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Berkhout-Byrne NC, Voorend CGN, Meuleman Y, Mooijaart SP, Brunsveld-Reinders AH, Bos WJW, Van Buren M. Nephrology-tailored geriatric assessment as decision-making tool in kidney failure. J Ren Care 2024; 50:112-127. [PMID: 37031361 DOI: 10.1111/jorc.12466] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 01/26/2023] [Accepted: 03/16/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Dialysis might not benefit all older patients with kidney failure, particularly those with multimorbid conditions and frailty. Patients' and healthcare professionals' awareness of the presence of geriatric impairments could improve outcomes by tailoring treatment plans and decisions for individual patients. OBJECTIVE We aimed to explore the perspectives of patients and healthcare professionals on nephrology-tailored geriatric assessment to fuel decision-making for treatment choices in older patients with kidney failure. DESIGN In an exploratory qualitative study using focus groups, participants discussed perspectives on the use and value of nephrology-tailored geriatric assessment for the decision-making process to start or forego dialysis. PARTICIPANTS AND MEASUREMENTS Patients (n = 18) with kidney failure, caregivers (n = 4), and professionals (n = 25) were purposively sampled from 10 hospitals. Interviews were audio-recorded, transcribed verbatim and inductively analysed using thematic analysis. RESULTS Three main themes emerged that supported or impeded decision-making in kidney failure: (1) patient psycho-social situation; (2) patient-related factors on modality choice; (3) organisation of health care. Patients reported feeling vulnerable due to multiple chronic conditions, old age, experienced losses in life and their willingness to trade longevity for quality of life. Professionals recognised the added value of nephrology-tailored geriatric assessment in three major themes: (i) facilitating continual holistic assessment, (ii) filling the knowledge gap, and (iii) uncovering important patient characteristics. CONCLUSIONS nephrology-tailored geriatric assessment was perceived as a valuable tool to identify geriatric impairments in older patients with kidney failure. Integration of its outcomes can facilitate a more holistic approach to inform choices and decisions about kidney replacement therapy.
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Affiliation(s)
- Noeleen C Berkhout-Byrne
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Carlijn G N Voorend
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Yvette Meuleman
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Willem Jan W Bos
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marjolijn Van Buren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Haga Hospital, The Hague, The Netherlands
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Voorend CG, Berkhout-Byrne NC, van Bodegom-Vos L, Diepenbroek A, Franssen CF, Joosten H, Mooijaart SP, Bos WJW, van Buren M. Geriatric Assessment in CKD Care: An Implementation Study. Kidney Med 2024; 6:100809. [PMID: 38660344 PMCID: PMC11039322 DOI: 10.1016/j.xkme.2024.100809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Rationale & Objective Older people with progressive chronic kidney disease (CKD) have complex health care needs. Geriatric evaluation preceding decision making for kidney replacement is recommended in guidelines, but implementation is lacking in routine care. We aimed to evaluate implementation of geriatric assessment in CKD care. Study Design Mixed methods implementation study. Setting & Participants Dutch nephrology centers were approached for implementation of geriatric assessment in patients aged ≥70 years and with an estimated glomerular filtration rate of ≤20 mL/min/1.73 m2. Quality Improvement Activities/Exposure We implemented a consensus-based nephrology-tailored geriatric assessment: a patient questionnaire and professionally administered test set comprising 16 instruments covering functional, cognitive, psychosocial, and somatic domains and patient-reported outcome measures. Outcomes We aimed for implementation in 10 centers and 200 patients. Implementation was evaluated by (i) perceived enablers and barriers of implementation, including integration in work routines (Normalization Measure Development Tool) and (ii) relevance of the instruments to routine care for the target population. Analytical Approach Variations in implementation practices were described based on field notes. The postimplementation survey among health care professionals was analyzed descriptively, using an explanatory qualitative approach for open-ended questions. Results Geriatric assessment was implemented in 10 centers among 191 patients. Survey respondents (n = 71, 88% response rate) identified determinants that facilitated implementation, ie, multidisciplinary collaboration (with geriatricians) -meetings and reports and execution of assessments by nurses. Barriers to implementation were patient illiteracy or language barrier, time constraints, and patient burden. Professionals considered geriatric assessment sufficiently integrated into work routines (mean, 6.7/10 ± 2.0 [SD]) but also subject to improvement. Likewise, the relevance of geriatric assessment for routine care was scored as 7.8/10 ± 1.2. The Clinical Frailty Score and Montreal Cognitive Assessment were perceived as the most relevant instruments. Limitations Selection bias of interventions' early adopters may limit generalizability. Conclusions Geriatric assessment could successfully be integrated in CKD care and was perceived relevant to health care professionals.
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Affiliation(s)
- Carlijn G.N. Voorend
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Noeleen C. Berkhout-Byrne
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Adry Diepenbroek
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Casper F.M. Franssen
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Hanneke Joosten
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Simon P. Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Jan W. Bos
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
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Okada H, Ono A, Tomori K, Inoue T, Hanafusa N, Sakai K, Narita I, Moriyama T, Isaka Y, Fukami K, Itano S, Kanda E, Kashihara N. Development of a prognostic risk score to predict early mortality in incident elderly Japanese hemodialysis patients. PLoS One 2024; 19:e0302101. [PMID: 38603695 PMCID: PMC11008820 DOI: 10.1371/journal.pone.0302101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/26/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Information of short-term prognosis after hemodialysis (HD) introduction is important for elderly patients with chronic kidney disease (CKD) and their families choosing a modality of renal replacement therapy. Therefore, we developed a risk score to predict early mortality in incident elderly Japanese hemodialysis patients. MATERIALS AND METHODS We analyzed data of incident elderly HD patients from a nationwide cohort study of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) to develop a prognostic risk score. Candidate risk factors for early death within 1 year was evaluated using multivariate logistic regression analysis. The risk score was developed by summing up points derived from parameter estimate values of independent risk factors. The association between risk score and early death was tested using Cox proportional hazards models. This risk score was validated twice by using an internal validation cohort derived from the JRDR and an external validation cohort collected for this study. RESULTS Using the development cohort (n = 2,000), nine risk factors were retained in the risk score: older age (>85), yes = 2, no = 0; sex, male = 2, female = 0; lower body mass index (<20), yes = 2, no = 0; cancer, yes = 1, no = 0; dementia, yes = 3, no = 0; lower creatinine (<6.5 mg/dL), yes = 1, no = 0; lower albumin (<3.0 g/dL), yes = 3, no = 0; normal or high calcium (≥8.5 mg/dL), yes = 1, no = 0; and higher C reactive protein (>2.0 mg/dL), yes = 2, no = 0. In the internal and external validation cohorts (n = 739, 140, respectively), the medium- and high-risk groups (total score, 6 to 10 and 11 or more, respectively) showed significantly higher risk of early death than the low-risk group (total score, 0 to 5) (p<0.001). CONCLUSION We developed a prognostic risk score predicting early death within 1 year in incident elderly Japanese HD patients, which may help detect elderly patients with a high-risk of early death after HD introduction.
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Affiliation(s)
- Hirokazu Okada
- Department of Nephrology, Saitama Medical University, Irumagun, Japan
| | - Atsushi Ono
- Department of Nephrology, Saitama Medical University, Irumagun, Japan
- Department of Nephrology, SUBARU Health Insurance Association Ota Memorial Hospital, Ota, Japan
| | - Koji Tomori
- Department of Nephrology, Saitama Medical University, Irumagun, Japan
| | - Tsutomu Inoue
- Department of Nephrology, Saitama Medical University, Irumagun, Japan
| | - Norio Hanafusa
- Department of Medicine, Blood Purification, Tokyo Women’s Medical University, Tokyo, Japan
| | - Ken Sakai
- Department of Nephrology, Toho University, Tokyo, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | | | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kei Fukami
- Department Medicine, Division of Nephrology, Kurume University School of Medicine, Fukuoka, Japan
| | - Seiji Itano
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Eiichiro Kanda
- Department of Medical Science, Kawasaki Medical School, Kurashiki, Japan
| | - Naoki Kashihara
- Department of Medical Science, Kawasaki Medical School, Kurashiki, Japan
- Geriatric Medical Center, Kawasaki Medical School, Okayama, Japan
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Fabre L, Rangel ÉB. Age-related markers and predictors of diabetic kidney disease progression in type 2 diabetes patients: a retrospective cohort study. Ther Adv Endocrinol Metab 2024; 15:20420188241242947. [PMID: 38585445 PMCID: PMC10999127 DOI: 10.1177/20420188241242947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 03/11/2024] [Indexed: 04/09/2024] Open
Abstract
Background Diabetic kidney disease (DKD) is characterized by reduced estimated glomerular filtration rate (eGFR) and albuminuria, which play a pivotal role in both diagnosing and determining the disease's progression. This study aimed to assess the trajectory of these markers concerning age in individuals with DKD and identify predictive factors for the decline in eGFR decline, variation in albuminuria, mortality, and progression to renal replacement therapy (RRT). Design This retrospective cohort encompassed patients with type 2 diabetes (T2D), divided into two age categories: <75 and ⩾75 years old. Methods Over a 3-year span, the study evaluated eGFR (CKD-EPI) and 24-h albuminuria. Univariate and multivariate analyses were employed to pinpoint factors associated with deteriorating renal function and mortality. Significance was set at p < 0.05, and Kaplan-Meier survival curves were constructed to illustrate renal and overall survival. Results The analysis comprised 304 patients. Comparable eGFR declines were evident in both age groups during the transition from the first to the second year and from the second to the third year. Nonetheless, a more pronounced rise in albuminuria was evident in the ⩾75 years group during the first to the second year. Multivariate analysis unveiled that systolic blood pressure (SBP) measurements in the first year positively forecasted eGFR decline. Age was associated with heightened albuminuria and mortality, while hospitalizations linked to cardiovascular causes robustly predicted mortality. Hospitalizations due to sepsis and cardiovascular reasons, coupled with first-year SBP measurements, served as predictive indicators for progression to RRT. Conclusion Both age groups experienced similar declines in eGFR, though the ⩾75 years group displayed a more significant increase in albuminuria during the first to the second year. Age, hospitalizations, and higher blood pressure levels were correlated with exacerbated renal function deterioration and/or elevated mortality in DKD. Timely intervention and tailored management strategies stand as critical components for enhancing outcomes among DKD patients.
