1
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Nouri A, Mansour-Ghanaei R, Esmaeilpour-Bandboni M, Gholami Chaboki B. Geriatric nutritional risk index and quality of life among elderly hemodialysis patients: a cross-sectional study. Ann Med Surg (Lond) 2024; 86:5101-5105. [PMID: 39238982 PMCID: PMC11374190 DOI: 10.1097/ms9.0000000000002378] [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: 04/12/2024] [Accepted: 07/05/2024] [Indexed: 09/07/2024] Open
Abstract
Background Nutritional problems are considered one of the main complications of hemodialysis, and the geriatric nutritional risk index (GNRI) is a new instrument for assessing geriatric nutritional status. The present study sought to evaluate the relationship between the GNRI and quality of life (QOL) among elderly hemodialysis patients. Methods In the present analytical cross-sectional study, 110 hemodialysis individuals were selected by applying a simple random sampling method, among whom 57 and 53 were males and females, respectively (mean: 70.3±6.93 years). Demographic characteristics, GNRI, and QOL status were determined. The data were analyzed using SPSS 20 software and descriptive statistics, Pearson's correlation, ANOVA, independent sample t-tests, and multiple linear regression analysis. Results The mean GNRI and mean total QOL were respectively obtained 93.903±11.067 and 20.95 ± 4.89. Among females, a significant direct relationship was observed between GNRI and total QOL (P = 0.010, r = 0.352), autonomy (P = 0.004, r = 0.389), and pleasure (P = 0.015, r = 0.333), while GNRI was not directly and significantly related to QOL in males (P = 0.161, r = 0.188). Conclusion Due to the presence of a significant association between Geriatric GNRI and QOL among elderly hemodialysis patients, particularly among females, highlighting the importance of addressing nutritional status in optimizing well-being.
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Affiliation(s)
- Ali Nouri
- Zeynab (P.B.U.H) School of Nursing and Midwifery, Guilan University of Medical Sciences
| | - Roya Mansour-Ghanaei
- Zeynab (P.B.U.H) School of Nursing and Midwifery, Guilan University of Medical Sciences
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | | | - Bahare Gholami Chaboki
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
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2
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Kalra S, Dhar M, Afsana F, Aggarwal P, Aye TT, Bantwal G, Barua M, Bhattacharya S, Das AK, Das S, Dasgupta A, Dhakal G, Dhingra A, Esfahanian F, Gadve S, Jacob J, Kapoor N, Latheef A, Mahadeb Y, Maskey R, Naseri W, Ratnasingam J, Raza A, Saboo B, Sahay R, Shah M, Shaikh S, Sharma SK, Shrestha D, Somasundaram N, Tiwaskar M, Jawdekar A. Asian Best Practices for Care of Diabetes in Elderly (ABCDE). Rev Diabet Stud 2022; 18:100-134. [PMID: 35831938 PMCID: PMC10044048 DOI: 10.1900/rds.2022.18.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The elderly population with diabetes is diverse with the majority experiencing a decline in physical and mental capabilities, impacting the entire diabetes management process. Therefore, a need for geriatric-specific guidelines, especially for the Asian population, was identified and
subsequently developed by an expert panel across government and private institutions from several Asian countries. The panel considered clinical evidence (landmark trials, position papers, expert opinions), recommendations from several important societies along with their decades of clinical
experience and expertise, while meticulously devising thorough geriatric-specific tailored management strategies. The creation of the ABCDE best practices document underscores and explores the gaps and challenges and determines optimal methods for diabetes management of the elderly population
in the Asian region.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Sambit Das
- Dr.Sambit's Centre of Diabetes and Endocrinology, India
| | | | | | | | | | | | | | | | - Ali Latheef
- National Diabetes Centre, Indira Gandhi Memorial, India
| | | | | | | | | | - Abbas Raza
- Shaukat Khanum Cancer Hospital and Research Centre, Pakistan
| | - Banshi Saboo
- Diabetes Care and Hormone Clinic, Ahmedabad, India
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3
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Portolés J, Vega A, Lacoba E, López-Sánchez P, Botella M, Yuste C, Martín Cleary C, Sanz Ballesteros S, González Sanchidrian S, Sánchez García L, Carreño A, Bajo MA, Janeiro D. Is peritoneal dialysis suitable technique CKD patients over 65 years? A prospective multicenter study. Nefrologia 2021; 41:529-538. [PMID: 36165135 DOI: 10.1016/j.nefroe.2021.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/18/2020] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is increasing in patients older than 65 years and is related to morbidity, frailty, and dependence. Peritoneal dialysis (PD) has classically been associated with young patients with an active life. HYPOTHESIS PD should be offered to patients over 65 years. We search for any unfavorable results that may advice not to recommend PD therapy for this group. OBJECTIVE To describe PD treatment and outcomes in patients > 65 years, to compare their results with patients < 65 years and to identify areas with room for improvement in a real-life study. STUDY Prospective, observational, and multicenter study performed in incident PD patients, from January 2003 until January 2018. RESULTS We included 2,435 PD patients, 31.9% were older than 65 years; there was a difference of 25 years between both groups. Median follow up was 2.1 years. Older than 65 years group had more comorbidity: Diabetes (29.5% vs 17.2%; p < 0.001), previous CV events 34.5% vs 14.0%; p < 0.001), Charlson index (3.8 vs 3.0; p < 0.001). We did not find differences in efficacy and PD adequacy objectives fulfillment, anaemia management or blood pressure during follow-up. Peritonitis rate was higher in older 65 years group (0.65 vs 0.45 episodes/patient/year; p < 0.001), but there was not differences in germs, admission rate and follow up. Mortality was higher in older 65 years group (28.4% vs 9.4%) as expected. PD permanence probability was similar (2.1 years). The main cause of PD withdrawal was transplant in group < 65 years (48.3%) and transfer to HD in group > 65 years. The main reason was caregiver or patient fatigue (20.2%), and not technique failure (7.3%). Multivariate Cox regression analysis showed a relation (HR [95%CI]) between mortality and age > 65 years 2.4 [1.9-3.0]; DM 1.6 [1.3-2.1]; CV events 2.1 [1.7-2.7]. Multivariate Cox regression analysis identify a relation between technique failure and age > 65 years 1.5 [1.3-1.9]; DM 1.6 [1.3-1.9] and previous transplant 1.5 [1.2-2.0]. CONCLUSION Patients older than 65 years fulfilled PD adequacy criteria during the follow up. We believe PD is a valid option for patients older 65 years. It is necessary to try to prevent infections and patient/caregiver fatigue, to avoid HD transfer for reasons not related to technique failure.
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Affiliation(s)
- Jose Portolés
- Servicio de Nefrología, H. Universitario Puerta de Hierro, Madrid, Spain; REDInREN RETIC ISCIII 016/009, Spain.
| | - Almudena Vega
- Servicio de Nefrología, H. Universitario Gregorio Marañón, Madrid, Spain; REDInREN RETIC ISCIII 016/009, Spain
| | - Enrique Lacoba
- Servicio de Nefrología, H. Universitario Puerta de Hierro, Madrid, Spain; REDInREN RETIC ISCIII 016/009, Spain
| | | | - Mario Botella
- Servicio de Nefrología, H. Universitario Puerta de Hierro, Madrid, Spain
| | - Claudia Yuste
- REDInREN RETIC ISCIII 016/009, Spain; Servicio de Nefrología, H. Universitario Doce de Octubre, Madrid, Spain
| | - Catalina Martín Cleary
- REDInREN RETIC ISCIII 016/009, Spain; Servicio de Nefrología, Fundación Jiménez Díaz, Madrid, Spain
| | | | | | | | - Agustín Carreño
- Servicio de Nefrología, H. Universitario Ciudad Real, Ciudad Real, Spain
| | - M Auxiliadora Bajo
- REDInREN RETIC ISCIII 016/009, Spain; Servicio de Nefrología, H. Universitario La Paz, Madrid, Spain
| | - Darío Janeiro
- Servicio de Nefrología, H. Universitario Puerta de Hierro, Madrid, Spain; REDInREN RETIC ISCIII 016/009, Spain
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4
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Hannan M, Collins EG, Phillips SA, Quinn L, Steffen A, Bronas UG. Cognitive and vascular function in older adults with and without CKD. Aging Clin Exp Res 2021; 33:1885-1894. [PMID: 32902822 PMCID: PMC8171583 DOI: 10.1007/s40520-020-01695-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/24/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cognitive impairment is a common complication of aging that is also associated with chronic kidney disease (CKD). Vascular dysfunction has been implicated as a potential cause of cognitive impairment in older adults, with particular deficits noted in those with CKD. AIMS To determine the differences in cognitive function and vascular compliance in older adults with and without CKD with preclinical cognitive impairment and the relationship between these factors. METHODS Utilizing a cross-sectional approach, 48 older adults with preclinical cognitive impairment (24 with and 24 without CKD) were evaluated for performance on a test of global cognition and executive function, and vascular compliance via tonometry and ultrasound. RESULTS Cognitive function and some indicators of vascular function were significantly different in older adults with and without CKD. Global cognition was correlated with carotid-femoral pulse wave velocity (r = - 0.36, p = 0.02) in the entire sample. Vascular function was not correlated with executive function. DISCUSSION Older adults with preclinical cognitive impairment and CKD had different cognitive and vascular function than those without CKD, and an indicator of vascular function may have a relationship with cognitive function in older adults. CONCLUSIONS The findings of this study support the assessment of cognitive and vascular function in older adults with and without CKD with preclinical cognitive impairment.
