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Germain MJ, Paul SK, Fadda G, Broumand V, Nguyen A, McGarvey NH, Gitlin MD, Bishop CW, Csomor P, Strugnell S, Ashfaq A. Real-world assessment: effectiveness and safety of extended-release calcifediol and other vitamin D therapies for secondary hyperparathyroidism in CKD patients. BMC Nephrol 2022; 23:362. [PMID: 36368937 PMCID: PMC9650892 DOI: 10.1186/s12882-022-02993-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/12/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Extended-release calcifediol (ERC), active vitamin D hormones and analogs (AVD) and nutritional vitamin D (NVD) are commonly used therapies for treating secondary hyperparathyroidism (SHPT) in adults with stage 3–4 chronic kidney disease (CKD) and vitamin D insufficiency (VDI). Their effectiveness for increasing serum total 25-hydroxyvitamin D (25D) and reducing elevated plasma parathyroid hormone (PTH), the latter of which is associated with increased morbidity and mortality, has varied across controlled clinical trials. This study aimed to assess real-world experience of ERC and other vitamin D therapies in reducing PTH and increasing 25D. Methods Medical records of 376 adult patients with stage 3–4 CKD and a history of SHPT and VDI from 15 United States (US) nephrology clinics were reviewed for up to 1 year pre- and post-ERC, NVD or AVD initiation. Key study variables included patient demographics, concomitant usage of medications and laboratory data. The mean age of the study population was 69.5 years, with gender and racial distributions representative of the US CKD population. Enrolled patients were grouped by treatment into three cohorts: ERC (n = 174), AVD (n = 55) and NVD (n = 147), and mean baseline levels were similar for serum 25D (18.8–23.5 ng/mL), calcium (Ca: 9.1–9.3 mg/dL), phosphorus (P: 3.7–3.8 mg/dL) and estimated glomerular filtration rate (eGFR: 30.3–35.7 mL/min/1.73m2). Mean baseline PTH was 181.4 pg/mL for the ERC cohort versus 156.9 for the AVD cohort and 134.8 pg/mL (p < 0.001) for the NVD cohort. Mean follow-up during treatment ranged from 20.0 to 28.8 weeks. Results Serum 25D rose in all cohorts (p < 0.001) during treatment. ERC yielded the highest increase (p < 0.001) of 23.7 ± 1.6 ng/mL versus 9.7 ± 1.5 and 5.5 ± 1.3 ng/mL for NVD and AVD, respectively. PTH declined with ERC treatment by 34.1 ± 6.6 pg/mL (p < 0.001) but remained unchanged in the other two cohorts. Serum Ca increased 0.2 ± 0.1 pg/mL (p < 0.001) with AVD but remained otherwise stable. Serum alkaline phosphatase remained unchanged. Conclusions Real-world clinical effectiveness and safety varied across the therapies under investigation, but only ERC effectively raised mean 25D (to well above 30 ng/mL) and reduced mean PTH levels without causing hypercalcemia.
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Weiner DE, Vervloet MG, Walpen S, Schaufler T, Munera C, Menzaghi F, Wen W, Bhaduri S, Germain MJ. Safety and Effectiveness of Difelikefalin in Patients With Moderate-to-Severe Pruritus Undergoing Hemodialysis: An Open-Label, Multicenter Study. Kidney Med 2022; 4:100542. [PMID: 36185706 PMCID: PMC9516453 DOI: 10.1016/j.xkme.2022.100542] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Daniel E. Weiner
- William B Schwartz MD Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
- Address for Correspondence: Daniel E Weiner, William B Schwartz MD Division of Nephrology, Tufts Medical Center, 800 Washington Street Box #391, Boston, MA 02111.