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Affiliation(s)
- Larissa Fabre
- Department of Medicine, Nephrology Division, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Hospital Regional Hans Dieter Schmidt, Joinville, SC, Brazil
| | - Érika Bevilaqua Rangel
- Nephrology Division, Department of Medicine, Universidade Federal de São Paulo, Borges Lagoa Street, 591, 6th floor, Vila Clementino, São Paulo, 04038-031, SP, Brazil
- Albert Einstein Research and Education Institute, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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St Clair-Sullivan N, Bristowe K, Adler Z, Bremner S, Harding R, Levett T, Maddocks M, Pargeter G, Roberts J, Yi D, Vera J. Silver Clinic: protocol for a feasibility randomised controlled trial of comprehensive geriatric assessment for people living with HIV and frailty. BMJ Open 2023; 13:e070590. [PMID: 37208140 DOI: 10.1136/bmjopen-2022-070590] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Many people ageing with HIV are also living with multiple comorbidities and geriatric syndromes including frailty and cognitive deterioration. These complex needs can be challenging to meet within existing HIV care services. This study investigates the acceptability and feasibility of screening for frailty and of using a comprehensive geriatric assessment approach, delivered via the Silver Clinic, to support people living with HIV affected by frailty. METHODS AND ANALYSIS Mixed-methods, parallel-group, randomised, controlled feasibility trial aiming to recruit 84 people living with HIV≥50, identified as frail. Participants will be recruited from the HIV unit at the Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK. Participants will be randomised 1:1 to receive usual HIV care or the Silver Clinic intervention, which uses a comprehensive geriatric assessment approach. Psychosocial, physical and service use outcomes will be measured at baseline, 26 weeks and 52 weeks. Qualitative interviews will be conducted with a subset of participants from both arms. Primary outcome measures include recruitment and retention rates and completion of clinical outcome measures. These will be used in conjunction with a priori progression criteria and the qualitative data (acceptability of trial procedures and intervention) to determine the feasibility and design of a definitive trial. ETHICS AND DISSEMINATION This study has been approved by East Midlands-Leicester Central Research Ethics Committee (reference 21/EM/0200). All participants will receive written information about the study and be required to provide informed consent. Results will be disseminated via peer-reviewed journals, conferences and community engagement. TRIAL REGISTRATION NUMBER ISRCTN14646435.
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Affiliation(s)
- Natalie St Clair-Sullivan
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Katherine Bristowe
- Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Zoe Adler
- University Hospitals Sussex NHS Trust, Brighton, UK
| | - Stephen Bremner
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Richard Harding
- Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Thomas Levett
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | | | | | - Deokhee Yi
- Department of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Jaime Vera
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
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Park JH, Park HC, Kim DH, Lee YK, Cho AJ. Mortality and Risk Factors in Very Elderly Patients Who Start Hemodialysis: Korean Renal Data System, 2016-2020. Am J Nephrol 2023; 54:175-183. [PMID: 37231807 DOI: 10.1159/000530933] [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: 03/06/2023] [Accepted: 04/23/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION The number of elderly patients with end-stage renal disease (ESRD) is increasing worldwide. However, decision-making about elderly patients with ESRD remains complex because of the lack of studies, especially in very elderly patients (≥75 years). We examined the characteristics of very elderly patients starting hemodialysis (HD) and the associated mortality and prognostic factors. METHODS Data were analyzed retrospectively using a nationwide cohort registry, the Korean Renal Data System. Patients who started HD between January 2016 and December 2020 were included and divided into three groups according to age at HD initiation (<65, 65-74, and ≥75 years). The primary outcome was all-cause mortality during the study period. Risk factors for mortality were analyzed using Cox proportional hazard models. RESULTS In total, 22,024 incident patients were included with 10,006, 5,668, and 6,350 in each group (<65, 65-74, and ≥75 years, respectively). Among the very elderly group, women had a higher cumulative survival rate than men. The survival rate was lower in patients with vascular access via a catheter than in those with an arteriovenous fistula or graft. Very elderly patients with more comorbid diseases had a significantly lower survival rate than those with fewer comorbidities. In the multivariate Cox models, old age, cancer presence, catheter use, low body mass index, low Kt/V, low albumin concentration, and capable status of partial self-care were associated with high risk of mortality. CONCLUSION Preparation of an arteriovenous fistula or graft when starting HD should be considered in very elderly patients with fewer comorbid diseases.
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Affiliation(s)
- Ji Hyeon Park
- Department of Internal Medicine, National Police Hospital, Seoul, Republic of Korea
| | - Hayne Cho Park
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
- Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Do Hyoung Kim
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
- Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - Young Ki Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
- Hallym University Kidney Research Institute, Seoul, Republic of Korea
| | - AJin Cho
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
- Hallym University Kidney Research Institute, Seoul, Republic of Korea
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Liu CK, Miao S, Giffuni J, Katzel LI, Fielding RA, Seliger SL, Weiner DE. Geriatric Syndromes and Health-Related Quality of Life in Older Adults with Chronic Kidney Disease. KIDNEY360 2023; 4:e457-e465. [PMID: 36790849 PMCID: PMC10278840 DOI: 10.34067/kid.0000000000000078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/23/2023] [Indexed: 02/16/2023]
Abstract
Key Points In older adults with CKD, geriatric syndromes are common and are associated with reduced quality of life. Addressing geriatric syndromes could potentially improve quality of life for older adults with CKD. Background Geriatric syndromes, which are multifactorial conditions common in older adults, predict health-related quality of life (HRQOL). Although CKD is associated with lower HRQOL, whether geriatric syndromes contribute to HRQOL in CKD is unknown. Our objective was to compare associations of geriatric syndromes and medical conditions with HRQOL in older adults with CKD. Methods This was a secondary analysis of a parallel-group randomized controlled clinical trial evaluating a 12-month exercise intervention in persons 55 years or older with CKD stage 3b–4. Participants were assessed for baseline geriatric syndromes (cognitive impairment, poor appetite, dizziness, fatigue, and chronic pain) and medical conditions (diabetes, hypertension, coronary artery disease, cancer, or chronic obstructive pulmonary disease). Participants' HRQOL was assessed with the Short Form Health Survey-36 (SF-36), EuroQol 5-Dimensions 5-Level, and the EuroQol Visual Analogue Scale. We examined the cross-sectional and longitudinal associations of geriatric syndromes and medical conditions with HRQOL using multiple linear regression. Results Among 99 participants, the mean age was 68.0 years, 25% were female, and 62% were Black. Participants had a baseline mean of 2.0 geriatric syndromes and 2.1 medical conditions; 49% had ≥ two geriatric syndromes and ≥ two medical conditions concurrently. Sixty-seven (68%) participants underwent 12-month assessments. In models using geriatric syndromes and medical conditions as concurrent exposures, the number of geriatric syndromes was cross-sectionally associated with SF-36 scores for general health (β =−0.385) and role limitations because of physical health (β =−0.374) and physical functioning (β =−0.300, all P <0.05). The number of medical conditions was only associated with SF-36 score for role limitations because of physical health (β =−0.205). Conclusions In older adults with CKD stage 3b–4, geriatric syndromes are common and are associated with lower HRQOL. Addressing geriatric conditions is a potential approach to improve HRQOL for older adults with CKD. Clinical Trial registry name and registration number: NCT01462097 ; Registration Date–October 26, 2011.
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Affiliation(s)
- Christine K. Liu
- Section of Geriatric Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
- Geriatric Research and Education Clinical Center, Veteran Affairs Palo Alto Health Care System, Palo Alto, California
- Nutrition Exercise Physiology and Sarcopenia Team, Jean Mayer United States Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Jamie Giffuni
- Geriatric Research Education and Clinical Center, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland
| | - Leslie I. Katzel
- Geriatric Research Education and Clinical Center, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland
- Division of Gerontology, Geriatrics, and Palliative Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Roger A. Fielding
- Nutrition Exercise Physiology and Sarcopenia Team, Jean Mayer United States Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
| | - Stephen L. Seliger
- Geriatric Research Education and Clinical Center, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel E. Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Thind AK, Levy S, Wellsted D, Willicombe M, Brown EA. Frailty and the psychosocial components of the edmonton frail scale are most associated with patient experience in older kidney transplant candidates - a secondary analysis within the kidney transplantation in older people (KTOP) study. FRONTIERS IN NEPHROLOGY 2023; 2:1058765. [PMID: 37675015 PMCID: PMC10479555 DOI: 10.3389/fneph.2022.1058765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/05/2022] [Indexed: 09/08/2023]
Abstract
Background Older people with end-stage kidney disease (ESKD) are vulnerable to frailty, which impacts on clinical and experiential outcomes. With kidney transplantation in older people increasing, a better understanding of patient experiences is necessary for guiding decision making. The Kidney Transplantation in Older People (KTOP):impact of frailty on outcomes study aims to explore this. We present a secondary analysis of the Edmonton Frail Scale (EFS) and its relationship with patient experience scores. Methods The KTOP study is a single centre, prospective study, which began in October 2019. All ESKD patients aged ≥60 considered for transplantation at Imperial College Renal and Transplant Centre were eligible. Frailty was assessed using the EFS and 5 questionnaires assessed patient experience and quality of life (QoL) (Short Form-12(v2), Palliative Care Outcome Scale-Symptoms Renal, Depression Patient Health Questionnaire-9, Illness Intrusiveness Ratings Scale, Renal Treatment Satisfaction Questionnaire). The EFS was divided into 4 subdomains (psychosocial, physical function, medical status, and general health) and then compared with the questionnaire scores. Results 210 patients have been recruited (aged 60-78), 186 of whom completed EFS assessments. 118 (63.4%) participants were not frail, 36 (19.4%) vulnerable, and 32 (17.2%) were frail. Worse frailty scores were associated with poorer patient experience and QoL scores across all questionnaires. Severe deficits in the EFS psychosocial subdomain showed a statistically significant association with higher depression screen scores (coefficient 4.9, 95% CI 3.22 to 6.59), lower physical (coefficient -4.35, 95% CI -7.59 to -1.12) and mental function scores (coefficient -8.33, 95% CI -11.77 to -4.88) from the Short Form-12(v2), and lower renal treatment satisfaction scores (coefficient -5.54, 95% CI -10.70 to -0.37). Deficits in the physical function and medical status EFS subdomians showed some association with patient experience scores. Conclusion In the KTOP study cohort at recruitment vulnerable and frail candidates reported worse QoL and patient experiences. Severe deficits in the psychosocial subdomains of the EFS showed a strong association with patient experience and QoL, whilst physical function and medical status deficits showed a lesser association. This has highlighted specific EFS domains that may be suitable for targeted interventions to improve experiences and optimise outcomes.
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Affiliation(s)
- Amarpreet K. Thind
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Shuli Levy
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - David Wellsted
- The Centre for Health Services and Clinical Research, The University of Hertfordshire, Hertfordshire, United Kingdom
| | - Michelle Willicombe
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Edwina A. Brown
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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Hurst H, Young HML, Nixon AC, Ormandy P, Brettle A, Winterbottom A, Bekker H, Brown EA, Murtagh FEM, Da Silva-Gane M, Coyle D, Finnigan R. Outcomes and care priorities for older people living with frailty and advanced chronic kidney disease: a multi-professional scoping review. Age Ageing 2022; 51:6964934. [PMID: 36580559 DOI: 10.1093/ageing/afac296] [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: 04/14/2022] [Indexed: 12/30/2022] Open
Abstract
The growing older population with advanced chronic kidney disease (ACKD stages 4-5) poses a challenge for healthcare worldwide. The high prevalence of frailty and associated adverse health outcomes highlights concerns for management and interventions specific to this population. The aim was to objectively review the evidence relating to older people (≥65 years) living with frailty and ACKD. More specifically how frailty is identified, what interventions have been studied and what outcomes have been reported including outcomes important to patients, families and carers. A scoping review was undertaken following the PRISMA-Scr guidelines. Nine databases were searched and a review team of five people followed a process using defined inclusion and exclusion criteria. Data were then analysed to answer the specific questions of the review. The World Health Organization's International Classification of Functioning Disability and Health was used to map outcomes across the domains. A total of 90 studies were included. The most reported frailty measure was the frailty phenotype. The most reported outcomes were mortality, hospitalisation and healthcare utilisation. Health-related quality of life was the most common patient-reported outcome measure. There were few intervention studies and limited evidence of patient and carer perspectives. This scoping review highlights important areas for further research in older people living with frailty and ACKD. This includes a 'gold standard' measure for identifying frailty, interventions and improvements in outcome measures that matter to patients (including studies that focus on carers and carer burden) and priority setting for future research.