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Affiliation(s)
- Mary Hannan
- College of Medicine, Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Eileen G Collins
- College of Nursing, Department of Biobehavioral Health Science (M/C 802), University of Illinois at Chicago, 845 S Damen Avenue, Chicago, IL, 60612, USA
| | - Shane A Phillips
- College of Applied Health Sciences, Department of Physical Therapy, University of Illinois at Chicago, Chicago, IL, USA
| | - Lauretta Quinn
- College of Nursing, Department of Biobehavioral Health Science (M/C 802), University of Illinois at Chicago, 845 S Damen Avenue, Chicago, IL, 60612, USA
| | - Alana Steffen
- College of Nursing, Department of Health Systems Science, University of Illinois at Chicago, Chicago, IL, USA
| | - Ulf G Bronas
- College of Nursing, Department of Biobehavioral Health Science (M/C 802), University of Illinois at Chicago, 845 S Damen Avenue, Chicago, IL, 60612, USA.
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5
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Portolés J, Vega A, Lacoba E, López-Sánchez P, Botella M, Yuste C, Martín Cleary C, Sanz Ballesteros S, González Sanchidrian S, Sánchez García L, Carreño A, Bajo MA, Janeiro D. Is peritoneal dialysis suitable technique CKD patients over 65 years? A prospective multicenter study. Nefrologia 2021. [PMID: 33610372 DOI: 10.1016/j.nefro.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is increasing in patients older than 65years and is related to morbidity, frailty, and dependence. Peritoneal dialysis (PD) has classically been associated with young patients with an active life. HYPOTHESIS PD should be offered to patients over 65years. We search for any unfavorable results that may advice not to recommend PD therapy for this group. OBJECTIVE To describe PD treatment and outcomes in patients >65years, to compare their results with patients <65years and to identify areas with room for improvement in a real-life study. STUDY Prospective, observational, and multicenter study performed in incident PD patients, from January 2003 until January 2018. RESULTS We included 2,435 PD patients, 31.9% were older than 65years; there was a difference of 25years between both groups. Median follow up was 2.1years. Older than 65years group had more comorbidity: Diabetes (29.5% vs 17.2%; p<0.001), previous CV events 34.5% vs 14.0%; p<0.001), Charlson index (3.8 vs 3.0; p<0.001). We did not find differences in efficacy and PD adequacy objectives fulfillment, anaemia management or blood pressure during follow-up. Peritonitis rate was higher in older 65years group (0.65 vs 0.45 episodes/patient/year; p<0.001), but there was not differences in germs, admission rate and follow up. Mortality was higher in older 65years group (28.4% vs 9.4%) as expected. PD permanence probability was similar (2.1years). The main cause of PD withdrawal was transplant in group <65years (48.3%) and transfer to HD in group >65years. The main reason was caregiver or patient fatigue (20.2%), and not technique failure (7.3%). Multivariate Cox regression analysis showed a relation (HR [95%CI]) between mortality and age>65years 2.4 [1.9-3.0]; DM 1.6 [1.3-2.1]; CV events 2.1 [1.7-2.7]. Multivariate Cox regression analysis identify a relation between technique failure and age>65years 1.5 [1.3-1.9]; DM 1.6 [1.3-1.9] and previous transplant 1.5 [1.2-2.0]. CONCLUSION Patients older than 65years fulfilled PD adequacy criteria during the follow up. We believe PD is a valid option for patients older 65years. It is necessary to try to prevent infections and patient/caregiver fatigue, to avoid HD transfer for reasons not related to technique failure.
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Affiliation(s)
- Jose Portolés
- Servicio de Nefrología, H. Universitario Puerta de Hierro, Madrid, España; REDInREN RETIC ISCIII 016/009, España.
| | - Almudena Vega
- Servicio de Nefrología, H. Universitario Gregorio Marañón, Madrid, España; REDInREN RETIC ISCIII 016/009, España
| | - Enrique Lacoba
- Servicio de Nefrología, H. Universitario Puerta de Hierro, Madrid, España; REDInREN RETIC ISCIII 016/009, España
| | | | - Mario Botella
- Servicio de Nefrología, H. Universitario Puerta de Hierro, Madrid, España
| | - Claudia Yuste
- REDInREN RETIC ISCIII 016/009, España; Servicio de Nefrología, H. Universitario Doce de Octubre, Madrid, España
| | - Catalina Martín Cleary
- REDInREN RETIC ISCIII 016/009, España; Servicio de Nefrología, Fundación Jiménez Díaz, Madrid, España
| | | | | | | | - Agustín Carreño
- Servicio de Nefrología, H. Universitario Ciudad Real, Ciudad Real, España
| | - M Auxiliadora Bajo
- REDInREN RETIC ISCIII 016/009, España; Servicio de Nefrología, H. Universitario La Paz, Madrid, España
| | - Darío Janeiro
- Servicio de Nefrología, H. Universitario Puerta de Hierro, Madrid, España; REDInREN RETIC ISCIII 016/009, España
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6
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Lysak N, Hashemighouchani H, Davoudi A, Pourafshar N, Loftus TJ, Ruppert M, Efron PA, Rashidi P, Bihorac A, Ozrazgat-Baslanti T. Cardiovascular death and progression to end-stage renal disease after major surgery in elderly patients. BJS Open 2019; 4:145-156. [PMID: 32011817 PMCID: PMC6996640 DOI: 10.1002/bjs5.50232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/11/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Reliable estimates for risk of cardiovascular-specific mortality and progression to end-stage renal disease (ESRD) among elderly patients undergoing major surgery are not available. This study aimed to develop simple risk scores to predict these events. METHODS In a single-centre cohort of elderly patients undergoing major surgery requiring hospital stay longer than 24 h, progression to ESRD and long-term cardiovascular-specific mortality were modelled using multivariable subdistribution hazard models, adjusting for co-morbidity, frailty and type of surgery. RESULTS Before surgery, 2·9 and 11·9 per cent of 16 655 patients had ESRD and chronic kidney disease (CKD) respectively. During the hospital stay, 46·9 per cent of patients developed acute kidney injury (AKI). Patients with kidney disease had a significantly higher risk of cardiovascular-specific (CV) mortality compared with patients without kidney disease (adjusted hazard ratio (HR) for CKD without AKI 1·60, 95 per cent c.i. 1·25 to 2·01; AKI without CKD 1·70, 1·52 to 1·87; AKI with CKD 2·80, 2·50 to 3·20; ESRD 5·21, 4·32 to 6·27), as well as increased progression to ESRD (AKI without CKD 5·40, 3·44 to 8·35; CKD without AKI 8·80, 4·60 to 17·00; AKI with CKD 31·60, 19·90 to 49·90). CV Death and ESRD Risk scores were developed to predict CV mortality and progression to ESRD. Calculated CV Death and ESRD Risk scores performed well with c-statistics: 0·77 (95 per cent c.i. 0·76 to 0·78) and 0·82 (0·78 to 0·86) respectively at 1 year. CONCLUSION Kidney disease in elderly patients undergoing major surgery is associated with a high risk of CV mortality and progression to ESRD. Risk scores can augment the shared decision-making process of informed consent and identify patients requiring postoperative renal-protective strategies.
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Affiliation(s)
- N Lysak
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - H Hashemighouchani
- Department of Medicine, University of Florida, Gainesville, Florida, USA.,Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, Florida, USA
| | - A Davoudi
- Department of Biomedical Engineering, University of Florida, Gainesville, Florida, USA.,Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, Florida, USA
| | - N Pourafshar
- Health Sciences Centre, University of Virginia, Charlottesville, Virginia, USA
| | - T J Loftus
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - M Ruppert
- Department of Medicine, University of Florida, Gainesville, Florida, USA.,Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, Florida, USA
| | - P A Efron
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - P Rashidi
- Department of Biomedical Engineering, University of Florida, Gainesville, Florida, USA.,Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, Florida, USA
| | - A Bihorac
- Department of Medicine, University of Florida, Gainesville, Florida, USA.,Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, Florida, USA
| | - T Ozrazgat-Baslanti
- Department of Medicine, University of Florida, Gainesville, Florida, USA.,Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, Florida, USA
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7
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Auguste BL, Chan CT. Home Dialysis Among Elderly Patients: Outcomes and Future Directions. Can J Kidney Health Dis 2019; 6:2054358119871031. [PMID: 31523436 PMCID: PMC6732853 DOI: 10.1177/2054358119871031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 06/16/2019] [Indexed: 12/18/2022] Open
Abstract
Elderly patients who receive home dialysis (peritoneal dialysis or home hemodialysis) may have reduced survival compared to younger patients. Therefore, it is important to ascertain the goals of home dialysis in the elderly rather than simply fixate on standard metrics such as technique survival. As Canada's population continues to age, the prevalence of end-stage kidney disease among the elderly population is increasing. Patients with multiple comorbidities are now surviving long enough to be started on dialysis. Although home dialysis has been associated with better survival and improved quality of life, its impact on the frail and elderly populations require further elucidation. Home dialysis patients can either independently perform tasks or have support in the home to safely conduct dialysis. Moreover, patients burdened with frailty and multiple comorbidities who lack support in the home may not be able to perform home dialysis safely. Innovative strategies to improve accessibility to home-based therapies need further exploration. In addition, the concept of goal-directed dialysis promotes more individualized treatment. Future continuous quality improvement initiatives must examine if goal-directed dialysis leads to better quality of life outcomes in the elderly.