| | - Marc G. Vervloet
- Department of Nephrology and Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | | | | | | | - Warren Wen
- Cara Therapeutics, Stamford, Connecticut
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Rodriguez de Sosa G, Nicklas A, Thamer M, Anderson E, Reddy N, Stevelos J, Germain MJ, Unruh ML, Lupu DE. Implementing Advance Care Planning for dialysis patients: HIGHway project. Palliat Care 2022; 21:129. [PMID: 35841019 PMCID: PMC9286956 DOI: 10.1186/s12904-022-01011-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background Patients undergoing hemodialysis have a high mortality rate and yet underutilize palliative care and hospice resources. The Shared Decision Making-Renal Supportive Care (SDM-RSC) intervention focused on goals of care conversations between patients and family members with the nephrologist and social worker. The intervention targeted deficiencies in communication, estimating prognosis, and transition planning for seriously ill dialysis patients. The intervention showed capacity to increase substantially completion of advance care directives. The HIGHway Project, adapted from the previous SDM-RSC, scale up training social workers or nurses in dialysis center in advance care planning (ACP), and then support them for a subsequent 9-month action period, to engage in ACP conversations with patients at their dialysis center regarding their preferences for end-of-life care. Methods We will train between 50–60 dialysis teams, led by social workers or nurses, to engage in ACP conversations with patients at their dialysis center regarding their preferences for end-of-life care. This implementation project uses the Knowledge to Action (KTA) Framework within the Consolidated Framework for Implementation Research (CFIR) to increase adoption and sustainability in the participating dialysis centers. This includes a curriculum about how to hold ACP conversation and coaching with monthly teleconferences through case discussion and mentoring. An application software will guide on the process and provide resources for holding ACP conversations. Our project will focus on implementation outcomes. Success will be determined by adoption and effective use of the ACP approach. Patient and provider outcomes will be measured by the number of ACP conversations held and documented; the quality and fidelity of ACP conversations to the HIGHway process as taught during education sessions; impact on knowledge and skills; content, relevance, and significance of ACP intervention for patients, and Supportive Kidney Care (SKC) App usage. Currently HIGHway is in the recruitment stage. Discussion Effective changes to advance care planning processes in dialysis centers can lead to institutional policy and protocol changes, providing a model for patients receiving dialysis treatment in the US. The result will be a widespread improvement in advance care planning, thereby remedying one of the current barriers to patient-centered, goal-concordant care for dialysis patients. Trial registration The George Washington University Protocol Record NCR213481, Honoring Individual Goals and Hopes: Implementing Advance Care Planning for Persons with Kidney Disease on Dialysis, is registered in ClinicalTrials.gov Identifier: NCT05324878 on April 11th, 2022.
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Affiliation(s)
| | - Amanda Nicklas
- School of Nursing, George Washington University, Washington, DC, USA
| | - Mae Thamer
- Medical Technology and Practice Patterns Institute, Bethesda, MD, USA
| | | | | | - JoAnn Stevelos
- School of Nursing, George Washington University, Washington, DC, USA
| | - Michael J Germain
- Renal and Transplant Associates of New England, PC, Springfield, MA, 01107, USA
| | - Mark L Unruh
- Department of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Dale E Lupu
- Center of Aging, Health and Humanities, George Washington University, Washington DC, USA
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Eneanya ND, Lakin JR, Paasche-Orlow MK, Lindvall C, Moseley ET, Henault L, Hanchate AD, Mandel EI, Wong SPY, Zupanc SN, Davis AD, El-Jawahri A, Quintiliani LM, Chang Y, Waikar SS, Bansal AD, Schell JO, Lundquist AL, Tamura MK, Yu MK, Unruh ML, Argyropoulos C, Germain MJ, Volandes A. Video Images about Decisions for Ethical Outcomes in Kidney Disease (VIDEO-KD): the study protocol for a multi-centre randomised controlled trial. BMJ Open 2022; 12:e059313. [PMID: 35396311 PMCID: PMC8996022 DOI: 10.1136/bmjopen-2021-059313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Older patients with advanced chronic kidney disease (CKD) often are inadequately prepared to make informed decisions about treatments including dialysis and cardiopulmonary resuscitation. Further, evidence shows that patients with advanced CKD do not commonly engage in advance care planning (ACP), may suffer from poor quality of life, and may be exposed to end-of-life care that is not concordant with their goals. We aim to study the effectiveness of a video intervention on ACP, treatment preferences and other patient-reported outcomes. METHODS AND ANALYSIS The Video Images about Decisions for Ethical Outcomes in Kidney Disease trial is a multi-centre randomised controlled trial that will test the effectiveness of an intervention that includes a CKD-related video decision aid followed by recording personal video declarations about goals of care and treatment preferences in older adults with advancing CKD. We aim to enrol 600 patients over 5 years at 10 sites. ETHICS AND DISSEMINATION Regulatory and ethical aspects of this trial include a single Institutional Review Board mechanism for approval, data use agreements among sites, and a Data Safety and Monitoring Board. We intend to disseminate findings at national meetings and publish our results. TRIAL REGISTRATION NUMBER NCT04347629.