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Affiliation(s)
- Helen Hurst
- The University of Manchester, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Hannah M L Young
- Department of Respiratory Sciences, University of Leicester, Leicester, UK.,Department of Research and Innovation, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Paula Ormandy
- School of Health and Society, University of Salford, Salford, UK
| | - Alison Brettle
- School of Health and Society, University of Salford, Salford, UK
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Voorend CGN, van Oevelen M, Verberne WR, van den Wittenboer ID, Dekkers OM, Dekker F, Abrahams AC, van Buren M, Mooijaart SP, Bos WJW. OUP accepted manuscript. Nephrol Dial Transplant 2022; 37:1529-1544. [PMID: 35195249 PMCID: PMC9317173 DOI: 10.1093/ndt/gfac010] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Indexed: 11/16/2022] Open
Abstract
Background Non-dialytic conservative care (CC) has been proposed as a treatment option for patients with kidney failure. This systematic review and meta-analysis aims at comparing survival outcomes between dialysis and CC in studies where patients made an explicit treatment choice. Methods Five databases were systematically searched from origin through 25 February 2021 for studies comparing survival outcomes among patients choosing dialysis versus CC. Adjusted and unadjusted survival rates were extracted and meta-analysis performed where applicable. Risk of bias analysis was performed according to the Cochrane Risk Of Bias In Non-randomized Studies of Interventions. Results A total of 22 cohort studies were included covering 21 344 patients. Most studies were prone to selection bias and confounding. Patients opting for dialysis were generally younger and had fewer comorbid conditions, fewer functional impairments and less frailty than patients who chose CC. The unadjusted median survival from treatment decision or an estimated glomerular filtration rate <15 mL/min/1.73 m2 ranged from 20 and 67 months for dialysis and 6 and 31 months for CC. Meta-analysis of 12 studies that provided adjusted hazard ratios (HRs) for mortality showed a pooled adjusted HR of 0.47 (95% confidence interval 0.39–0.57) for patients choosing dialysis compared with CC. In subgroups of patients with older age or severe comorbidities, the reduction of mortality risk remained statistically significant, although analyses were unadjusted. Conclusions Patients opting for dialysis have an overall lower mortality risk compared with patients opting for CC. However, a high risk of bias and heterogeneous reporting preclude definitive conclusions and results cannot be translated to an individual level.
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Affiliation(s)
| | | | - Wouter R Verberne
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Friedo Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
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11
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Risk factors for high fall risk in elderly patients with chronic kidney disease. Int Urol Nephrol 2021; 54:349-356. [PMID: 33966153 DOI: 10.1007/s11255-021-02884-w] [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: 12/28/2020] [Accepted: 05/01/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE Patients with chronic kidney disease (CKD) usually represent an aging population, and both older age and CKD are associated with a higher risk of falling. Studies on risk factors among subjects with CKD are lacking. METHODS Records of outpatients from one geriatric clinic in Turkey were retrospectively reviewed. A result of ≥ 13.5 s on the timed up and go (TUG) test was accepted as a high risk of falls. Independent predictors of an increased risk of falls among subjects with CKD (estimated glomerular filtration rate of < 60 mL/min/1.73 m2) were identified using logistic regression models. RESULTS Patients with CKD (n = 205), represented the 20.2% of the entire cohort and was identified as an independent predictor of increased fall risk (OR 2.59). Within the CKD cohort, serum folic acid levels and frailty were independent predictors of an increased risk of falls. The CKD/fall risk group was older, had a lower median years of education, lower vitamin D levels, and lower serum folic acid levels than the CKD/non-fall risk group. In addition to higher serum creatinine and potassium levels, the only significant difference between patients with CKD/fall risk and a matched non-CKD/fall risk was a lower median folic acid level in the former group. CONCLUSIONS Frailty and low folic acid levels are independently associated with an increased risk of falls among elderly outpatients with CKD. Prevention of frailty may reduce the risk of falls in these subjects. Possible benefit of folic acid supplementation requires further studies.
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12
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Voorend CGN, Joosten H, Berkhout-Byrne NC, Diepenbroek A, Franssen CFM, Bos WJW, Van Buren M, Mooijaart SP. Design of a consensus-based geriatric assessment tailored for older chronic kidney disease patients: results of a pragmatic approach. Eur Geriatr Med 2021; 12:931-942. [PMID: 33871790 PMCID: PMC8463384 DOI: 10.1007/s41999-021-00498-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/08/2021] [Indexed: 12/15/2022]
Abstract
Aim To propose a consensus-based geriatric assessment for optimizing both routine care and research in older patients with advanced chronic kidney disease. Findings Using a pragmatic approach, we reached consensus on a suitable nephrology-tailored geriatric assessment to routinely identify major geriatric impairments in older patients with advanced chronic kidney disease. This geriatric assessment contains instruments in functional, cognitive, psychological, somatic, patient preferences, nutritional status, and social domains, and can be administered with patient questionnaires and professional-administered instruments by nurse (practitioners) in approximately 20 and 40 minutes, respectively. Message We propose a consensus test set for standardized nephrology-tailored geriatric assessment, which is currently being implemented in multiple hospitals and studies, to benefit clinical care for older patients with advanced chronic kidney disease and enhance research comparability. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00498-0. Purpose Unidentified cognitive decline and other geriatric impairments are prevalent in older patients with advanced chronic kidney disease (CKD). Despite guideline recommendation of geriatric evaluation, routine geriatric assessment is not common in these patients. While high burden of vascular disease and existing pre-dialysis care pathways mandate a tailored geriatric assessment, no consensus exists on which instruments are most suitable in this population to identify geriatric impairments. Therefore, the aim of this study was to propose a geriatric assessment, based on multidisciplinary consensus, to routinely identify major geriatric impairments in older people with advanced CKD. Methods A pragmatic approach was chosen, which included focus groups, literature review, inventory of current practices, an expert consensus meeting, and pilot testing. In preparation of the consensus meeting, we composed a project team and an expert panel (n = 33), drafted selection criteria for the selection of instruments, and assessed potential instruments for the geriatric assessment. Results Selection criteria related to general geriatric domains, clinical relevance, feasibility, and duration of the assessment. The consensus-assessment contains instruments in functional, cognitive, psychological, somatic, patient preferences, nutritional status, and social domains. Administration of (seven) patient questionnaires and (ten) professional-administered instruments, by nurse (practitioners), takes estimated 20 and 40 min, respectively. Results are discussed in a multidisciplinary meeting including at least nephrology and geriatric expertise, informing nephrology treatment decisions, and follow-up interventions among which comprehensive geriatric assessment. Conclusion This first multidisciplinary consensus on nephrology-tailored geriatric assessment intent to benefit clinical care and enhance research comparability for older patients with advanced CKD. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00498-0.
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Affiliation(s)
- Carlijn G N Voorend
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands.
| | - Hanneke Joosten
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Noeleen C Berkhout-Byrne
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Adry Diepenbroek
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Casper F M Franssen
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St. Antonius hospital, Nieuwegein, The Netherlands
| | - Marjolijn Van Buren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Haga Hospital, The Hague, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
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13
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Brown EA, Zhao J, McCullough K, Fuller DS, Figueiredo AE, Bieber B, Finkelstein FO, Shen J, Kanjanabuch T, Kawanishi H, Pisoni RL, Perl J. Burden of Kidney Disease, Health-Related Quality of Life, and Employment Among Patients Receiving Peritoneal Dialysis and In-Center Hemodialysis: Findings From the DOPPS Program. Am J Kidney Dis 2021; 78:489-500.e1. [PMID: 33872688 DOI: 10.1053/j.ajkd.2021.02.327] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 02/02/2021] [Indexed: 01/17/2023]
Abstract
RATIONALE & OBJECTIVE Individuals faced with decisions regarding kidney replacement therapy options need information on how dialysis treatments might affect daily activities and quality of life, and what factors might influence the evolution over time of the impact of dialysis on daily activities and quality of life. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 7,771 hemodialysis (HD) and peritoneal dialysis (PD) participants from 6 countries participating in the Peritoneal and Dialysis Outcomes and Practice Patterns Studies (PDOPPS/DOPPS). PREDICTORS Patient-reported functional status (based on daily living activities), country, demographic and clinical characteristics, and comorbidities. OUTCOME Employment status and patient-reported outcomes (PROs) including Kidney Disease Quality of Life (KDQOL) instrument physical and mental component summary scores (PCS, MCS), kidney disease burden score, and depression symptoms (Center for Epidemiologic Studies Depression Scale [CES-D] score > 10). ANALYTICAL APPROACH Linear regression (PCS, MCS, kidney disease burden score), logistic regression (depression symptoms), adjusted for predictors plus 12 additional comorbidities. RESULTS In both dialysis modalities, patients in Japan had the highest PCS and employment (55% for HD and 68% for PD), whereas those in the United States had the highest MCS score, lowest kidney disease burden, and lowest employment (20% in HD and 42% in PD). After covariate adjustment, the association of age, sex, dialysis vintage, diabetes, and functional status with PROs was similar in both modalities, with women having lower PCS and kidney disease burden scores. Lower functional status (score <11) was strongly associated with lower PCS and MCS scores, a much greater burden of kidney disease, and greater likelihood of depression symptoms (CES-D, >10). The median change in KDQOL-based PROs was negligible over 1 year in participants who completed at least 2 annual questionnaires. LIMITATIONS Selection bias due to incomplete survey responses. Generalizability was limited to the dialysis populations of the included countries. CONCLUSIONS Variation exists in quality of life, burden of kidney disease, and depression across countries but did not appreciably change over time. Functional status remained one of the strongest predictors of all PROs. Routine assessment of functional status may provide valuable insights for patients and providers in anticipating outcomes and support needs for patients receiving either PD or HD.