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8
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Hawley CE, Triantafylidis LK, Paik JM. The missing piece: Clinical pharmacists enhancing the interprofessional nephrology clinic model. J Am Pharm Assoc (2003) 2019; 59:727-735. [PMID: 31231002 PMCID: PMC8150925 DOI: 10.1016/j.japh.2019.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To embed pharmacy residents in an interprofessional nephrology clinic to conduct medication reconciliation in targeted high-risk patients with nondialysis kidney disease. SETTING This pilot was a prospective quality improvement initiative conducted in an interprofessional outpatient nephrology clinic. PRACTICE DESCRIPTION The nephrology clinic team includes nephrology providers, a social worker, and a geriatrician. The team is responsible for the management of conditions such as nondialysis kidney disease, resistant hypertension, acute kidney injury, proteinuria, and nephropathy. EVALUATION Primary outcomes included the number and type of medication discrepancies and drug therapy problems identified. Secondary outcomes included the changes in care process directly resulting from the pharmacy residents' recommendations. The perceived value of the pharmacy residents to the interprofessional team was assessed through postintervention anonymous surveys and semistructured interviews. RESULTS The pharmacy residents conducted 118 visits for 87 unique patients (mean age 73 years, 97% male) with nondialysis kidney disease (89% stages III-V), polypharmacy (87% of patients taking > 10 medications), and a heavy comorbidity burden (85% hypertension, 80% dyslipidemia, 59% diabetes mellitus type II) from January to October 2017. Pharmacists identified 344 medication discrepancies and 301 drug therapy problems, resulting in 398 changes in care process. The most frequently identified discrepancies and drug therapy problems were the omission of an active medication from the medication list (86 of 344 discrepancies, 25%) and potentially inappropriate medications (106 of 301 drug therapy problems, 35%). Pharmacists recommended 228 medication changes, provided 76 adherence devices, facilitated 24 consults or referrals, and communicated with the primary care team on 70 occasions. The interprofessional team members all strongly agreed that patients and the team benefited from the pharmacists' involvement. CONCLUSION Pharmacy resident-led medication reconciliation resulted in the identification and resolution of medication discrepancies and drug therapy problems, leading to changes in the care process.
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Affiliation(s)
- Chelsea E. Hawley
- New England Geriatric Research, Education, and Clinical Center
- Department of Pharmacy, VA Boston Healthcare System, Boston, MA
| | | | - Julie M. Paik
- New England Geriatric Research, Education, and Clinical Center
- Renal Section, VA Boston Healthcare System
- Brigham and Women’s Hospital
- Department of Medicine, Harvard Medical School, Boston, MA
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9
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Vezza C, Vettoretti S, Caldiroli L, Bergamaschini L, Messa P, Cesari M. Use of the Frailty Index in Older Persons With Chronic Kidney Disease. J Am Med Dir Assoc 2019; 20:1179-1180. [PMID: 31176674 DOI: 10.1016/j.jamda.2019.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/14/2019] [Accepted: 04/16/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Carlotta Vezza
- Geriatric Fellowship Program, University of Milan, Milan, Italy
| | - Simone Vettoretti
- Nephrology Dialysis and Kidney Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lara Caldiroli
- Nephrology Dialysis and Kidney Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luigi Bergamaschini
- Department of Clinical Sciences and Community, University of Milan, Milan, Italy
| | - Piergiorgio Messa
- Nephrology Dialysis and Kidney Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community, University of Milan, Milan, Italy
| | - Matteo Cesari
- Department of Clinical Sciences and Community, University of Milan, Milan, Italy; Geriatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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10
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Urban AK, Foote C, Brennan FP, Brown M, Lee BWH. Retrospective chart review to assess domains of quality of death (recognition of dying, appropriate limitations, symptom monitoring, anticipatory prescribing) of patients dying in the acute hospital under the care of a nephrology service with renal supportive care support over time. Nephrology (Carlton) 2018; 24:511-517. [PMID: 30091497 DOI: 10.1111/nep.13447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2018] [Indexed: 11/30/2022]
Abstract
AIM To explore the quality of deaths in an acute hospital under a nephrology service at two teaching hospitals in Sydney with renal supportive care services over time. METHODS Retrospective chart review of all deaths in the years 2004, 2009 and 2014 at St George Hospital (SGH) and in 2014 at the Concord Repatriation General Hospital. Domains assessed were recognition of dying, invasive interventions, symptom assessment, anticipatory prescribing, documentation of spiritual needs and bereavement information for families. End-of-life care plan (EOLCP) use was also evaluated at SGH. RESULTS Over 90% of patients were recognized to be dying in all 3 years at SGH. Rates of interventions in the last week of life were low and did not differ across the 3 years. There was a significant increase in the prescription of anti-psychotic, anti-emetic and anti-cholinergic medication over the years at SGH. Use of EOLCP was significantly higher at SGH, and their use improved several quality domains. Of all deaths, 68% were referred to palliative care at SGH and 33% at Concord Repatriation General Hospital (not significant). Cessation of observations and non-essential medications and documentation of bereavement information given to families was low across both sites in all years, although this significantly improved when EOLCP were used. CONCLUSION While acute teams are good at recognizing dying, they need support to care for dying patients. The use of EOLCP in acute services can facilitate improvements in caring for the dying. Renal supportive care services need time to become embedded in the culture of the acute hospital.
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Affiliation(s)
- Agnes K Urban
- Palliative Care Department, Concord Repatriation General Hospital, New South Wales, Australia.,University of Sydney, New South Wales, Australia
| | - Celine Foote
- Palliative Care Department, Concord Repatriation General Hospital, New South Wales, Australia.,University of Sydney, New South Wales, Australia
| | - Frank P Brennan
- St George Hospital, New South Wales, Australia.,University of New South Wales, New South Wales, Australia
| | - Mark Brown
- St George Hospital, New South Wales, Australia.,University of New South Wales, New South Wales, Australia
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11
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Piccoli GB, Breuer C, Cabiddu G, Testa A, Jadeau C, Brunori G. Where Are You Going, Nephrology? Considerations on Models of Care in an Evolving Discipline. J Clin Med 2018; 7:jcm7080199. [PMID: 30081442 PMCID: PMC6111293 DOI: 10.3390/jcm7080199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/21/2018] [Accepted: 08/01/2018] [Indexed: 12/18/2022] Open
Abstract
Nephrology is a complex discipline, including care of kidney disease, dialysis, and transplantation. While in Europe, about 1:10 individuals is affected by chronic kidney disease (CKD), 1:1000 lives thanks to dialysis or transplantation, whose costs are as high as 2% of all the health care budget. Nephrology has important links with surgery, bioethics, cardiovascular and internal medicine, and is, not surprisingly, in a delicate balance between specialization and comprehensiveness, development and consolidation, cost constraints, and competition with internal medicine and other specialties. This paper proposes an interpretation of the different systems of nephrology care summarising the present choices into three not mutually exclusive main models (“scientific”, “pragmatic”, “holistic”, or “comprehensive”), and hypothesizing an “ideal-utopic” prevention-based fourth one. The so-called scientific model is built around kidney transplantation and care of glomerulonephritis and immunologic diseases, which probably pose the most important challenges in our discipline, but do not mirror the most common clinical problems. Conversely, the pragmatic one is built around dialysis (the most expensive and frequent mode of renal replacement therapy) and pre-dialysis treatment, focusing attention on the most common diseases, the holistic, or comprehensive, model comprehends both, and is integrated by several subspecialties, such as interventional nephrology, obstetric nephrology, and the ideal-utopic one is based upon prevention, and early care of common diseases. Each model has strength and weakness, which are commented to enhance discussion on the crucial issue of the philosophy of care behind its practical organization. Increased reflection and research on models of nephrology care is urgently needed if we wish to rise to the challenge of providing earlier and better care for older and more complex kidney patients with acute and chronic kidney diseases, with reduced budgets.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino Italy, 10100 Torino, Italy.
- Nephrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Conrad Breuer
- Direction, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | | | | | - Christelle Jadeau
- Centre de Recherche Clinique, Centre Hospitalier Le Mans, 72000 Le Mans, France.
