chiu-Ching Huang
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
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Van den Bosch J, Warren DS, Rutherford PA. Review of predialysis education programs: a need for standardization. Patient Prefer Adherence 2015; 9:1279-91. [PMID: 26396500 PMCID: PMC4574882 DOI: 10.2147/ppa.s81284] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
To make an informed decision on renal replacement therapy, patients should receive education about dialysis options in a structured program covering all modalities. Many patients do not receive such education, and there is disparity in the information they receive. This review aims to compile evidence on effective components of predialysis education programs as related to modality choice and outcomes. PubMed MEDLINE, Cochrane Library, and Ovid searches (from January 1, 1995 to December 31, 2013) with the main search terms of "predialysis", "peritoneal dialysis", "home dialysis", "education", "information", and "decision" were performed. Of the 1,005 articles returned from the initial search, 110 were given full text reviews as they potentially met inclusion criteria (for example, they included adults or predialysis patients, or the details of an education program were reported). Only 29 out of the 110 studies met inclusion criteria. Ten out of 13 studies using a comparative design, showed an increase in home dialysis choice after predialysis education. Descriptions of the educational process varied and included individual and group education, multidisciplinary intervention, and varying duration and frequency of sessions. Problem-solving group sessions seem to be an effective component for enhancing the proportion of home dialysis choice. Evidence is lacking for many components, such as timing and staff competencies. There is a need for a standardized approach to evaluate the effect of predialysis educational interventions.
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Affiliation(s)
| | - D Simone Warren
- Pallas Health Research and Consultancy BV, Rotterdam, the Netherlands
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32
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Chen PM, Lai TS, Chen PY, Lai CF, Yang SY, Wu V, Chiang CK, Kao TW, Huang JW, Chiang WC, Lin SL, Hung KY, Chen YM, Chu TS, Wu MS, Wu KD, Tsai TJ. Multidisciplinary care program for advanced chronic kidney disease: reduces renal replacement and medical costs. Am J Med 2015; 128:68-76. [PMID: 25149427 DOI: 10.1016/j.amjmed.2014.07.042] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 07/24/2014] [Accepted: 07/24/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Multidisciplinary care is advocated as an effective chronic kidney disease treatment program in a few, but not all, studies. Our study aimed to evaluate the effect of multidisciplinary care on renal outcome and patient survival using a larger cohort. METHOD A total 1382 chronic kidney disease patients, ages 18-80 years, with chronic kidney disease stage 3B-5, in nephrology outpatient clinics were enrolled. Using age, sex, chronic kidney disease stage, and diabetes mellitus as variables, 592 multidisciplinary care program participants were matched with 614 nonmultidisciplinary care patients. The primary outcomes were long-term renal replacement therapy and mortality. Secondary outcomes included changes of biochemical markers and blood pressure, infection hospitalization, cardiovascular events, and emergent start of long-term dialysis. Annual medical costs were compared. RESULTS There were no between-group differences regarding mortality. In the multivariate competing-risk regression model, the multidisciplinary care group had a better renal survival (hazard ratio 0.640; 95% confidence interval, 0.484-0.847; P = .002). This effect was most prominent in stage 4 (hazard ratio 0.375; 95% confidence interval, 0.219-0.640; P < .001), but not in stage 3B and 5 patients. The multidisciplinary care group showed a slower estimated glomerular filtration rate decline (-2.57 vs -3.74 mL/min/1.73 m(2), P = .021), and a smaller increase in phosphate (+ 0.03 vs + 0.33 mg/dL, P = .013). Cardiovascular and infection events were both decreased in the multidisciplinary care group (P < .001). There was also less requirement of emergent start dialysis (39.6% vs 54.5%, P = .001). The annual cost for the multidisciplinary care group was lower than the nonmultidisciplinary care group (US $2372 vs $3794, P < .001). In addition, considering the reduction of patients requiring renal replacement therapy, the multidisciplinary care program saved a total US $1931 per patient annually. CONCLUSIONS Our analysis demonstrated that the multidisciplinary care program provided better health care and reduced renal replacement therapy in patients with advanced chronic kidney disease. By decreasing hospitalizations, emergent start, and the need for renal replacement therapy, the multidisciplinary care program was cost-effective.