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Affiliation(s)
- Edwina A Brown
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Junhui Zhao
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | | | - Ana E Figueiredo
- School of Health Sciences and Life, Nursing School, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | - Jenny Shen
- Division of Nephrology and Hypertension, LaBiomed at Harbor-UCLA Medical Center, Torrance, CA
| | - Talerngsak Kanjanabuch
- Center of Excellence in Kidney Metabolic Disorders and Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | | | - Jeffrey Perl
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
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Yamamoto S, Bieber BA, Komaba H, Hanafusa N, Kitabayashi H, Nomura T, Cases A, Combe C, Pisoni RL, Robinson BM, Fukagawa M. Medical Director Practice of Advising Increased Dietary Protein Intake in Hemodialysis Patients With Hyperphosphatemia: Associations With Mortality in the Dialysis Outcomes and Practice Patterns Study. J Ren Nutr 2021; 32:243-250. [PMID: 33820694 DOI: 10.1053/j.jrn.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 01/11/2021] [Accepted: 02/14/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Patients undergoing hemodialysis (HD) may have poor nutritional status and hyperphosphatemia. Nephrologists sometimes manage hyperphosphatemia by prescribing phosphate binders and/or recommending restriction of dietary phosphate including protein-rich foods; the later may, however, adversely affect nutritional status. DESIGN AND METHODS The analysis includes 8805 HD patients on dialysis ≥ 120 days in 12 countries in Dialysis Outcomes and Practice Patterns Study (DOPPS) phase 4 (2009-2011), from 248 facilities. The primary exposure variable was response to the following question: "For patients with serum albumin 3.0 g/dL and phosphate 6.0 mg/dL, do you recommend to (A) increase or (B) decrease/no change in dietary protein intake (DPI)?". The association between medical director's practice of recommending an increase in DPI and all-cause mortality was analyzed with Cox regression adjusted for potential confounders. Linear and logistic regressions were used to model the cross-sectional associations between DPI advice practice and intermediate markers of patient nutrition. RESULTS Median follow-up was 1.6 years. In the case scenario, 91% of medical directors in North America had a practice of recommending DPI increase compared to 58% in Europe (range = 36%-83% across 7 countries) and 56% in Japan. The practice of advising DPI increase was weakly associated with lower mortality [HR (95% CI): 0.88 (0.76-1.02)]. The association tended to be stronger in patients with age 70+ years [HR (95% CI): 0.82 (0.69-0.97), P = .12 for interaction]. The practice of advising DPI increase was associated with 0.276 mg/dL higher serum creatinine levels (95% CI: 0.033-0.520) after adjustment for case mix. CONCLUSIONS Medical director's practice of recommending an increase in DPI for HD patients with low albumin and high phosphate levels was associated with higher serum creatinine levels and potentially lower all-cause mortality. To recommend protein intake liberalization in parallel with phosphate management by physicians may be a critical practice for better nutritional status and outcomes in HD patients.
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Affiliation(s)
- Suguru Yamamoto
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
| | - Brian A Bieber
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | - Hirotaka Komaba
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
| | - Norio Hanafusa
- Department of Blood Purification, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Takanobu Nomura
- Medical Affairs Department, Kyowa Kirin Co. Ltd., Tokyo, Japan
| | - Aleix Cases
- Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | | | - Ronald L Pisoni
- Arbor Research Collaborative for Health, Ann Arbor, Michigan
| | | | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, Isehara, Japan
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Hurst H, Jones E, Ormandy P, Brettle A, Nixon AC, Young H, Mooney A, Winterbottom A, Bekker H, Brown E, Murtagh FE, Da Silva-Gane M, Coyle D, Finnigan R. Outcomes and care priorities for older people living with frailty and advanced chronic kidney disease: a multiprofessional scoping review protocol. BMJ Open 2021; 11:e040715. [PMID: 33727262 PMCID: PMC7970237 DOI: 10.1136/bmjopen-2020-040715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 12/22/2020] [Accepted: 12/30/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Reported outcomes for older people with advanced chronic kidney disease (CKD) often focus on survival and mortality and little attention is paid to symptom burden and health-related quality of life. Recognising frailty and providing interventions that may improve outcomes have been studied in the general population with a growing research interest within CKD. METHODS AND ANALYSIS A scoping review will be undertaken following a recommended process to understand relevant research and priorities for older people living with frailty and advanced CKD. Databases will be searched and following a systematic process by a core team, a final list of included studies will be analysed. Focus groups will then be conducted with older people with advanced CKD to incorporate stakeholder views. ETHICS AND DISSEMINATION Our scoping review will use robust methodology to identify relevant literature focused on outcomes and care priorities for older people with advanced CKD. Ethical approval will be sought to conduct the focus groups. The result of this review will be disseminated through patient networks and national conferences. The interdisciplinary team collaborating plan to continue work in this area to improve the care and management of older people with advanced CKD.
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Affiliation(s)
- Helen Hurst
- Elderly Health, Manchester University NHS Foundation Trust, Manchester, UK
| | - Elizabeth Jones
- Renal Dietetics, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Paula Ormandy
- School of Health and Society, University of Salford School of Nursing Midwifery and Social Work, Manchester, UK
| | - Alison Brettle
- School of Health and Society, University of Salford, Salford, Manchester, UK
| | - Andrew Christopher Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - Hannah Young
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
- Leicester Kidney Lifestyle Team, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Andrew Mooney
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Anna Winterbottom
- Psychology, University of Leeds Leeds Institute of Health Sciences, Leeds, Leeds, UK
| | - Hilary Bekker
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Edwina Brown
- Renal, Imperial College London/Hammersmith Hospital, London, UK
| | - Fliss Em Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Maria Da Silva-Gane
- Renal Medicine, Lister Hospital, Stevenage, Hertfordshire, UK
- Renal Medicine, Lister Hospital, Stevenage, Hertfordshire, UK
| | - David Coyle
- Kideny Patiemt, Patient Representative, Manchester, UK
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16
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Nutrition-Based Management of Inflammaging in CKD and Renal Replacement Therapies. Nutrients 2021; 13:nu13010267. [PMID: 33477671 PMCID: PMC7831904 DOI: 10.3390/nu13010267] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 12/12/2022] Open
Abstract
Access to renal transplantation guarantees a substantial improvement in the clinical condition and quality of life (QoL) for end-stage renal disease (ESRD) patients. In recent years, a greater number of older patients starting renal replacement therapies (RRT) have shown the long-term impact of conservative therapies for advanced CKD and the consequences of the uremic milieu, with a frail clinical condition that impacts not only their survival but also limits their access to transplantation. This process, referred to as “inflammaging,” might be reversible with a tailored approach, such as RRT accompanied by specific nutritional support. In this review, we summarize the evidence demonstrating the presence of several proinflammatory substances in the Western diet (WD) and the positive effect of unprocessed food consumption and increased fruit and vegetable intake, suggesting a new approach to reduce inflammaging with the improvement of ESRD clinical status. We conclude that the Mediterranean diet (MD), because of its modulative effects on microbiota and its anti-inflammaging properties, may be a cornerstone in a more precise nutritional support for patients on the waiting list for kidney transplantation.
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17
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Perspectives and experiences of patients and healthcare professionals with geriatric assessment in chronic kidney disease: a qualitative study. BMC Nephrol 2021; 22:9. [PMID: 33407240 PMCID: PMC7789317 DOI: 10.1186/s12882-020-02206-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/10/2020] [Indexed: 12/24/2022] Open
Abstract
Background Older patients with end-stage kidney disease (ESKD) often live with unidentified frailty and multimorbidity. Despite guideline recommendations, geriatric assessment is not part of standard clinical care, resulting in a missed opportunity to enhance (clinical) outcomes including quality of life in these patients. To develop routine geriatric assessment programs for patients approaching ESKD, it is crucial to understand patients’ and professionals’ experiences with and perspectives about the benefits, facilitators and barriers for geriatric assessment. Methods In this qualitative study, semi-structured focus group discussions were conducted with ESKD patients, caregivers and professionals. Participants were purposively sampled from three Dutch hospital-based study- and routine care initiatives involving geriatric assessment for (pre-)ESKD care. Transcripts were analysed inductively using thematic analysis. Results In six focus-groups, participants (n = 47) demonstrated four major themes: (1) Perceived characteristics of the older (pre)ESKD patient group. Patients and professionals recognized increased vulnerability and (cognitive) comorbidity, which is often unrelated to calendar age. Both believed that often patients are in need of additional support in various geriatric domains. (2) Experiences with geriatric assessment. Patients regarded the content and the time spent on the geriatric assessment predominantly positive. Professionals emphasized that assessment creates awareness among the whole treatment team for cognitive and social problems, shifting the focus from mainly somatic to multidimensional problems. Outcomes of geriatric assessment were observed to enhance a dialogue on suitability of treatment options, (re)adjust treatment and provide/seek additional (social) support. (3) Barriers and facilitators for implementation of geriatric assessment in routine care. Discussed barriers included lack of communication about goals and interpretation of geriatric assessment, burden for patients, illiteracy, and organizational aspects. Major facilitators are good multidisciplinary cooperation, involvement of geriatrics and multidisciplinary team meetings. (4) Desired characteristics of a suitable geriatric assessment concerned the scope and use of tests and timing of assessment. Conclusions Patients and professionals were positive about using geriatric assessment in routine nephrology care. Implementation seems achievable, once barriers are overcome and facilitators are endorsed. Geriatric assessment in routine care appears promising to improve (clinical) outcomes in patients approaching ESKD. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-020-02206-9.
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Apports d’une consultation gériatrique dans une association d’antennes d’auto-dialyse. Nephrol Ther 2020; 16:364-371. [DOI: 10.1016/j.nephro.2020.07.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 04/16/2020] [Accepted: 07/10/2020] [Indexed: 11/18/2022]
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19
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Hall R, Rutledge J, Colón-Emeric C, Fish LJ. Unmet Needs of Older Adults Receiving In-Center Hemodialysis: A Qualitative Needs Assessment. Kidney Med 2020; 2:543-551.e1. [PMID: 33094273 PMCID: PMC7568084 DOI: 10.1016/j.xkme.2020.04.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Rationale & Objective Attention to geriatric impairments is not routinely provided to older adults receiving dialysis. Our objective was to identify patient and personnel perspectives on experiences with geriatric problems, unmet needs that may affect a patient’s ability to maintain his or her functional status, and preferences for design of a geriatric model of care tailored to address the unmet needs. Study Design Qualitative study using semi-structured interviews and focus groups. Setting & Participants 14 hemodialysis patients 55 years and older and 24 dialysis unit personnel (eg, nephrologists, nurses, patient care technicians, and social workers) representing 5 dialysis units. Analytical Approach Content analysis to identify themes reflecting unmet needs and design considerations for a geriatric model of care for older adults receiving dialysis. Results 4 themes (or unmet needs) identified from both patient and personnel transcripts were: (1) mobility, which referred to the insufficient mobility assessment and transportation services; (2) medications, which referred to insufficient attention to appropriate prescribing and medication self-management; (3) social support, which referred to insufficient support for activities of daily living and emotional problems; and (4) communication, which referred to insufficient patient-provider and interprofessional communication, including data transfer across separate health systems. Although participants generally acknowledged that an integrated model of care could result in benefits across all 4 areas of unmet need, they noted that the program design would need to minimize disruption of current workflow and practices in dialysis units. Limitations The findings may not be broadly representative of all older adults receiving dialysis and dialysis unit personnel. Conclusions There is insufficient attention to mobility, medication management, social support, and communication needs for older adults receiving in-center hemodialysis. Addressing these unmet needs in a geriatric model of care and measuring its effectiveness are areas of future research.