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Guvercin G, Karakus V, Aksit M, Dere Y, Aktar M, Alpay H, Bozkaya G, Tatar E. Matrix metalloproteinase-9, 10, and stress hyperglycaemia in acute kidney injury. Eur J Clin Invest 2018; 48:e12963. [PMID: 29856477 DOI: 10.1111/eci.12963] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 05/30/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study investigated the effect of matrix metalloproteinase (MMP)-9 and 10, and stress hyperglycaemia on the necessity of emergency renal replacement therapy (RRT) and mortality in nondiabetic geriatric patients with acute kidney injury (AKI). MATERIALS AND METHODS The present observational and longitudinal study included 101 nondiabetic geriatric patients (age >65 years) with AKI. The serum levels of MMP-9 and MMP-10 were evaluated in these patients. Serum glucose level >140 mg/dL at the time of admission was accepted as stress hyperglycaemia. RESULTS The average age of patients was 81 ± 7.1 years. Stress hyperglycaemia was diagnosed in 34.6% of the cases; the majority of these cases were patients with high-serum urea, CRP, and chronic kidney disease. The average levels of MMP-9 and MMP-10 were found to be 199 ± 38 and 16.5 ± 7.5 ng/mL, respectively. Thirty-one cases (30.6%) mortality during hospitalization and 20 cases (20%) underwent emergency RRT. Multiregression analysis showed the serum urea (P < .001) and stress hyperglycaemia (P = .03) to be independently associated with mortality. Also, serum urea (P = .01), potassium level (P = .03), and MMP-10 levels (P = .03) were independently associated with the necessity of the emergency RRT. The MMP-9 levels exhibited no relation with the necessity of emergency RRT and mortality. CONCLUSION Stress hyperglycaemia is a common condition among nondiabetic geriatric patients with AKI and is related to mortality. Serum MMP-10 levels serve as an important predictor of the necessity of emergency RRT in these patients.
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Affiliation(s)
- Guray Guvercin
- Department of Internal Medicine, Izmir Bozyaka Education and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Volkan Karakus
- Division of Hematology, Mugla Sitki Kocman University Training and Research Hospital, Mugla, Turkey
| | - Murat Aksit
- Department of Biochemistry, Izmir Bozyaka Education and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Yelda Dere
- Division of Pathology, Mugla Sitki Kocman University Training and Research Hospital, Mugla, Turkey
| | - Merve Aktar
- Department of Internal Medicine, Izmir Bozyaka Education and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Hasan Alpay
- Department of Internal Medicine, Izmir Bozyaka Education and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Giray Bozkaya
- Department of Biochemistry, Izmir Bozyaka Education and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Erhan Tatar
- Department of Nephrology, Izmir Bozyaka Education and Research Hospital, Health Sciences University, Izmir, Turkey
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Niemczyk M. Increasing economic burden caused by nephro-geriatric patients. J Med Econ 2018; 21:271-272. [PMID: 29124993 DOI: 10.1080/13696998.2017.1403923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mariusz Niemczyk
- a Department of Immunology, Transplant Medicine, and Internal Diseases , Medical University of Warsaw , Poland
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Turgutalp K, Bardak S, Horoz M, Helvacı I, Demir S, Kiykim AA. Clinical outcomes of acute kidney injury developing outside the hospital in elderly. Int Urol Nephrol 2016; 49:113-121. [PMID: 27704319 DOI: 10.1007/s11255-016-1431-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 09/26/2016] [Indexed: 01/21/2023]
Abstract
PURPOSE Although various studies have improved our knowledge about the clinical features and outcomes of acute kidney injury developing in the hospital (AKI-DI) in elderly subjects, data about acute kidney injury developing outside the hospital (AKI-DO) in elderly patients (age ≥ 65 years) are still extremely limited. This study was performed to investigate prevalence, clinical outcomes, hospital cost and related factors of AKI-DO in elderly and very elderly patients. METHODS We conducted a prospective, observational study in patients (aged ≥ 65 years) who were admitted to our center between May 01, 2012, and May 01, 2013. Subjects with AKI-DO were divided into two groups as "elderly" (group 1, 65-75 years old) and "very elderly" (group 2, >75 years old). Control group (group 3) consisted of the hospitalized patients aged 65 years and older with normal serum creatinine level. In-hospital outcomes and 6-month outcomes were recorded. Rehospitalization rate within 6 months of discharge was noted. Hospital costs and mortality rates of each group were investigated. Risk factors for AKI-DO were determined. RESULTS The incidence of AKI-DO that required hospitalization in elderly and very elderly patients was 5.8 % (136/2324) and 11 % (100/905), respectively (p < 0.001), with an overall incidence of 7.3 % (236/3229). Chronic kidney disease (CKD) was developed in 43.4 % of group 1 and 67 % of group 2 within the 6 months of discharge (p < 0.001). Progression to CKD was significantly lower in the control group than in groups 1 and 2 (p < 0.001). Mortality rates for groups 1, 2 and 3 were 23.5 % (n = 32), 31 % (n = 31) and 4.2 % (n = 8), respectively (p < 0.05). Rehospitalization rate within the 6 months of discharge for the groups with AKI-DO was higher than for the control group (p < 0.001). Hospital cost of groups 1 and 2 was significantly higher than that of the control group (p < 0.001). Nonsteroidal anti-inflammatory drugs (NSAIDs) (OR: 6.839, 95 % CI = 4.392-10.648), angiotensin-converting enzyme inhibitors (ACEI) (OR: 7.846, 95 % CI = 5.161-11.928), angiotensin receptor blockers (ARB) (OR: 6.466, 95 % CI = 4.813-8.917), radiocontrast agents (OR: 8.850, 95 % CI = 5.857-13.372), hypertension (OR: 4.244, 95 % CI = 2.729-6.600), diabetes mellitus (OR: 2.303, 95 % CI = 1.411-3.761), heart failure (OR: 3.647, 95 % CI = 2.276-5.844) and presence of infection (OR: 3.149, 95 % CI = 1.696-5.845) were found as the risk factors for AKI-DO in elderly patients (p < 0.001 for all). Patients with AKI-DO had higher 6-month mortality rate (HR 1.721, 95 % CI: 1.451-2.043, p < 0.001). Mortality risk increased 0.519 times at 20th day. CONCLUSIONS The incidence of AKI-DO requiring hospitalization is higher in very elderly patients than elderly ones, especially in male gender. Use of ACEI, ARB, NSAID and radiocontrast agents is the main risk factors for the development of AKI-DO in the elderly.
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Affiliation(s)
- K Turgutalp
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Mersin University, 33079, Mersin, Turkey.
| | - S Bardak
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Mersin University, 33079, Mersin, Turkey
| | - M Horoz
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Istanbul Bahcesehir University, Istanbul, Turkey
| | - I Helvacı
- Silifke School of Applied Technology and Management, Department of Business Information Management and Biostatistic, Mersin University, Silifke, Mersin, Turkey
| | - S Demir
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Mersin University, 33079, Mersin, Turkey
| | - A A Kiykim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Mersin University, 33079, Mersin, Turkey
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Falke LL, Kinashi H, Dendooven A, Broekhuizen R, Stoop R, Joles JA, Nguyen TQ, Goldschmeding R. Age-dependent shifts in renal response to injury relate to altered BMP6/CTGF expression and signaling. Am J Physiol Renal Physiol 2016; 311:F926-F934. [PMID: 27558559 DOI: 10.1152/ajprenal.00324.2016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/17/2016] [Indexed: 02/07/2023] Open
Abstract
Age is associated with an increased prevalence of chronic kidney disease (CKD), which, through progressive tissue damage and fibrosis, ultimately leads to loss of kidney function. Although much effort is put into studying CKD development experimentally, age has rarely been taken into account. Therefore, we investigated the effect of age on the development of renal tissue damage and fibrosis in a mouse model of obstructive nephropathy (i.e., unilateral ureter obstruction; UUO). We observed that after 14 days, obstructed kidneys of old mice had more tubulointerstitial atrophic damage but less fibrosis than those of young mice. This was associated with reduced connective tissue growth factor (CTGF), and higher bone morphogenetic protein 6 (BMP6) expression and pSMAD1/5/8 signaling, while transforming growth factor-β expression and transcriptional activity were no different in obstructed kidneys of old and young mice. In vitro, CTGF bound to and inhibited BMP6 activity. In summary, our data suggest that in obstructive nephropathy atrophy increases and fibrosis decreases with age and that this relates to increased BMP signaling, most likely due to higher BMP6 and lower CTGF expression.