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Affiliation(s)
- Ping Min Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tai Shuan Lai
- Department of Internal Medicine, National Taiwan University Hospital Bei-Hu Branch, Taipei, Taiwan
| | - Ping Yu Chen
- Department of Internal Medicine, Chi Mei Medical Center, Chia Li Campus, Tainan, Taiwan
| | - Chun Fu Lai
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shao Yu Yang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - VinCent Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih Kang Chiang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tze Wah Kao
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jenq Wen Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen Chih Chiang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Shuei Liong Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuan Yu Hung
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yung Ming Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzong Shinn Chu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming Shiou Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kwan Dun Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tun Jun Tsai
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Torchi TS, Araújo STCD, Moreira AGM, Koeppe GBO, Santos BTUD. Condições clínicas e comportamento de procura de cuidados de saúde pelo paciente renal crônico. ACTA PAUL ENFERM 2014. [DOI: 10.1590/1982-0194201400095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objetivo Identificar as condições clínicas e comportamento de procura de cuidados de saúde pelo paciente renal crônico no itinerário terapêutico para a hemodiálise.Métodos Estudo qualitativo, descritivo e exploratório a partir de entrevista com dez pacientes de uma clínica de terapia renal substitutiva em tratamento hemodialítico e análise resultante da utilização da técnica do Discurso do Sujeito Coletivo por meio do software qualiquantisofty.Resultados As condições clínicas no itinerário terapêutico evidenciaram sintomas de mal-estar e o perfil das doenças de base identificadas foram nefroesclerose hipertensiva, nefroesclerose diabética, causa indeterminada e nefroesclerose diabética associada com hipertensão arterial. Os comportamentos que prejudicaram o controle de saúde foram à demora no atendimento na rede de saúde, a não aceitação da doença e do tratamento.Conclusão Poucos tiveram acompanhamento precoce, sem manifestação de sintomas. Todavia, a maioria deles tiveram internação hospitalar de maneira repentina.
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Yu YJ, Wu IW, Huang CY, Hsu KH, Lee CC, Sun CY, Hsu HJ, Wu MS. Multidisciplinary predialysis education reduced the inpatient and total medical costs of the first 6 months of dialysis in incident hemodialysis patients. PLoS One 2014; 9:e112820. [PMID: 25398129 PMCID: PMC4232513 DOI: 10.1371/journal.pone.0112820] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 10/15/2014] [Indexed: 11/18/2022] Open
Abstract
Background The multidisciplinary pre-dialysis education (MPE) retards renal progression, reduce incidence of dialysis and mortality of CKD patients. However, the financial benefit of this intervention on patients starting hemodialysis has not yet been evaluated in prospective and randomized trial. Methods We studied the medical expenditure and utilization incurred in the first 6 months of dialysis initiation in 425 incident hemodialysis patients who were randomized into MPE and non-MPE groups before reaching end-stage renal disease. The content of the MPE was standardized in accordance with the National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines. Results The mean age of study patients was 63.8±13.2 years, and 221 (49.7%) of them were men. The mean serum creatinine level and estimated glomerular filtration rate was 6.1±4.0 mg/dL and 7.6±2.9 mL⋅min−1⋅1.73 m−2, respectively, at dialysis initiation. MPE patients tended to have lower total medical cost in the first 6 months after hemodialysis initiation (9147.6±0.1 USD/patient vs. 11190.6±0.1 USD/patient, p = 0.003), fewer in numbers [0 (1) vs. 1 (2), p<0.001] and length of hospitalization [0 (15) vs. 8 (27) days, p<0.001], and also lower inpatient cost [0 (2617.4) vs. 1559,4 (5019.6) USD/patient, p<0.001] than non-MPE patients, principally owing to reduced cardiovascular hospitalization and vascular access–related surgeries. The decreased inpatient and total medical cost associated with MPE were independent of patients' demographic characteristics, concomitant disease, baseline biochemistry and use of double-lumen catheter at initiation of hemodialysis. Conclusions Participation of multidisciplinary education in pre-dialysis period was independently associated with reduction in the inpatient and total medical expenditures of the first 6 months post-dialysis owing to decreased inpatient service utilization secondary to cardiovascular causes and vascular access–related surgeries. Trial Registration ClinicalTrials.gov NCT00644046