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Affiliation(s)
- Rasheeda Hall
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, NC.,Geriatric Research Education and Clinical Center, Durham Veterans Affairs Healthcare System, Durham, NC.,Division of Nephrology, Department of Medicine, Duke University, Durham, NC.,Center for the Study of Aging and Human Development, Duke University, Durham, NC
| | - Jeanette Rutledge
- Division of Nephrology, Department of Medicine, Duke University, Durham, NC
| | - Cathleen Colón-Emeric
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Healthcare System, Durham, NC.,Center for the Study of Aging and Human Development, Duke University, Durham, NC.,Division of Geriatric Medicine, Department of Medicine, Duke University, Durham, NC
| | - Laura J Fish
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC.,Duke Cancer Institute, Behavioral Health and Survey Research Core, Duke University School of Medicine, Durham, NC
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20
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Nixon AC, Brown J, Brotherton A, Harrison M, Todd J, Brannigan D, Ashcroft Q, So B, Pendleton N, Ebah L, Mitra S, Dhaygude AP, Brady ME. Implementation of a frailty screening programme and Geriatric Assessment Service in a nephrology centre: a quality improvement project. J Nephrol 2020; 34:1215-1224. [PMID: 33040293 PMCID: PMC8357770 DOI: 10.1007/s40620-020-00878-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/23/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The aims of this quality improvement project were to: (1) proactively identify people living with frailty and CKD; (2) introduce a practical assessment, using the principles of the comprehensive geriatric assessment (CGA), for people living with frailty and chronic kidney disease (CKD) able to identify problems; and (3) introduce person-centred management plans for people living with frailty and CKD. METHODS A frailty screening programme, using the Clinical Frailty Scale (CFS), was introduced in September 2018. A Geriatric Assessment (GA) was offered to patients with CFS ≥ 5 and non-dialysis- or dialysis-dependent CKD. Renal Frailty Multidisciplinary Team (MDT) meetings were established to discuss needs identified and implement a person-centred management plan. RESULTS A total of 450 outpatients were screened using the CFS. One hundred and fifty patients (33%) were screened as frail. Each point increase in the CFS score was independently associated with a hospitalisation hazard ratio of 1.35 (95% CI 1.20-1.53) and a mortality hazard ratio of 2.15 (95% CI 1.63-2.85). Thirty-five patients received a GA and were discussed at a MDT meeting. Patients experienced a median of 5.0 (IQR 3.0) problems, with 34 (97%) patients experiencing at least three problems. CONCLUSIONS This quality improvement project details an approach to the implementation of a frailty screening programme and GA service within a nephrology centre. Patients living with frailty and CKD at risk of adverse outcomes can be identified using the CFS. Furthermore, a GA can be used to identify problems and implement a person-centred management plan that aims to improve outcomes for this vulnerable group of patients.
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Affiliation(s)
- Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK. .,Division of Cardiovascular Sciences, University of Manchester, Manchester, UK. .,Centre for Health Research and Innovation, National Institute of Health Research Lancashire Clinical Research Facility, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.
| | - Julie Brown
- Lancashire Teaching Hospitals Integrated Frailty Team, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Ailsa Brotherton
- Continuous Improvement Team, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Mark Harrison
- Lancashire Teaching Hospitals Integrated Frailty Team, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Judith Todd
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK
| | - Dawn Brannigan
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK
| | - Quinta Ashcroft
- Department of Business Intelligence, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Beng So
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK
| | - Neil Pendleton
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
| | - Leonard Ebah
- Department of Renal Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Sandip Mitra
- Department of Renal Medicine, Manchester University NHS Foundation Trust, Manchester, UK.,Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.,Devices for Dignity, National Institute of Health Research MedTech and In-vitro Diagnostics Co-operative, Sheffield, UK
| | - Ajay P Dhaygude
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK
| | - Mark E Brady
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT, UK
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Potok OA, Rifkin DE. Applying a Geriatrics Framework to Older Dialysis Patients’ Needs: Getting There Is Half the Battle. Kidney Med 2020; 2:514-516. [PMID: 33095846 PMCID: PMC7568080 DOI: 10.1016/j.xkme.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Song YH, Cai GY, Xiao YF, Chen XM. Risk factors for mortality in elderly haemodialysis patients: a systematic review and meta-analysis. BMC Nephrol 2020; 21:377. [PMID: 32867718 PMCID: PMC7457491 DOI: 10.1186/s12882-020-02026-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 08/18/2020] [Indexed: 12/16/2022] Open
Abstract
Background Older haemodialysis patients accompany a high burden of functional impairment, limited life expectancy, and healthcare utilization. This meta-analysis aimed to evaluate how various risk factors influenced the prognosis of haemodialysis patients in late life, which might contribute to decision making by patients and care providers. Methods PubMed, Embase, and Cochrane Central were searched systematically for studies evaluating the risk factors for mortality in elderly haemodialysis patients. Twenty-eight studies were included in the present systematic review. The factors included age, cardiovascular disease, diabetes mellitus, type of vascular access, dialysis initiation time, nutritional status and geriatric impairments. Geriatric impairments included frailty, cognitive or functional impairment and falls. Relative risks with 95% confidence intervals were derived. Results Functional impairment (OR = 1.45, 95% CI: 1.20–1.75), cognitive impairment (OR = 1.46, 95% CI: 1.32–1.62) and falls (OR = 1.14, 95% CI: 1.06–1.23) were significantly and independently associated with increased mortality in elderly haemodialysis patients. Low body mass index conferred a mortality risk (OR = 1.43, 95% CI: 1.31–1.56) paralleling that of frailty as a marker of early death. The results also confirmed that the older (OR = 1.43, 95% CI: 1.22–1.68) and sicker (in terms of Charlson comorbidity index) (OR = 1.41, 95% CI: 1.35–1.50) elderly haemodialysis patients were, the more likely they were to die. In addition, increased mortality was associated with early-start dialysis (OR = 1.18, 95% CI: 1.01–1.37) and with the use of a central venous catheter (OR = 1.53, 95% CI: 1.44–1.62). Conclusions Multiple factors influence the risk of mortality in elderly patients undergoing haemodialysis. Geriatric impairment is related to poor outcome. Functional/cognitive impairment and falls in elderly dialysis patients are strongly and independently associated with mortality.
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Affiliation(s)
- Yu-Huan Song
- Department of Nephrology, Aerospace Center Hospital, 15 Yuquan Road, Beijing, 100049, China.,Department of Nephrology, Chinese PLA Generl Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, 28 Fuxing Road, Beijing, 100853, China
| | - Guang-Yan Cai
- Department of Nephrology, Chinese PLA Generl Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, 28 Fuxing Road, Beijing, 100853, China.
| | - Yue-Fei Xiao
- Department of Nephrology, Aerospace Center Hospital, 15 Yuquan Road, Beijing, 100049, China.
| | - Xiang-Mei Chen
- Department of Nephrology, Chinese PLA Generl Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, 28 Fuxing Road, Beijing, 100853, China
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23
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Depression does not predict clinical outcome of Chinese peritoneal Dialysis patients after adjusting for the degree of frailty. BMC Nephrol 2020; 21:329. [PMID: 32758180 PMCID: PMC7405374 DOI: 10.1186/s12882-020-01994-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 07/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Depression and frailty contribute to the adverse clinical outcome of peritoneal dialysis (PD) patients. However, the interaction between depression and frailty in PD patients remains uncertain. We determined the prevalence of depression and frailty in prevalent Chinese PD patients, dissected the internal relationship between depression and frailty, and determined their relative contribution to the adverse clinical outcome in PD patients. METHODS In a prospective observational study, we recruited 267 prevalent PD patients. Depression was identified by Patient Health Questionnaire (PHQ-9). Frailty was identified by a validated Frailty Score. All cases were followed for one year. Outcome measures included number and duration of hospitalization, peritonitis rate, and all-cause mortality. RESULTS Of the 267 patients, 197 patients (73.8%) were depressed, and 157 (58.8%) were frail. There was a substantial overlap between depression and frailty. Although depression and frailty were associated the number and duration of hospitalization by univariate analysis, the association became insignificant after adjusting for confounding factors by multivariate analysis. Both depression and frailty were associated with one-year mortality by univariate analysis. One-year patient survival was 95.9, 86.5, 82.4 and 71.0% for patients with nil, mild, moderate and severe frailty, respectively (p = 0.001). Frailty was an independent predictor of patient survival by multivariate analysis (adjusted hazard ratio 1.424, 95% confidence interval 1.011-2.005. p = 0.043), while the prognostic effect of depression disappears after adjusting for frailty score. CONCLUSION Depression and frailty were common among Chinese PD patients. Frailty, but not depression, was an independent predictor of one-year mortality.
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24
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Hall RK, Rutledge J, Luciano A, Hall K, Pieper CF, Colón-Emeric C. Physical Function Assessment in Older Hemodialysis Patients. Kidney Med 2020; 2:425-431. [PMID: 32775982 PMCID: PMC7406854 DOI: 10.1016/j.xkme.2020.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
RATIONALE & OBJECTIVE Physical function is not routinely measured in older adults receiving dialysis. We evaluated the appropriateness of repeated measurements of physical function, including Short Physical Performance Battery (SPPB), handgrip strength, and activities of daily living (ADLs), in older adults receiving dialysis. STUDY DESIGN Prospective study. SETTING & PARTICIPANTS 37 community-dwelling adults 65 years and older receiving in-center hemodialysis at 5 dialysis units located in North Carolina. EXPOSURES SPPB (an assessment of standing balance, chair stands, and gait speed), handgrip strength, and Katz and Lawton ADLs at baseline and subsequent 3-month intervals up to 6 months. OUTCOMES Completion rate, presence of floor or ceiling effects, and presence of clinically meaningful change in physical function measurements. RESULTS Of 55 potential participants, we enrolled 37 (67%) older adults receiving hemodialysis. Among 35 enrolled participants who completed baseline assessment in a dialysis unit, mean age was 70.1 (SD, 5) years, 46% (n = 16) were women, 77% (n = 27) were African American, and median time receiving dialysis was 2.7 (IQR, 0.6-5.0) years. There were 3 deaths within the observation period, and study retention at 3 and 6 months was 83% (n = 29) and 74% (n = 26), respectively. Participants tolerated measurements; only 2 participants did not attempt 1 of the performance-based tests at a study visit. Baseline median SPPB score, grip strength, and gait speed were 6 (IQR, 4-9), 55 (IQR, 42-70) kg, and 0.76 (IQR, 0.46-0.86) m/s, respectively. Baseline median for Katz and Lawton ADLs were 6 (IQR, 6-6) and 7 (IQR, 4-8), respectively; ceiling effects were observed for both measures. For some participants, clinically meaningful changes (improvement or decline) in SPPB score, grip strength, and gait speed occurred at each 3-month interval. LIMITATIONS Limited geographic and ethnic variation. CONCLUSIONS SPPB, handgrip strength, and gait speed alone are appropriate measures for interval physical function assessment in community-dwelling older adults receiving in-center hemodialysis.