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Affiliation(s)
- Lucas L Falke
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hiroshi Kinashi
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Nephrology and Renal Replacement Therapy, Nagoya University, Nagoya, Japan
| | - Amelie Dendooven
- Department of Pathology, University Medical Center, Antwerp, Belgium
| | - Roel Broekhuizen
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Reinout Stoop
- Department of Metabolic Health Research, TNO, Leiden, The Netherlands; and
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tri Q Nguyen
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roel Goldschmeding
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands;
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Elliott RA. Geriatric medicine and pharmacy practice: a historical perspective. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2016. [DOI: 10.1002/jppr.1214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Rohan A. Elliott
- Pharmacy Department; Austin Health; Heidelberg Victoria Australia
- Centre for Medicine Use and Safety; Monash University; Parkville Victoria Australia
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Collister D, Russell R, Verdon J, Beaulieu M, Levin A. Perspectives on optimizing care of patients in multidisciplinary chronic kidney disease clinics. Can J Kidney Health Dis 2016; 3:32. [PMID: 27182444 PMCID: PMC4866402 DOI: 10.1186/s40697-016-0122-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 04/27/2016] [Indexed: 11/23/2022] Open
Abstract
Purpose of review To summarize a jointly held symposium by the Canadian Society of Nephrology (CSN), the Canadian Association of Nephrology Administrators (CANA), and the Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) entitled “Perspectives on Optimizing Care of Patients in Multidisciplinary Chronic Kidney Disease (CKD) Clinics” that was held on April 24, 2015, in Montreal, Quebec. Sources of information The panel consisted of a variety of members from across Canada including a multidisciplinary CKD clinic patient (Randall Russell), nephrology fellow (Dr. David Collister), geriatrician (Dr. Josee Verdon), and nephrologists (Dr. Monica Beaulieu, Dr. Adeera Levin). Findings The objectives of the symposium were (1) to gain an understanding of the goals of care for CKD patients, (2) to gain an appreciation of different perspectives regarding optimal care for patients with CKD, (3) to examine the components required for optimal care including education strategies, structures, and tools, and (4) to describe a framework and metrics for CKD care which respect patient and system needs. This article summarizes the key concepts discussed at the symposium from a patient and physician perspectives. Key messages include (1) understanding patient values and preferences is important as it provides a framework as to what to prioritize in multidisciplinary CKD clinic and provincial renal program models, (2) barriers to effective communication and education are common in the elderly, and adaptive strategies to limit their influence are critical to improve adherence and facilitate shared decision-making, (3) the use of standardized operating procedures (SOPs) improves efficiency and minimizes practice variability among health care practitioners, and (4) CKD scorecards with standardized system processes are useful in approaching variability as well as measuring and improving patient outcomes. Limitations The perspectives provided may not be applicable across centers given the differences in patient populations including age, ethnicity, culture, language, socioeconomic status, education, and multidisciplinary CKD clinic structure and function. Implications Knowledge transmission by collaborative interprovincial and interprofessional networks may play a role in facilitating optimal CKD care. Validation of system and clinic models that improve outcomes is needed prior to disseminating these best practices.
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Affiliation(s)
- David Collister
- Section of Nephrology, University of Manitoba, Winnipeg, MB Canada
| | | | - Josee Verdon
- Division of Geriatric Medicine, McGill University, Montreal, QC Canada
| | - Monica Beaulieu
- Division of Nephrology, University of British Columbia, Vancouver, BC Canada
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, BC Canada
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Sharif MU, Elsayed ME, Stack AG. The global nephrology workforce: emerging threats and potential solutions! Clin Kidney J 2016; 9:11-22. [PMID: 26798456 PMCID: PMC4720191 DOI: 10.1093/ckj/sfv111] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 10/06/2015] [Indexed: 02/04/2023] Open
Abstract
Amidst the rising tide of chronic kidney disease (CKD) burden, the global nephrology workforce has failed to expand in order to meet the growing healthcare needs of this vulnerable patient population. In truth, this shortage of nephrologists is seen in many parts of the world, including North America, Europe, Australia, New Zealand, Asia and the African continent. Moreover, expert groups on workforce planning as well as national and international professional organizations predict further reductions in the nephrology workforce over the next decade, with potentially serious implications. Although the full impact of this has not been clearly articulated, what is clear is that the delivery of care to patients with CKD may be threatened in many parts of the world unless effective country-specific workforce strategies are put in place and implemented. Multiple factors are responsible for this apparent shortage in the nephrology workforce and the underpinning reasons may vary across health systems and countries. Potential contributors include the increasing burden of CKD, aging workforce, declining interest in nephrology among trainees, lack of exposure to nephrology among students and residents, rising cost of medical education and specialist training, increasing cultural and ethnic disparities between patients and care providers, increasing reliance on foreign medical graduates, inflexible work schedules, erosion of nephrology practice scope by other specialists, inadequate training, reduced focus on scholarship and research funds, increased demand to meet quality of care standards and the development of new care delivery models. It is apparent from this list that the solution is not simple and that a comprehensive evaluation is required. Consequently, there is an urgent need for all countries to develop a policy framework for the provision of kidney disease services within their health systems, a framework that is based on accurate projections of disease burden, a full understanding of the internal care delivery systems and a framework that is underpinned by robust health intelligence on current and expected workforce numbers required to support the delivery of kidney disease care. Given the expected increases in global disease burden and the equally important increase in many established kidney disease risk factors such as diabetes and hypertension, the organization of delivery and sustainability of kidney disease care should be enshrined in governmental policy and legislation. Effective nephrology workforce planning should be comprehensive and detailed, taking into consideration the structure and organization of the health system, existing care delivery models, nephrology workforce practices and the size, quality and success of internal nephrology training programmes. Effective training programmes at the undergraduate and postgraduate levels, adoption of novel recruitment strategies, flexible workforce practices, greater ownership of the traditional nephrology landscape and enhanced opportunities for research should be part of the implementation process. Given that many of the factors that impact on workforce capacity are generic across countries, cooperation at an international level would be desirable to strengthen efforts in workforce planning and ensure sustainable models of healthcare delivery.
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Affiliation(s)
- Muhammad U. Sharif
- Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Ireland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Mohamed E. Elsayed
- Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Ireland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Austin G. Stack
- Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Ireland
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
- Health Research Institute (HRI), University of Limerick, Limerick, Ireland
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Assessment of the geriatric competence and perceived needs of Italian nephrologists: an internet survey. J Nephrol 2015; 29:385-390. [PMID: 26385799 DOI: 10.1007/s40620-015-0232-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 08/29/2015] [Indexed: 10/23/2022]
Abstract
An internet survey was set up to assess the geriatric competence and perceived needs of 337 members of the Italian society of nephrology (SIN). The survey assessed how well aware nephrologists are of the typical geriatric conditions and needs of their elderly chronic kidney disease (CKD) patients. SIN associates were also questioned about their current use of comprehensive geriatric assessment, prescription of potentially nephrotoxic drugs, and screening for osteoporosis. The main finding is that CKD and dialysis are almost unanimously perceived as typically geriatric conditions, but knowledge and use of geriatric tools are scanty. While use of potentially inappropriate drugs is rare, almost half of the patients are not screened for osteoporosis. The significant clinical gaps observed could greatly impair the management of older CKD patients, and call for an urgent educational intervention.
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Rajaobelina K, Cougnard-Gregoire A, Delcourt C, Gin H, Barberger-Gateau P, Rigalleau V. Autofluorescence of Skin Advanced Glycation End Products: Marker of Metabolic Memory in Elderly Population. J Gerontol A Biol Sci Med Sci 2015; 70:841-6. [PMID: 25589479 DOI: 10.1093/gerona/glu243] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/05/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Advanced glycation end products are involved in the vascular complications of diabetes, in chronic kidney disease, and in the aging process. Their accumulation in the elderly people, as reflected by skin autofluorescence (sAF), may be a marker of metabolic memory. We aimed to examine the association of sAF with glycemic and renal status 10 years earlier in older persons. METHODS In retrospective cohort study, 328 elderly community dwellers aged of 75 years and over had sAF measurement 10 years after their inclusion in the Three-City cohort. Fasting plasma glucose and serum creatinine were measured at baseline and at 10-year follow-up. In 125 participants, HbA1c was available at these two times. Associations between sAF and the glycemic and renal status 10 years before were analyzed by multivariate linear regression adjusted for age, sex, hypertension, body mass index, hypertriglyceridemia, and smoking. RESULTS Participants were 82.4 (standard deviation = 4.1) years on average, and their mean sAF was 2.8 (standard deviation = 0.7) arbitrary units (AU). After adjustment, sAF was higher in participants with long-standing diabetes (+0.38 AU, p = .01) or chronic kidney disease (+0.29 AU, p = .02) compared with healthy participants. sAF was related to fasting plasma glucose (+1 mmol/L associated with +0.08 AU, p = .01) and HbA1c (+1% associated with +0.15 AU, p = .03) 10 years earlier, but not to the current fasting plasma glucose (p = .82) and HbA1c (p = .32). sAF was also related to the distal and current estimated glomerular filtration rates (p = .002 and .004, respectively). CONCLUSIONS sAF reflects glycemic and renal status 10 years before, supporting its value as a marker of metabolic memory in the elderly people.