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Affiliation(s)
- Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua R Lakin
- Harvard Medical School, Boston, Massachusetts, USA
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael K Paasche-Orlow
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Edward T Moseley
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lori Henault
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Amresh D Hanchate
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ernest I Mandel
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Renal (Kidney) Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Susan P Y Wong
- University of Washington, Seattle, Washington State, USA
| | - Sophia N Zupanc
- Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Areej El-Jawahri
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa M Quintiliani
- Boston University School of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Yuchiao Chang
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sushrut S Waikar
- Section of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Amar D Bansal
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Department of General Medicine, Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Andrew L Lundquist
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Manjula Kurella Tamura
- Division of Nephrology, Stanford University School of Medicine; and Geriatric Research Education Clinical Center, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Margaret K Yu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Mark L Unruh
- Department of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Christos Argyropoulos
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Michael J Germain
- Baystate Medical Center-University of Massachusetts Springfield, Springfield, Massachusetts, USA
| | - Angelo Volandes
- Harvard Medical School, Boston, Massachusetts, USA
- ACP Decisions Non-profit Foundation, Newton, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Greco B, Chait Y, Nathanson BH, Germain MJ. A Novel Hypertension Management Algorithm Guided by Hemodynamic Data. Kidney Int Rep 2022; 7:330-333. [PMID: 35155873 PMCID: PMC8820980 DOI: 10.1016/j.ekir.2021.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/11/2021] [Accepted: 11/22/2021] [Indexed: 11/17/2022] Open
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Lipman ZM, Paramasivam V, Yosipovitch G, Germain MJ. Clinical management of chronic kidney disease-associated pruritus: current treatment options and future approaches. Clin Kidney J 2021; 14:i16-i22. [PMID: 34987779 PMCID: PMC8702820 DOI: 10.1093/ckj/sfab167] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD)-associated pruritus (CKD-aP) is an underdiagnosed yet severely distressing condition that impacts 60% of patients on dialysis and many nondialysis patients with Stages 3–5 CKD. However, despite its high prevalence, there are currently limited treatment options available for these patients and a lack of treatment guidelines for clinicians. In this manuscript, we reviewed the available literature in order to evaluate the current management and treatment options for CKD-aP, including dialysis management, topical treatments, gabapentinoids, opioids and alternative medicine. We also review the available data on CKD-aP treatments in development and propose new guidelines for managing patients with CKD-aP.