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Affiliation(s)
- Rasheeda K. Hall
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, NC
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Healthcare System, Durham, NC
- Division of Nephrology, Department of Medicine, Duke University, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
| | - Jeanette Rutledge
- Division of Nephrology, Department of Medicine, Duke University, Durham, NC
| | - Alison Luciano
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
| | - Katherine Hall
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Healthcare System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Division of Geriatric Medicine, Department of Medicine, Duke University, Durham, NC
| | - Carl F. Pieper
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Cathleen Colón-Emeric
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Healthcare System, Durham, NC
- Center for the Study of Aging and Human Development, Duke University, Durham, NC
- Division of Geriatric Medicine, Department of Medicine, Duke University, Durham, NC
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25
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Verberne WR, van den Wittenboer ID, Voorend CGN, Abrahams AC, van Buren M, Dekker FW, van Jaarsveld BC, van Loon IN, Mooijaart SP, Ocak G, van Delden JJM, Bos WJW. Health-related quality of life and symptoms of conservative care versus dialysis in patients with end-stage kidney disease: a systematic review. Nephrol Dial Transplant 2020; 36:1418-1433. [DOI: 10.1093/ndt/gfaa078] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/18/2020] [Indexed: 12/17/2022] Open
Abstract
Abstract
Background
Non-dialytic conservative care (CC) has been proposed as a viable alternative to maintenance dialysis for selected older patients to treat end-stage kidney disease (ESKD). This systematic review compares both treatment pathways on health-related quality of life (HRQoL) and symptoms, which are major outcomes for patients and clinicians when deciding on preferred treatment.
Methods
We searched PubMed, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus and PsycINFO from inception to 1 October 2019 for studies comparing patient-reported HRQoL outcomes or symptoms between patients who chose either CC or dialysis for ESKD.
Results
Eleven observational cohort studies were identified comprising 1718 patients overall. There were no randomized controlled trials. Studies were susceptible to selection bias and confounding. In most studies, patients who chose CC were older and had more comorbidities and worse functional status than patients who chose dialysis. Results were broadly consistent across studies, despite considerable clinical and methodological heterogeneity. Patient-reported physical health outcomes and symptoms appeared to be worse in patients who chose CC compared with patients who chose dialysis but had not yet started, but similar compared with patients on dialysis. Mental health outcomes were similar between patients who chose CC or dialysis, including before and after dialysis start. In patients who chose dialysis, the burden of kidney disease and impact on daily life increased after dialysis start.
Conclusions
The available data, while heterogeneous, suggest that in selected older patients, CC has the potential to achieve similar HRQoL and symptoms compared with a dialysis pathway. High-quality prospective studies are needed to confirm these provisional findings.
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Affiliation(s)
- Wouter R Verberne
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Carlijn G N Voorend
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
- Department of Nephrology, Haga Hospital, The Hague, the Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Brigit C van Jaarsveld
- Department of Nephrology and Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, VU University, Amsterdam, the Netherlands
| | - Ismay N van Loon
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Gurbey Ocak
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Johannes J M van Delden
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
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26
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Brown EA, Hurst H. Delivering peritoneal dialysis for the multimorbid, frail and palliative patient. Perit Dial Int 2020; 40:327-332. [DOI: 10.1177/0896860819893558] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Peritoneal dialysis (PD) is only one component of care for older multimorbid, frail and/or palliative patients. Goals of care should be determined for all patients by shared decision-making at the start of during time on PD. Burden of PD should be minimized by individualizing the prescription by allowing for residual renal function and tailored to what is acceptable to the patient. PD facilities should develop the care pathways needed for this group of patients including integration with local geriatric, palliative care and social services
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Affiliation(s)
- Edwina A Brown
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, UK
| | - Helen Hurst
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, UK
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27
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Meyer AM, Becker I, Siri G, Brinkkötter PT, Benzing T, Pilotto A, Polidori MC. The prognostic significance of geriatric syndromes and resources. Aging Clin Exp Res 2020; 32:115-124. [PMID: 30911909 DOI: 10.1007/s40520-019-01168-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 03/03/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Geriatric syndromes (GS) do not fit into discrete disease categories and are often underdiagnosed in hospitalized older adults. Geriatric resources (GR) are also not routinely collected in clinical settings, although this may potentiate the beneficial effects of clinical decisions. The prognostic relevance of GS and GR has never been systematically evaluated through clinical tools developed for clinical decision purposes. AIM To ascertain the impact of common GS and GR on patients' prognosis as assessed by means of the comprehensive geriatric assessment (CGA)-based Multidimensional Prognostic Index (MPI). METHODS One hundred and thirty-five hospitalized patients aged 70 years and older underwent a CGA evaluation with calculation of the MPI on admission and discharge. Accordingly, patients were subdivided in low (MPI-1, score 0-0.33), moderate (MPI-2, score 0.34-0.66), and severe (MPI-3, score 0.67-1)-risk of mortality at 1 month and 1 year. Nine GR and 17 GS were identified and collected accordingly. RESULTS A lower number of GS and a higher number of GR were shown to be highly significantly correlated with a lower MPI, as well as years of education, grade of care, and number of medications independent of age, sex and number of GS or GR. Underweight and obesity according to the BMI were significantly correlated to higher number of GS. Patients with more GR had a significantly higher chance of being discharged home. CONCLUSIONS The MPI evaluation together with GS and GR in acute care for older patients should be encouraged to improve clinical decision-making.
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Affiliation(s)
- Anna Maria Meyer
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Ingrid Becker
- Institute of Medical Statistics and Computational Biology, University Hospital of Cologne, Cologne, Germany
| | - Giacomo Siri
- Scientific Directorate - Biostatistics, E.O. Galliera Hospital, Genova, Italy
| | - Paul Thomas Brinkkötter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- CECAD, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Thomas Benzing
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- CECAD, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Alberto Pilotto
- Department Geriatric Care, Orthogeriatrics and Rehabilitation, Frailty Area, E.O. Galliera Hospital, Genova, Italy
| | - M Cristina Polidori
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
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28
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van Loon IN, Goto NA, Boereboom FTJ, Bots ML, Hoogeveen EK, Gamadia L, van Bommel EFH, van de Ven PJG, Douma CE, Vincent HH, Schrama YC, Lips J, Siezenga MA, Abrahams AC, Verhaar MC, Hamaker ME. Geriatric Assessment and the Relation with Mortality and Hospitalizations in Older Patients Starting Dialysis. Nephron Clin Pract 2019; 143:108-119. [PMID: 31408861 DOI: 10.1159/000501277] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 06/01/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES A geriatric assessment (GA) is a structural method for identifying frail patients. The relation of GA findings and risk of death in end-stage kidney disease (ESKD) is not known. The objective of the GA in OLder patients starting Dialysis Study was to assess the association of GA at dialysis initiation with early mortality and hospitalization. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS Patients ≥65 years old were included just prior to dialysis initiation. All participants underwent a GA, including assessment of (instrumental) activities of daily living (ADL), mobility, cognition, mood, nutrition, and comorbidity. In addition, a frailty screening (Fried Frailty Index, [FFI]) was applied. Outcome measures were 6- and 12-month mortality, and 6-month hospitalization. Associations with mortality were assessed with cox-regression adjusting for age, sex, comorbidity burden, smoking, residual kidney function and dialysis modality. Associations with hospitalization were assessed with logistic regression, adjusting for relevant confounders. RESULTS In all, 192 patients were included, mean age 75 ± 7 years, of whom 48% had ≥3 geriatric impairments and were considered frail. The FFI screening resulted in 46% frail patients. Mortality rate was 8 and 15% at 6- and 12-months after enrolment, and transplantation rate was 2 and 4% respectively. Twelve-month mortality risk was higher in patients with ≥3 impairments (hazard ratio [HR] 2.97 [95% CI 1.19-7.45]) compared to less impaired patients. FFI frail patients had a higher risk of 12-month mortality (HR 7.22 [95% CI 2.47-21.13]) and hospitalization (OR 1.93 [95% CI 1.00-3.72]) compared to fit patients. Malnutrition was associated with 12-month mortality, while impaired ADL and depressive symptoms were associated with 12-month mortality and hospitalization. CONCLUSIONS Frailty as assessed by a GA is related to mortality in elderly patients with ESKD. Individual components of the GA are related to both mortality and hospitalization. As the GA allows for distinguishing between frail and fit patients initiating dialysis, it is potentially of added value in the decision-making process concerning dialysis initiation.