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Affiliation(s)
- Kalina Rajaobelina
- INSERM (Institut National de la Santé et de la Recherche Médicale), ISPED (Institut de Santé Publique d'Epidémiologie et de Développement), Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France. University of Bordeaux, France.
| | - Audrey Cougnard-Gregoire
- INSERM (Institut National de la Santé et de la Recherche Médicale), ISPED (Institut de Santé Publique d'Epidémiologie et de Développement), Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France. University of Bordeaux, France
| | - Cecile Delcourt
- INSERM (Institut National de la Santé et de la Recherche Médicale), ISPED (Institut de Santé Publique d'Epidémiologie et de Développement), Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France. University of Bordeaux, France
| | - Henri Gin
- Department of Nutrition-Diabetology, Haut-Lévêque Hospital, Pessac, France
| | - Pascale Barberger-Gateau
- INSERM (Institut National de la Santé et de la Recherche Médicale), ISPED (Institut de Santé Publique d'Epidémiologie et de Développement), Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France. University of Bordeaux, France
| | - Vincent Rigalleau
- INSERM (Institut National de la Santé et de la Recherche Médicale), ISPED (Institut de Santé Publique d'Epidémiologie et de Développement), Centre INSERM U897-Epidemiologie-Biostatistique, Bordeaux, France. University of Bordeaux, France. Department of Nutrition-Diabetology, Haut-Lévêque Hospital, Pessac, France
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Rivas Velasquez KM, Hames E, Masri H. Evaluation and Management of the Older Adult with Chronic Kidney Disease. Prim Care 2014; 41:857-74. [DOI: 10.1016/j.pop.2014.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Flores Ruano T, Cruz Jentoft AJ, González Montalvo JI, López Soto A, Abizanda Soler P. [Geriatric assessment tools in Spanish Geriatric Departments]. Rev Esp Geriatr Gerontol 2014; 49:235-242. [PMID: 24953247 DOI: 10.1016/j.regg.2014.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 05/06/2014] [Accepted: 05/08/2014] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Comprehensive Geriatric Assessment (CGA) is the main measurement tool used by Geriatricians. A 2000 survey demonstrated great variability in the tools used for CGA among Spanish Geriatric Departments. A new survey to detect 13-year trends in the use of CGA tools in our country is presented. MATERIAL AND METHODS Descriptive study using a structured questionnaire on the use of CGA tools in different levels of care sent to the Heads of 39 Spanish Geriatric Departments or Services (27 with postgraduate teaching in Geriatrics) during the first three months of 2013. RESULTS The response rate was 97.4%. It was found that 78.4% (29 centers) used different tools depending on the level of care. Barthel and Lawton index were the most used functional assessment tools in all Departments and across all geriatric levels, although gait speed and Tinetti scale were frequently used in Day Hospital and Outpatient clinics. The Mini Mental State Exam and its Spanish version Mini Examen Cognoscitivo were the most used mental scales (97.4%), followed by tools for assessing depression-behavior (86.8%) and severity of cognitive impairment tools (84.2%). CGA tools were used in 43.2% of the emergency departments of the hospitals surveyed, being the most frequent. More than two-thirds (69.4%) of the Departments reported that their affiliated Primary Care centers used CGA tools, with the Barthel and Lawton again being indexes the most used. Most of the responding Departments considered that the main domains of CGA are functional, mental and social status. Nutrition, comorbidity, falls and pressure ulcers are other important domains. CONCLUSIONS There is still a great variability in the CGA tools being used in Spanish Geriatric Departments, although there is a trend towards a greater use of Barthel index, greater adaptation of tools to each level of care, and increasing assessment of new domains like frailty, nutrition or comorbidity.
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Affiliation(s)
- Teresa Flores Ruano
- Servicio de Geriatría, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | | | | | | | - Pedro Abizanda Soler
- Servicio de Geriatría, Complejo Hospitalario Universitario de Albacete, Albacete, España.
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Pippin JW, Glenn ST, Krofft RD, Rusiniak ME, Alpers CE, Hudkins K, Duffield JS, Gross KW, Shankland SJ. Cells of renin lineage take on a podocyte phenotype in aging nephropathy. Am J Physiol Renal Physiol 2014; 306:F1198-209. [PMID: 24647714 DOI: 10.1152/ajprenal.00699.2013] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Aging nephropathy is characterized by podocyte depletion accompanied by progressive glomerulosclerosis. Replacement of terminally differentiated podocytes by local stem/progenitor cells is likely a critical mechanism for their regeneration. Recent studies have shown that cells of renin lineage (CoRL), normally restricted to the kidney's extraglomerular compartment, might serve this role after an abrupt depletion in podocyte number. To determine the effects of aging on the CoRL reserve and if CoRL moved from an extra- to the intraglomerular compartment during aging, genetic cell fate mapping was performed in aging Ren1cCre × Rs-ZsGreen reporter mice. Podocyte number decreased and glomerular scarring increased with advanced age. CoRL number decreased in the juxtaglomerular compartment with age. There was a paradoxical increase in CoRL in the intraglomerular compartment at 52 and 64 wk of age, where a subset coexpressed the podocyte proteins nephrin, podocin, and synaptopodin. Transmission electron microscopy studies showed that a subset of labeled CoRL in the glomerulus displayed foot processes, which attached to the glomerular basement membrane. No CoRL in the glomerular compartment stained for renin. These results suggest that, despite a decrease in the reserve, a subpopulation of CoRL moves to the glomerulus after chronic podocyte depletion in aging nephropathy, where they acquire a podocyte-like phenotype. This suggests that they might serve as adult podocyte stem/progenitor cells under these conditions, albeit in insufficient numbers to fully replace podocytes depleted with age.
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Affiliation(s)
- Jeffrey W Pippin
- Division of Nephrology, University of Washington, Seattle, Washington
| | - Sean T Glenn
- Department of Molecular and Cellular Biology, Roswell Park Cancer Institute, Buffalo, New York; and
| | - Ronald D Krofft
- Division of Nephrology, University of Washington, Seattle, Washington
| | - Michael E Rusiniak
- Department of Molecular and Cellular Biology, Roswell Park Cancer Institute, Buffalo, New York; and
| | - Charles E Alpers
- Department of Pathology, University of Washington, Seattle, Washington
| | - Kelly Hudkins
- Department of Pathology, University of Washington, Seattle, Washington
| | - Jeremy S Duffield
- Division of Nephrology, University of Washington, Seattle, Washington
| | - Kenneth W Gross
- Department of Molecular and Cellular Biology, Roswell Park Cancer Institute, Buffalo, New York; and
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Malavade T, Sokwala A, Jassal SV. Dialysis therapies in older patients with end-stage renal disease. Clin Geriatr Med 2014; 29:625-39. [PMID: 23849012 DOI: 10.1016/j.cger.2013.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Each year a large number of older individuals with advanced renal disease are started on chronic dialysis therapy. Life expectancy is estimated at between 2 and 4 years depending on age, comorbidity, and intensity of medical care required in the weeks around the dialysis start time. Survivors remain at high risk of ongoing morbidity. Regarding quality of life, many older patients express regret over having opted for chronic dialysis therapy and subsequently choose to withdraw from treatment, whereas many others maintain a quality of life similar to that of age-matched peers. Early assessment and ongoing comprehensive geriatric assessment is recommended.
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Affiliation(s)
- Tuschar Malavade
- Division of Nephrology, Department of Medicine, University of Toronto, University Health Network, 200 Elizabeth Street, 8N857, Toronto, Ontario M5G 2K8, Canada
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Qian Q, Nasr SH. Diagnosis and treatment of glomerular diseases in elderly patients. Adv Chronic Kidney Dis 2014; 21:228-46. [PMID: 24602472 DOI: 10.1053/j.ackd.2014.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 12/19/2013] [Accepted: 01/07/2014] [Indexed: 02/07/2023]
Abstract
Glomerular diseases are common in elderly patients and are a major cause of kidney failure. Most glomerular diseases in the elderly are caused by chronic systemic diseases, including arterial hypertension, diabetes, and atherosclerotic vascular diseases, although acute systemic vasculitis, especially anti-neutrophil-cytoplamic-antibody-mediated vasculitis, and membranous nephropathy related to malignancy, drug toxicity, and idiopathic form also occur often. Complex age-related changes and sensitivity to drug toxicity can render diagnosis and treatment for elderly patients challenging. As the general population is aging and the rate of CKD rising, updating knowledge on managing these patients is critical for care providers. We provide a comprehensive review and update of the diagnosis and treatment of glomerular diseases in the elderly.
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Perlman RL, Rao PS. Quality of Life of Older Patients Undergoing Renal Transplantation: Finding the Right Immunosuppressive Treatment. Drugs Aging 2014; 31:103-9. [DOI: 10.1007/s40266-013-0149-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Corriere M, Rooparinesingh N, Kalyani RR. Epidemiology of diabetes and diabetes complications in the elderly: an emerging public health burden. Curr Diab Rep 2013; 13:805-13. [PMID: 24018732 PMCID: PMC3856245 DOI: 10.1007/s11892-013-0425-5] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Diabetes in the elderly is a growing public health burden. Persons with diabetes are living longer and are vulnerable to the traditional microvascular and macrovascular complications of diabetes but also at increased risk for geriatric syndromes. Peripheral vascular disease, heart disease, and stroke all have a high prevalence among older adults with diabetes. Traditional microvascular complications such as retinopathy, nephropathy, and neuropathy also frequently occur. Unique to this older population is the effect of diabetes on functional status. Older adults with diabetes are also more likely to experience geriatric syndromes such as falls, dementia, depression, and incontinence. Further studies are needed to better characterize those elderly individuals who may be at the highest risk of adverse complications from diabetes.