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Affiliation(s)
- Yu-Jen Yu
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - I-Wen Wu
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Chun-Yu Huang
- Laboratory for Epidemiology, Department of Health Care Management, Chang Gung University, Tao-Yuan, Taiwan
| | - Kuang-Hung Hsu
- Laboratory for Epidemiology, Department of Health Care Management, Chang Gung University, Tao-Yuan, Taiwan
| | - Chin-Chan Lee
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Chio-Yin Sun
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Heng-Jung Hsu
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Mai-Szu Wu
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
- Division of Nephrology, Taipei Medical University Hospital, Taipei, Taiwan
- School of Medicine, Taipei Medical University, Taipei, Taiwan
- * E-mail:
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35
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Donovan K, Carrington C. Peritoneal dialysis outcomes after temporary haemodialysis for peritonitis--influence on current practice. Nephrol Dial Transplant 2014; 29:1803-5. [DOI: 10.1093/ndt/gfu210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Chen PM, Chen PY, Chiang WC. Comments on "Progression of stages 3b-5 chronic kidney disease--preliminary results of Taiwan national pre-ESRD disease management program in Southern Taiwan". J Formos Med Assoc 2014; 113:770-1. [PMID: 25023978 DOI: 10.1016/j.jfma.2014.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 06/04/2014] [Indexed: 11/25/2022] Open
Affiliation(s)
- Ping Min Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ping Yu Chen
- Department of Internal Medicine, Chi Mei Medical Center, Chia Li Campus, Tainan, Taiwan
| | - Wen Chih Chiang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Bonner A, Havas K, Douglas C, Thepha T, Bennett P, Clark R. Self-management programmes in stages 1-4 chronic kidney disease: a literature review. J Ren Care 2014; 40:194-204. [PMID: 24628848 DOI: 10.1111/jorc.12058] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a complex health problem, which requires individuals to invest considerable time and energy in managing their health and adhering to multifaceted treatment regimens. OBJECTIVES To review studies delivering self-management interventions to people with CKD (Stages 1-4) and assess whether these interventions improve patient outcomes. DESIGN Systematic review. METHODS Nine electronic databases (MedLine, CINAHL, EMBASE, ProQuest Health & Medical Complete, ProQuest Nursing & Allied Health, The Cochrane Library, The Joanna Briggs Institute EBP Database, Web of Science and PsycINFO) were searched using relevant terms for papers published between January 2003 and February 2013. RESULTS The search strategy identified 2,051 papers, of which 34 were retrieved in full with only 5 studies involving 274 patients meeting the inclusion criteria. Three studies were randomised controlled trials, a variety of methods were used to measure outcomes, and four studies included a nurse on the self-management intervention team. There was little consistency in the delivery, intensity, duration and format of the self-management programmes. There is some evidence that knowledge- and health-related quality of life improved. Generally, small effects were observed for levels of adherence and progression of CKD according to physiologic measures. CONCLUSION The effectiveness of self-management programmes in CKD (Stages 1-4) cannot be conclusively ascertained, and further research is required. It is desirable that individuals with CKD are supported to effectively self-manage day-to-day aspects of their health.
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Affiliation(s)
- Ann Bonner
- School of Nursing, Queensland University of Technology, Kelvin Grove, QLD, Australia; CKD.QLD and Royal Brisbane and Women's Hospital, Herston, QLD, Australia
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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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39
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Novak M, Costantini L, Schneider S, Beanlands H. Approaches to Self-Management in Chronic Illness. Semin Dial 2013; 26:188-94. [DOI: 10.1111/sdi.12080] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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