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Affiliation(s)
- Ismay N van Loon
- Dianet Dialysis Center, Utrecht, The Netherlands, .,Department of Internal Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands, .,Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands,
| | - Namiko A Goto
- Department of Geriatrics, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Franciscus T J Boereboom
- Dianet Dialysis Center, Utrecht, The Netherlands.,Department of Internal Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ellen K Hoogeveen
- Department of Internal Medicine Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Laila Gamadia
- Department of Internal Medicine Tergooi Hospital, Hilversum, The Netherlands
| | - E F H van Bommel
- Department of Internal Medicine Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - P J G van de Ven
- Department of Internal Medicine Maasstad Hospital, Rotterdam, The Netherlands
| | - Caroline E Douma
- Department of Internal Medicine Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - H H Vincent
- Department of Internal Medicine Antonius Hospital, Nieuwegein, The Netherlands
| | - Yvonne C Schrama
- Department of Internal Medicine St. Franciscus Hospital, Rotterdam, The Netherlands
| | - Joy Lips
- Department of Internal Medicine Bernhoven Hospital, Uden, The Netherlands
| | - Machiel A Siezenga
- Department of Internal Medicine Gelderse Vallei Hospital, Ede, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marije E Hamaker
- Department of Geriatrics University Medical Center Utrecht, Utrecht, The Netherlands
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29
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Huenefeld D, Rodde S, Bureick G, Elkeles B, Hasebrook J. Improving Treatment of Elderly Patients by Interprofessional Education in a Quality Network of Geriatric Medicine: Protocol for Evaluating an Educational Initiative. JMIR Res Protoc 2019; 8:e11067. [PMID: 31066716 PMCID: PMC6524453 DOI: 10.2196/11067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 11/28/2018] [Accepted: 03/24/2019] [Indexed: 01/17/2023] Open
Abstract
Background All statistics on the development of demand for care for multimorbid elderly patients highlight the acute pressure to act to adequately respond to the expected increase in geriatric patient population in the next 15 years. Against this background, great importance must be attached to the improvement of cross-occupational group and cross-sector treatment of these patients. In addition, many professionals in the health care sector often have little knowledge about the special treatment and care needs of the elderly. Objective The Quality Network of Geriatric Medicine in north-west Germany is the body responsible for the project; with its member organizations, it provides care for over 400,000 inpatients and is thus one of the largest associations for geriatrics in Germany. The Quality Network conducts binding evaluated qualification measures for staff involved in the treatment and care of multimorbid elderly patients. The training offers are especially intended for staff who have not yet been trained in working with elderly patients. This approach is intended to improve the expertise of various occupational groups on different hierarchy levels, to include patients and their family members in the evaluation process, and to initiate changes within the organizations. Methods Various instruments are used in the evaluation of qualification measures: besides written surveys and questionnaires, structured work groups (consensus groups) and interviews are conducted. The evaluation starts before the qualification measures to determine the starting point and then continues during the measure and after its completion. This allows major findings to be integrated directly into the ongoing qualification program. At least 100 trainings on geriatric topics, 80 consensus groups, and 120 patients (and family members) are going to be included in the study. Results The evaluation of the educational initiative is funded by the State of Northrhine-Westfalia (Germany; LZG TG 71 001 / 2015 and LZG TG 71 002 / 2015). The results of the study will be published after review and approval by the state authorities – presumably by the end of 2019. The before and after comparison of the treatment-related outcomes at the beginning and near the completion of the educational initiative gives insights into how transfer-oriented education can improve the treatment of elderly patients across sector lines for inpatients as well as outpatients. The evaluation of the implementation of educational content in day-to-day work and occupational groups is to facilitate recommendations about economically sensible use of educational resources and about further adjustments to the training content. Conclusions The evaluation develops the foundation for targeted and needs-oriented qualification measures as well as transfer in cross-sector, multiprofessional networks. Instruments and results will be published and provided to other health care networks and institutions. The Quality Network will implement the results of the evaluation process in its member institutions. International Registered Report Identifier (IRRID) DERR1-10.2196/11067
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Affiliation(s)
- Daisy Huenefeld
- Board of the Foundation, St Franziskus Foundation, Muenster, Germany
| | - Sibyll Rodde
- zeb.healthcare, zeb.rolfes.schierenbeck.associates, Muenster, Germany
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30
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Nixon AC, Bampouras TM, Pendleton N, Mitra S, Brady ME, Dhaygude AP. Frailty is independently associated with worse health-related quality of life in chronic kidney disease: a secondary analysis of the Frailty Assessment in Chronic Kidney Disease study. Clin Kidney J 2019; 13:85-94. [PMID: 32083613 PMCID: PMC7025341 DOI: 10.1093/ckj/sfz038] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 03/04/2019] [Indexed: 01/19/2023] Open
Abstract
Background Understanding how frailty affects health-related quality of life (HRQOL) in those with chronic kidney disease (CKD) could assist in the development of management strategies to improve outcomes for this vulnerable patient group. This study aimed to evaluate the relationship between frailty and HRQOL in patients with CKD Stages 4 and 5 (G4–5) and those established on haemodialysis (G5D). Methods Ninety participants with chronic kidney disease (CKD G4–5D) were recruited between December 2016 and December 2017. Frailty was assessed using the Frailty Phenotype, which included assessments of unintentional weight loss, weakness (handgrip strength), slowness (walking speed), physical activity and self-perceived exhaustion. HRQOL was assessed using the RAND 36-Item Health Survey Version 1.0 (SF-36). Results Nineteen (21%) patients were categorized as frail. Frailty, when adjusted for age, gender, dialysis dependence and comorbidity, had a significant effect on five of the eight SF-36 domains: physical functioning, role limitations due to emotional problems, energy/fatigue, social functioning and pain. Regression modelling best explained the variation in the physical functioning domain (adj. R2 = 0.27, P < 0.001), with frailty leading to a 26-point lower score. Exhaustion was the only Frailty Phenotype component that had a significant effect on scores across all SF-36 domains. Conclusions Frailty is independently associated with worse HRQOL in patients with CKD G4–5D, with self-perceived exhaustion being the most significant Frailty Phenotype component contributing to HRQOL. Efforts should be made to identify frail patients with CKD so that management strategies can be offered that aim to improve morbidity, mortality and patient-reported outcomes, including HRQOL and fatigue.
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Affiliation(s)
- Andrew C Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston,UK.,Centre for Health Research and Innovation, National Institute of Health Research Lancashire Clinical Research Facility, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.,Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Theodoros M Bampouras
- Active Ageing Research Group, University of Cumbria, Lancaster, UK.,Lancaster Medical School, Lancaster University, Lancaster, UK
| | - Neil Pendleton
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
| | - Sandip Mitra
- Manchester Academy of Health Sciences Centre, University of Manchester, Manchester, UK.,Devices for Dignity, National Institute of Health Research MedTech & In-vitro Diagnostics Co-operative, UK
| | - Mark E Brady
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston,UK
| | - Ajay P Dhaygude
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston,UK
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Abdulan IM, Onofriescu M, Stefaniu R, Mastaleru A, Mocanu V, Alexa ID, Covic A. The predictive value of malnutrition for functional and cognitive status in elderly hemodialysis patients. Int Urol Nephrol 2018; 51:155-162. [DOI: 10.1007/s11255-018-2000-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 09/30/2018] [Indexed: 10/27/2022]
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Cassidy BP, Getchell LE, Harwood L, Hemmett J, Moist LM. Barriers to Education and Shared Decision Making in the Chronic Kidney Disease Population: A Narrative Review. Can J Kidney Health Dis 2018; 5:2054358118803322. [PMID: 30542621 PMCID: PMC6236635 DOI: 10.1177/2054358118803322] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 08/21/2018] [Indexed: 12/13/2022] Open
Abstract
PURPOSE OF REVIEW Provision of education to inform decision making for renal replacement therapy (RRT) is a key component in the management of chronic kidney disease (CKD), yet patients report suboptimal satisfaction with the process of selecting a dialysis modality. Our purpose is to review the influencers of RRT decision making in the CKD population, which will better inform the process of shared decision making between clinicians and patients. SOURCES OF INFORMATION PubMed and Google Scholar. METHODS A narrative review was performed using the main terms "chronic kidney disease," "CKD," "dialysis," "review," "decision-making," "decision aids," "education," and "barriers." Only articles in English were accessed. The existing literature was critically analyzed from a theoretical and contextual perspective and thematic analysis was performed. KEY FINDINGS Eight common themes were identified as influencers for decision making. "Patient-focused" themes including social influence, values and beliefs, comprehension, autonomy and sociodemographics, and "clinician-focused" themes including screening, communication, and engagement. Early predialysis education and decision aids can effectively improve decision making. Patient-valued outcomes need to be more fully integrated into clinical guidelines. LIMITATIONS This is not a systematic review; therefore, no formal tool was utilized to evaluate the rigor and quality of studies included and findings may not be generalizable. IMPLICATIONS Standardized comprehensive RRT education programs through multidisciplinary health teams can help optimize CKD patient education and shared decision making. Involving patients in the research process itself and implementing patient values and preferences into clinical guidelines can help to achieve a patient-centered model of care.
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Affiliation(s)
- Brendan P. Cassidy
- Schulich School of Medicine and
Dentistry, Western University, London, ON, Canada
- Kidney Clinical Research Unit, London
Health Sciences Centre, London, ON, Canada
| | - Leah E. Getchell
- Kidney, Dialysis and Transplantation
Program, ICES Western, London, ON, Canada
| | - Lori Harwood
- Renal Services, London Health Sciences
Centre, London, ON, Canada
| | - Juliya Hemmett
- Schulich School of Medicine and
Dentistry, Western University, London, ON, Canada
- Kidney Clinical Research Unit, London
Health Sciences Centre, London, ON, Canada
| | - Louise M. Moist
- Schulich School of Medicine and
Dentistry, Western University, London, ON, Canada
- Kidney Clinical Research Unit, London
Health Sciences Centre, London, ON, Canada
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33
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Goto NA, van Loon IN, Morpey MI, Verhaar MC, Willems HC, Emmelot-Vonk MH, Bots ML, Boereboom FTJ, Hamaker ME. Geriatric Assessment in Elderly Patients with End-Stage Kidney Disease. Nephron Clin Pract 2018; 141:41-48. [PMID: 30384369 PMCID: PMC6381867 DOI: 10.1159/000494222] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND/AIMS Decision-making in elderly patients considering dialysis is highly complex. With the increasing number of elderly with end-stage kidney disease (ESKD), it may be important to assess geriatric impairments in this population. The aim of the Geriatric assessment in OLder patients starting Dialysis (GOLD) study was to assess the prevalence of geriatric impairments and frailty in the elderly ESKD population by means of a geriatric assessment (GA), which is a comprehensive tool for overall health assessment. METHODS This study included 285 patients ≥65 years: 196 patients at the time of dialysis initiation and 89 patients who chose maximal conservative management (MCM). The GA assessed cognition, mood, nutritional status, (instrumental) activities of daily living (ADL), mobility, comorbidity burden, quality of life and overall frailty. RESULTS The mean age of the participants was 78 years and 36% were women. Of the incident dialysis patients, 77% started haemodialysis and 23% started peritoneal dialysis. Geriatric impairments were highly prevalent in both dialysis and MCM patients. Most frequently impaired geriatric domains in the dialysis group were functional performance (ADL 29%, instrumental ADL (iADL) 79%), cognition (67%) and comorbidity (41%). According to the GA, 77% in the dialysis group and 88% in the MCM group had 2 or more geriatric impairments. In the MCM group, functional impairment (ADL 45%, iADL 85%) was highly prevalent. CONCLUSIONS Geriatric impairments are highly prevalent in the elderly ESKD population. Since impairments can be missed when not searched for in regular (pre)dialysis care, the first step of improving nephrologic care is awareness of the extensiveness of geriatric impairment.
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Affiliation(s)
- Namiko A Goto
- Dianet Dialysis Center, Utrecht, The Netherlands,
- Department of Geriatrics, University Medical Center Utrecht, Utrecht, The Netherlands,
| | - Ismay N van Loon
- Dianet Dialysis Center, Utrecht, The Netherlands
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Moira I Morpey
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Hanna C Willems
- Department of Geriatrics, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | | | - Michiel L Bots
- Julius center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Franciscus T J Boereboom
- Dianet Dialysis Center, Utrecht, The Netherlands
- Department of Internal Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Marije E Hamaker
- Department of Geriatrics, Diakonessenhuis Utrecht, Utrecht, The Netherlands
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Plantinga L, Tift BD, Dunlop-Thomas C, Sam Lim S, Barrett Bowling C, Drenkard C. Geriatric Assessment of Physical and Cognitive Functioning in a Diverse Cohort of Systemic Lupus Erythematosus Patients: A Pilot Study. Arthritis Care Res (Hoboken) 2018; 70:1469-1477. [PMID: 29316334 DOI: 10.1002/acr.23507] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 01/02/2018] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To use multidomain functional assessment, which is commonly performed in geriatric patients but is novel in patients with systemic lupus erythematosus (SLE), to better understand functional impairment in patients with SLE. METHODS We recruited 60 adult participants (aged 20-39 years [26.7%], 40-59 years [50.0%], and ≥60 years [23.3%]; 80.0% African American and 90.0% female) from an existing cohort of SLE patients. During in-person visits (from October 2016 to April 2017), we evaluated physical performance (range 0-4, with higher scores indicating better performance), cognitive performance (5 fluid cognition domains; adjusted T scores), and self-reported measures including physical functioning (T scores), activities of daily living (ADLs), falls, and life-space mobility. RESULTS In the SLE patients, the mean balance score (3.7) and gait speed score (3.4) were high, while the mean lower body strength score was low (1.8). Cognitive performance was average (score of 5.0) for episodic (47.7) and working (48.6) memory and low average for cognitive flexibility (43.7), processing speed (42.6), and attention/inhibitory control (38.8 [>1 SD below average]) when compared with healthy individuals of the same age, sex, race, ethnicity, and education level. Most participants reported the ability to independently perform basic ADLs, but many reported the inability to independently perform instrumental ADLs. Nearly half (45.0%) of participants reported falling in the prior year. Only 40.0% reported unlimited ability to travel without the help of another person. Scores generally did not differ substantially according to age. CONCLUSION Our results suggest a high prevalence of impairment across multiple domains of function in SLE patients of all ages, similar to or exceeding the prevalence observed in much older geriatric populations. Further research into the added value of geriatric assessment in routine care for SLE is warranted.