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Affiliation(s)
- Mark Corriere
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 East Monument St, Suite 333, Baltimore, MD, 21287, USA
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Redahan L, Brady B, Smyth A, Higgins S, Wall C. The use of palliative care services amongst end-stage kidney disease patients in an Irish tertiary referral centre. Clin Kidney J 2013; 6:604-8. [PMID: 26069830 PMCID: PMC4438365 DOI: 10.1093/ckj/sft117] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 08/29/2013] [Indexed: 11/17/2022] Open
Abstract
Background Although patients with end-stage kidney disease (ESKD) have a shortened life expectancy, their end-of-life (EOL) care is suboptimal. The aim of this study was to review the utilization of specialist palliative care (SPC) in patients with ESKD in Dublin, Ireland. Methods We conducted a retrospective chart review of prevalent patients with ESKD who died between January 2005 and December 2009 at a tertiary referral centre. We recorded SPC referrals, modality of renal replacement therapy, age and place of death. Results Of 131 included patients, 88 (67.2%) were male, mean age at death was 63.2 ± 15.1 years and 102 (77.9%) were treated with haemodialysis. Forty-eight patients (36.7%) were referred to SPC, who were involved in the patients' management for a median of 12 days (range 0–907) before death. A total 104 patients (79.4%) died in an acute hospital, 19 (14.5%) died at home, 3 (2.3%) died in an inpatient hospice and the place of death was unknown for 5 patients (3.8%). Dialysis was withdrawn prior to death in 50 patients (38.1%), with a median time to death after withdrawal of dialysis of 6 days (0–105 days). A discussion regarding the withdrawal of dialysis was more frequently held with family member(s) rather than the patient. Conclusions SPC was involved in the antemortem care of ∼1/3 of the patients with the majority of referrals placed at a late stage. Given the short timeframe until death once dialysis is withdrawn, it is imperative that appropriate EOL care is instituted. This study identifies an underutilization of SPC and improved integration of palliative care and nephrology services may optimize EOL care for patients with ESKD.
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Affiliation(s)
- Lynn Redahan
- Department of Nephrology , AMNCH, Tallaght , Dublin , Ireland
| | - Bernadette Brady
- Department of Palliative Care Medicine , AMNCH, Tallaght , Dublin , Ireland
| | - Andrew Smyth
- Department of Nephrology , AMNCH, Tallaght , Dublin , Ireland
| | - Stephen Higgins
- Department of Palliative Care Medicine , AMNCH, Tallaght , Dublin , Ireland
| | - Catherine Wall
- Department of Nephrology , AMNCH, Tallaght , Dublin , Ireland
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Faller B, Beuscart JB, Frimat L. Competing-risk analysis of death and dialysis initiation among elderly (≥80 years) newly referred to nephrologists: a French prospective study. BMC Nephrol 2013; 14:103. [PMID: 23659341 PMCID: PMC3662583 DOI: 10.1186/1471-2369-14-103] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 04/25/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Reasons underlying dialysis decision-making in Octogenarians and Nonagenarians have not been further explored in prospective studies. METHODS This regional, multicentre, non-interventional and prospective study was aimed to describe characteristics and quality of life (QoL) of elderly (≥80 years of age) with advanced chronic kidney disease (stage 3b-5 CKD) newly referred to nephrologists. Predictive factors of death and dialysis initiation were also assessed using competing-risk analyses. RESULTS All 155 included patients had an estimated glomerular filtration rate (eGFR) below 45 ml/min/1.73 m2. Most patients had a non anaemic haemoglobin level (Hb) with no iron deficiency, and normal calcium and phosphate levels. They were well-fed and had a normal cognitive function and a good QoL. The 3-year probabilities of death and dialysis initiation reached 27% and 11%, respectively. The leading causes of death were cardiovascular (32%), cachexia (18%), cancer (9%), infection (3%), trauma (3%), dementia (3%), and unknown (32%). The reasons for dialysis initiation were based on uncontrolled biological abnormalities, such as hyperkalemia or acidosis (71%), uncontrolled digestive disorders (35%), uncontrolled pulmonary or peripheral oedema (29%), and uncontrolled malnutrition (12%). No patients with acute congestive heart failure or cancer initiated dialysis. Predictors of death found in both multivariate regression models (Cox and Fine & Gray) included acute congestive heart failure, age, any walking impairment and Hb<10 g/dL. Regarding dialysis initiation, eGFR <23 mL/min/1.73 m2 was the only predictor found in the Cox multivariate regression model whereas eGFR<23 mL/min/1.73 m2 and diastolic blood pressure were both independently associated with dialysis initiation in the Fine & Gray analysis. Such findings suggested that death and dialysis were independent events. CONCLUSIONS Octogenarians and Nonagenarians newly referred to nephrologists by general practitioners were highly selected patients, without any symptoms of the common geriatric syndrome. In this population, nephrologists' dialysis decision was based exclusively on uremic criteria.
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Affiliation(s)
| | - Jean-Baptiste Beuscart
- Department of biostatistics, EA 2694, UDSL, Lille, France; Geriatric Department, University Hospital, Lille, France
| | - Luc Frimat
- Department of Nephrology, University Hospital, Vandœuvre-lès-Nancy, France
- Nancy University, P. Verlaine Metz University, and Paris Descartes University, EA 4360 Apemac, Nancy, France
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Chiu K, Alam A, Iqbal S. Predictors of suboptimal and crash initiation of dialysis at two tertiary care centers. Hemodial Int 2013; 16 Suppl 1:S39-46. [PMID: 23036035 DOI: 10.1111/j.1542-4758.2012.00744.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Many end-stage renal disease patients do not have an optimal start to dialysis. Many patients have suboptimal initiation, while others "crash" start on dialysis without prior care from a nephrologist. We examined factors associated with suboptimal or crash starts. We conducted a retrospective cohort study of 377 incident dialysis patients at two tertiary care centers from January 2006 to April 2011. Logistic regression was used to identify factors associated with suboptimal and crash starts to dialysis. Out of 377 patients, 102 (27%) had optimal starts, 221 (59%) had suboptimal starts, and 54 (14%) had crash starts. Three hundred thirty-four patients (89%) began with hemodialysis, while 11% started with peritoneal dialysis. Factors independently associated with a suboptimal start as opposed to an optimal start included nephrology care more than 12 months prior to initiation of dialysis (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.12-0.58), Charlson Comorbidity Index (OR, 1.25 per 1 point; 95% CI, 1.09-1.43), and age (OR, 1.02 per 1 year; 95% CI, 1.00-1.04). In comparison, diabetic nephropathy (OR, 0.25; 95% CI, 0.12-0.54), a history of pulmonary edema within 6 months prior to initiation of dialysis (OR, 3.70; 95% CI, 1.77-7.75), and a diagnosis of chronic obstructive lung disease (OR, 0.07; 95% CI, 0.01-0.52) were independently associated with a crash start. There was a low incidence of optimal dialysis starts in our tertiary care dialysis population. Our study highlights that suboptimal and crash start patients are distinct populations. Modifying factors that predict nonoptimal dialysis starts will need to consider these distinctions.
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Affiliation(s)
- Kenrry Chiu
- Department of Medicine, McGill University, Montreal, Canada
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Abstract
The treatment of diabetic nephropathy in elderly individuals is based primarily on data from younger age groups. However, the assumption that the same treatment approaches for the younger age groups can be uniformly applied to elderly individuals is likely to be incorrect. The cornerstones of aggressive therapy for diabetic kidney disease in general may have drawbacks in elderly patients. For example, significant risks of tight glycemic control have emerged in recent studies. Excessive decrease of blood pressure to existing targets may be unsafe in elderly individuals. Limited data do indicate that renin-angiotensin blockade may be as effective and no riskier than in middle-aged diabetic kidney patients. Until further studies are carried out, it is prudent to treat the elderly patient with similar approaches as in younger patients, but tempered by the issues reviewed in this article. There is a growing need for the development of clinical guidelines to retool CKD management in the elderly diabetic population using both current and emerging therapies.