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Affiliation(s)
| | - Benjamin D Tift
- Edward Via College of Osteopathic Medicine, Spartanburg, South Carolina
| | | | | | - C Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, and Duke University, Durham, North Carolina
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Hall RK, McAdams-DeMarco MA. Breaking the cycle of functional decline in older dialysis patients. Semin Dial 2018; 31:462-467. [PMID: 29642268 DOI: 10.1111/sdi.12695] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Currently, older adults comprise nearly one-third of prevalent US dialysis patients, and this proportion will increase as the population ages. Older dialysis patients experience greater morbidity and mortality than nondialysis patients of the same age, and in part, it is related to progressive functional decline. Progressive functional decline, characterized by need for assistance with more than 2 activities of daily living, contributes to risk of hospitalization, further functional decline, and subsequent nursing home placement when a patient no longer functions independently at home. Progressive functional decline may appear to be unavoidable for older dialysis patients; however, comprehensive geriatric assessment (CGA) may alleviate the prevalence and severity of functional decline. This editorial summarizes common risk factors of functional decline and introduces CGA as a potentially transformative approach to breaking the cycle of functional decline in older dialysis patients.
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Affiliation(s)
- Rasheeda K Hall
- Durham VA Geriatric Research, Education and Clinical Center, Durham, NC, USA.,Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
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36
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Delanaye P, Quinonez K, Buckinx F, Krzesinski JM, Bruyère O. Hand grip strength measurement in haemodialysis patients: before or after the session? Clin Kidney J 2017; 11:555-558. [PMID: 30090629 PMCID: PMC6070033 DOI: 10.1093/ckj/sfx139] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 11/05/2017] [Indexed: 02/07/2023] Open
Abstract
Background Hand grip strength (HGS) is a key measurement in the assessment of frailty phenotype in haemodialysis patients. However, the measurement is not very standardized, and notably, current data on the potential impact of a haemodialysis session on the results are both limited and controversial. In the present analysis, we compared HGS results before and after a haemodialysis session in 101 patients. Methods In the current observational study, HGS has been measured in adult haemodialysis patients on the same day, first before connection to the dialysis machine and then just after disconnection. At each timing, measurements were repeated three times with an interval of 5 s between measurements and the higher value was used for analysis. Results One hundred and one patients (64% men) with a median (interquartile range, 25th percentile; 75th percentile) age of 66 (46; 76) years were included. In the whole population, a significant decline in HGS was observed after dialysis, with an absolute median decline of − 4 (0; −6) kg and a relative median difference of −11 (0; −20)%. These differences were observed in both genders and were independent of the baseline HGS value. Conclusions Our results suggest that the timing (before or after the dialysis session) of hand grip assessment is clinically relevant and should be taken into account in clinical practice and also in epidemiological and clinical studies.
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Affiliation(s)
- Pierre Delanaye
- Department of Nephrology, Dialysis, Hypertension, University of Liège (ULg CHU), Liège, Belgium
| | - Kevin Quinonez
- Department of Nephrology, Dialysis, Hypertension, University of Liège (ULg CHU), Liège, Belgium
| | - Fanny Buckinx
- Department of Public Health, Epidemiology and Health Economics, University of Liège (ULg CHU), Liège, Belgium
| | - Jean-Marie Krzesinski
- Department of Nephrology, Dialysis, Hypertension, University of Liège (ULg CHU), Liège, Belgium
| | - Olivier Bruyère
- Department of Public Health, Epidemiology and Health Economics, University of Liège (ULg CHU), Liège, Belgium
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van Loon IN, Goto NA, Boereboom FT, Bots ML, Verhaar MC, Hamaker ME. Frailty Screening Tools for Elderly Patients Incident to Dialysis. Clin J Am Soc Nephrol 2017; 12:1480-1488. [PMID: 28716855 PMCID: PMC5586582 DOI: 10.2215/cjn.11801116] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 05/30/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES A geriatric assessment is an appropriate method for identifying frail elderly patients. In CKD, it may contribute to optimize personalized care. However, a geriatric assessment is time consuming. The purpose of our study was to compare easy to apply frailty screening tools with the geriatric assessment in patients eligible for dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A total of 123 patients on incident dialysis ≥65 years old were included <3 weeks before to ≤2 weeks after dialysis initiation, and all underwent a geriatric assessment. Patients with impairment in two or more geriatric domains on the geriatric assessment were considered frail. The diagnostic abilities of six frailty screening tools were compared with the geriatric assessment: the Fried Frailty Index, the Groningen Frailty Indicator, Geriatric8, the Identification of Seniors at Risk, the Hospital Safety Program, and the clinical judgment of the nephrologist. Outcome measures were sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS In total, 75% of patients were frail according to the geriatric assessment. Sensitivity of frailty screening tools ranged from 48% (Fried Frailty Index) to 88% (Geriatric8). The discriminating features of the clinical judgment were comparable with the other screening tools. The Identification of Seniors at Risk screening tool had the best discriminating abilities, with a sensitivity of 74%, a specificity of 80%, a positive predictive value of 91%, and a negative predictive value of 52%. The negative predictive value was poor for all tools, which means that almost one half of the patients screened as fit (nonfrail) had two or more geriatric impairments on the geriatric assessment. CONCLUSIONS All frailty screening tools are able to detect geriatric impairment in elderly patients eligible for dialysis. However, all applied screening tools, including the judgment of the nephrologist, lack the discriminating abilities to adequately rule out frailty compared with a geriatric assessment.
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Affiliation(s)
- Ismay N. van Loon
- Dianet Dialysis Center, Utrecht, The Netherlands
- Departments of Internal Medicine and
- Departments of Nephrology and Hypertension and
| | | | | | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Mohammadi-Kalaveh S, Toulabi T, Hasanvand S, Gholami M, Ghasemi F. The Impact of Multidisciplinary Rehabilitation on Depressive Symptoms in Hemodialysis Patients. West J Nurs Res 2017; 40:738-752. [PMID: 28322670 DOI: 10.1177/0193945916685091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Depressive symptom is the most frequent psychological problem reported among chronic kidney disease (CKD) patients being treated by hemodialysis. This article evaluates the effectiveness of multidisciplinary rehabilitation on depressive symptoms in hemodialysis patients and clarifies the role of nurses. This quasi-experimental study was done on 30 patients in the hemodialysis center (educational hospital) in 2013. Eight rehabilitation plans were conducted by nurses. Beck Depression Inventory (BDI) was used before and after intervention. Our data were analyzed using descriptive and inferential statistics. Result of this study shows that there was a significant difference between mean depressive symptom score before (36.4 ± 10.9) and after (10.5 ± 3.1) rehabilitation ( p < .001). It is recommended that rehabilitation program be implemented in all hemodialysis centers with the participation of specialists in different fields.
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Affiliation(s)
| | - Tahereh Toulabi
- 1 Lorestan University of Medical Sciences, Khorramabad, Iran
| | | | | | - Fatemeh Ghasemi
- 1 Lorestan University of Medical Sciences, Khorramabad, Iran
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39
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Rodrigues J, Cuppari L, Campbell KL, Avesani CM. Nutritional assessment of elderly patients on dialysis: pitfalls and potentials for practice. Nephrol Dial Transplant 2017; 32:1780-1789. [DOI: 10.1093/ndt/gfw471] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/21/2016] [Indexed: 01/08/2023] Open
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40
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Javier AD, Figueroa R, Siew ED, Salat H, Morse J, Stewart TG, Malhotra R, Jhamb M, Schell JO, Cardona CY, Maxwell CA, Ikizler TA, Abdel-Kader K. Reliability and Utility of the Surprise Question in CKD Stages 4 to 5. Am J Kidney Dis 2017; 70:93-101. [PMID: 28215946 DOI: 10.1053/j.ajkd.2016.11.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/20/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Prognostic uncertainty is one barrier to engaging in goals-of-care discussions in chronic kidney disease (CKD). The surprise question ("Would you be surprised if this patient died in the next 12 months?") is a tool to assist in prognostication. However, it has not been studied in non-dialysis-dependent CKD and its reliability is unknown. STUDY DESIGN Observational study. SETTING & PARTICIPANTS 388 patients at least 60 years of age with non-dialysis-dependent CKD stages 4 to 5 who were seen at an outpatient nephrology clinic. PREDICTOR Trinary (ie, Yes, Neutral, or No) and binary (Yes or No) surprise question response. OUTCOMES Mortality, test-retest reliability, and blinded inter-rater reliability. MEASUREMENTS Baseline comorbid conditions, Charlson Comorbidity Index, cause of CKD, and baseline laboratory values (ie, serum creatinine/estimated glomerular filtration rate, serum albumin, and hemoglobin). RESULTS Median patient age was 71 years with median follow-up of 1.4 years, during which time 52 (13%) patients died. Using the trinary surprise question, providers responded Yes, Neutral, and No for 202 (52%), 80 (21%), and 106 (27%) patients, respectively. About 5%, 15%, and 27% of Yes, Neutral, and No patients died, respectively (P<0.001). Trinary surprise question inter-rater reliability was 0.58 (95% CI, 0.42-0.72), and test-retest reliability was 0.63 (95% CI, 0.54-0.72). The trinary surprise question No response had sensitivity and specificity of 55% and 76%, respectively (95% CIs, 38%-71% and 71%-80%, respectively). The binary surprise question had sensitivity of 66% (95% CI, 49%-80%; P=0.3 vs trinary), but lower specificity of 68% (95% CI, 63%-73%; P=0.02 vs trinary). LIMITATIONS Single center, small number of deaths. CONCLUSIONS The surprise question associates with mortality in CKD stages 4 to 5 and demonstrates moderate to good reliability. Future studies should examine how best to deploy the surprise question to facilitate advance care planning in advanced non-dialysis-dependent CKD.
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Affiliation(s)
- Andrei D Javier
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN
| | - Rocio Figueroa
- Division of Nephrology, University of New Mexico, Albuquerque, NM
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN
| | - Huzaifah Salat
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN
| | - Jennifer Morse
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Thomas G Stewart
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Rakesh Malhotra
- Division of Nephrology, University of California at San Diego, San Diego, CA
| | - Manisha Jhamb
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jane O Schell
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA; Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Cesar Y Cardona
- Division of Nephrology, Meharry Medical College, Nashville, TN
| | | | - T Alp Ikizler
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN.
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