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Short- and mid-term effects of irreversible electroporation on normal renal tissue: an animal model. Cardiovasc Intervent Radiol 2012; 36:512-20. [PMID: 22893419 DOI: 10.1007/s00270-012-0452-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 07/12/2012] [Indexed: 12/11/2022]
Abstract
PURPOSE Irreversible electroporation (IRE) is a novel nonthermal tissue ablation technique by high current application leading to apoptosis without affecting extracellular matrix. Previous results of renal IRE shall be supplemented by functional MRI and differentiated histological analysis of renal parenchyma in a chronic treatment setting. METHODS Three swine were treated with two to three multifocal percutaneous IRE of the right kidney. MRI was performed before, 30 min (immediate-term), 7 days (short-term), and 28 days (mid-term) after IRE. A statistical analysis of the lesion surrounded renal parenchyma intensities was made to analyze functional differences depending on renal part, side and posttreatment time. Histological follow-up of cortex and medulla was performed after 28 days. RESULTS A total of eight ablations were created. MRI showed no collateral damage of surrounded tissue. The highest visual contrast between lesions and normal parenchyma was obtained by T2-HR-SPIR-TSE-w sequence of DCE-MRI. Ablation zones showed inhomogeneous necroses with small perifocal edema in the short-term and sharp delimitable scars in the mid-term. MRI showed no significant differences between adjoined renal parenchyma around ablations and parenchyma of untreated kidney. Histological analysis demonstrated complete destruction of cortical glomeruli and tubules, while collecting ducts, renal calyxes, and pelvis of medulla were preserved. Adjoined kidney parenchyma around IRE lesions showed no qualitative differences to normal parenchyma of untreated kidney. CONCLUSIONS This porcine IRE study reveals a multifocal renal ablation, while protecting surrounded renal parenchyma and collecting system over a mid-term period. That offers prevention of renal function ablating centrally located or multifocal renal masses.
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De Nicola L, Minutolo R, Chiodini P, Borrelli S, Zoccali C, Postorino M, Iodice C, Nappi F, Fuiano G, Gallo C, Conte G. The effect of increasing age on the prognosis of non-dialysis patients with chronic kidney disease receiving stable nephrology care. Kidney Int 2012; 82:482-8. [DOI: 10.1038/ki.2012.174] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Latos DL, Lucas J. Geriatric nephrology: a paradigm shift in the approach to renal replacement therapy. Adv Chronic Kidney Dis 2011; 18:412-9. [PMID: 22098659 DOI: 10.1053/j.ackd.2011.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 09/23/2011] [Accepted: 09/26/2011] [Indexed: 11/11/2022]
Abstract
The population of elderly individuals diagnosed with CKD continues to grow. Many have multiple comorbid conditions that will impact life expectancy as well as decisions about whether to pursue renal replacement therapy. Nephrologists are uniquely positioned to assist their patients and caregivers in this regard and spend considerable time counseling them about the benefits and risks associated with dialysis therapy. This article presents an overview of many of the issues facing nephrologists, and provides tools to assist busy clinicians in helping their elderly patients in deciding whether to consider dialysis or intensive, nondialysis care.
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McAdoo SP, Brown EA, Chesser AM, Farrington K, Salisbury EM. Measuring the quality of end of life management in patients with advanced kidney disease: results from the pan-Thames renal audit group. Nephrol Dial Transplant 2011; 27:1548-54. [PMID: 21980155 DOI: 10.1093/ndt/gfr514] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Despite a recent increased awareness of the need for quality End of Life (EOL) care for patients with advanced kidney disease, there is no established method for measuring or auditing outcomes relating to EOL care in this population. METHODS We designed a one-page proforma, which was used to collect data on various aspects of EOL care relating to all deaths of patients on dialysis and patients dying on specialist renal wards, over a predefined 8-week period in 10 hospitals in London and South-East England. RESULTS One hundred and thirty-eight deaths were recorded over the 8-week study period. The majority of patients (83%) were receiving maintenance haemodialysis prior to their terminal presentation. About 69% of deaths occurred during an in-patient hospital admission-of these, 36% were considered 'unexpected' and most quality markers of good EOL management were significantly less likely to be achieved in these patients, including use of palliative care strategies, good symptom control and overall quality of death. Thirty-six per cent of patients were from various ethnic minorities, and in this group, there was a trend towards lower use of palliative care pathways and lower rates of withdrawal from dialysis. CONCLUSIONS This study confirms that it is possible to measure many important outcomes relating to quality of EOL care using a proforma completed at the time of death. Our findings suggest that many aspects of good EOL care are under-achieved in our region. This, in part, is due to a failure to recognize the worsening trajectory of the deteriorating patient, resulting in missed opportunities for EOL care planning and appropriate symptom control. Our observations suggest that there is a need for improved education and training in this area, particularly in detection of the dying patient, the value of advance care planning and the utility of tools such as the Liverpool Care Pathway.
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Affiliation(s)
- Stephen P McAdoo
- Imperial College Kidney and Transplant Institute, Hammersmith Hospital, London, UK.
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Should there be an expanded role for palliative care in end-stage renal disease? Curr Opin Nephrol Hypertens 2011; 19:556-60. [PMID: 20644475 DOI: 10.1097/mnh.0b013e32833d67bc] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In this review, we outline the rationale for expanding the role of palliative care in end-stage renal disease (ESRD), describe the components of a palliative care model, and identify potential barriers in implementation. RECENT FINDINGS Patients receiving chronic dialysis have reduced life expectancy and high rates of chronic pain, depression, cognitive impairment, and physical disability. Delivery of prognostic information and advance care planning are desired by patients, but occur infrequently. Furthermore, although hospice care is associated with improved symptom control and lower healthcare costs at the end of life, it is underutilized by the ESRD population, even among patients who withdraw from dialysis. A palliative care model incorporating communication of prognosis, advance care planning, symptom assessment and management, and timely hospice referral may improve quality of life and quality of dying. Resources and clinical practice guidelines are available to assist practitioners with incorporating palliative care into ESRD management. SUMMARY There is a large unmet need to alleviate the physical, psychosocial, and existential suffering of patients with ESRD. More fully integrating palliative care into ESRD management by improving end-of-life care training, eliminating structural and financial barriers to hospice use, and identifying optimal methods to deliver palliative care are necessary if we are to successfully address the needs of an aging ESRD population.
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Moss AH. Revised dialysis clinical practice guideline promotes more informed decision-making. Clin J Am Soc Nephrol 2010; 5:2380-3. [PMID: 21051749 DOI: 10.2215/cjn.07170810] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Over a decade ago, the Renal Physicians Association and the American Society of Nephrology published the clinical practice guideline, Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, to assist nephrologists, patients, and families in making decisions to initiate and withdraw dialysis. Since then, researchers have extensively studied dialysis decision-making, and there is a substantial body of new evidence with regard to 1) the poor prognosis of some elderly stage 4 and 5 chronic kidney disease patients, many of whom are likely to die before initiation of dialysis or for whom dialysis may not provide a survival advantage over medical management without dialysis; 2) the prevalence of cognitive impairment in dialysis patients and the need to periodically assess them for decision-making capacity; 3) the under-recognition and undertreatment of pain and other symptoms in dialysis patients; 4) the underutilization of hospice in dialysis patients; and 5) the distinctly different treatment goals of ESRD patients based on their overall condition and personal preferences. The Renal Physicians Association developed this second edition of the guideline to provide clinicians, patients, and families with 1) the most current evidence about the benefits and burdens of dialysis for patients with diverse conditions; 2) recommendations for quality in decision-making about treatment of patients with acute kidney injury, chronic kidney disease, and ESRD; and 3) practical strategies to help clinicians implement the guideline recommendations.
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Affiliation(s)
- Alvin H Moss
- West Virginia University Center for Health Ethics and Law, Morgantown, WV 26506-9022, USA.
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Fried LF, Unruh ML. Aging in kidney disease: key issues and gaps in knowledge. Adv Chronic Kidney Dis 2010; 17:291-2. [PMID: 20610355 DOI: 10.1053/j.ackd.2010.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Accepted: 05/14/2010] [Indexed: 11/11/2022]
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Turgut F, Balogun RA, Abdel-Rahman EM. Renin-angiotensin-aldosterone system blockade effects on the kidney in the elderly: benefits and limitations. Clin J Am Soc Nephrol 2010; 5:1330-9. [PMID: 20498247 DOI: 10.2215/cjn.08611209] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The proportion of the population that is elderly (age>or=65 years) is growing across the world. The increasing longevity of humans results in a higher number of elderly patients' presenting with multiple chronic diseases such as hypertension, diabetes, and chronic kidney disease (CKD). These problems increase morbidity and mortality in the elderly. Overactivity of the renin-angiotensin-aldosterone system (RAAS) is associated with the development of hypertension, cardiovascular events, and CKD, so targeting the RAAS is a logical therapeutic approach. Elderly patients present special concerns regarding the benefits versus risks of using RAAS blockers. Plasma renin activity declines with age, which has been attributed to the effect of age-associated nephrosclerosis. Plasma aldosterone is also reduced with age, resulting in a greater risk for hyperkalemia in older individuals, especially when coupled with the age-associated decline in GFR. Moreover, the elderly have a higher frequency of concurrent conditions and are on many medications, which may further increase the risk for adverse effects of RAAS blocking agents. Unfortunately, there is a paucity of literature that is specifically aimed at studying elderly using the RAAS blockers. We present in our in-depth review data regarding benefits and limitations of the use of the RAAS blockades on the various sites along the RAAS pathway for elderly patients. Specific attention was given to the role of combination RAAS blockade therapy and higher monotherapy dosing in the treatment of hypertension in the elderly.
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Affiliation(s)
- Faruk Turgut
- Department of Medicine, University of Virginia Health System, P.O. Box 800133, Charlottesville, VA 22908, USA.
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