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Affiliation(s)
- Zoe M Lipman
- Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, Miami, FL, USA
| | - Vijayakumar Paramasivam
- Division of Nephrology, Renal Transplant Associates of New England, Baystate Medical Center U Mass Medical School, Springfield, MA, USA
| | - Gil Yosipovitch
- Dr Phillip Frost Department of Dermatology and Miami Itch Center, University of Miami, Miami, FL, USA
| | - Michael J Germain
- Division of Nephrology, Renal Transplant Associates of New England, Baystate Medical Center U Mass Medical School, Springfield, MA, USA
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Fadda G, Germain MJ, Broumand V, Nguyen A, McGarvey N, Gitlin M, Bishop CW, Ashfaq A. Real-World Assessment: Clinical Effectiveness and Safety of Extended-Release Calcifediol. Am J Nephrol 2021; 52:798-807. [PMID: 34818216 DOI: 10.1159/000518545] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/16/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The safety and efficacy of extended-release calcifediol (ERC) as a treatment for secondary hyperparathyroidism (SHPT) in adults with stage 3 or 4 chronic kidney disease (CKD) and vitamin D insufficiency (VDI) has been demonstrated in prospective randomized clinical trials (RCTs). ERC (Rayaldee®) was approved by the Food and Drug Administration in 2016 on the basis of these prospective RCTs. The current retrospective study assessed the postlaunch data available with respect to ERC's efficacy and safety in increasing serum 25-hydroxyvitamin D (25D) and reducing parathyroid hormone (PTH) in the indicated population. MATERIALS AND METHODS Medical records of 174 patients who met study criteria from 15 geographically representative United States nephrology clinics were reviewed for 1 year before and after initiation of ERC treatment. Enrolled subjects had ages ≥18 years, stage 3 or 4 CKD, and a history of SHPT and VDI. Key study variables included patient demographics, medication usage, and laboratory results, including serial 25D and PTH determinations. RESULTS The enrolled subjects had a mean age of 69.0 years, gender and racial distributions representative of the indicated population, and were balanced for CKD stage. Most (98%) received 30 mcg of ERC/day during the course of treatment (mean follow-up: 24 weeks). Baseline 25D and PTH levels averaged 20.3 ± 0.7 (standard error) ng/mL and 181 ± 7.4 pg/mL, respectively. ERC treatment raised 25D by 23.7 ± 1.6 ng/mL (p < 0.001) and decreased PTH by 34.1 ± 6.6 pg/mL (p < 0.001) with nominal changes of 0.1 mg/dL (p > 0.05) in serum calcium (Ca) and phosphorus (P) levels. DISCUSSION/CONCLUSION Analysis of postlaunch data confirmed ERC's effectiveness in increasing serum 25D and reducing PTH levels without statistically significant or notable impact on serum Ca and P levels. A significant percentage of these subjects achieved 25D levels ≥30 mg/mL and PTH levels which decreased by at least 30% from baseline. Dose titration to 60 mcgs was rarely prescribed. Closer patient monitoring and appropriate dose titration may have led to a higher percentage of subjects achieving an increase in 25D levels to at least 50 ng/mL and a reduction in PTH levels of at least 30%.
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Affiliation(s)
- George Fadda
- California Institute of Renal Research, San Diego, California, USA
| | - Michael J Germain
- Renal Transplant Associates of New England, Springfield, Massachusetts, USA
| | | | - Andy Nguyen
- BluePath Solutions, Los Angeles, California, USA
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Germain MJ, Greco BA, Hodgins S, Chapagain B, Thadhani R, Wojciechowski D, Crisalli K, Nathanson BH, Chait Y. Assessing accuracy of estimated dry weight in dialysis patients post transplantation: the kidney knows best. J Nephrol 2021; 34:2093-2097. [PMID: 34031847 DOI: 10.1007/s40620-021-01029-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/16/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Estimated dry weight is used to guide fluid removal during outpatient hemodialysis sessions. Errors in estimated dry weight can result in intradialytic hypotension and interdialytic fluid overload. The goal of this study was to assess the accuracy of estimated dry weight by comparing it to the 2-week post-transplant weight in two cohorts of hemodialysis patients. METHODS This observational, multi-center, retrospective cohort study included maintenance hemodialysis patients who underwent kidney transplantation at two medical centers in Massachusetts. The relationship between estimated dry weight pre-transplant and weight at week 2 post-transplant in patients with good allograft function (serum creatinine ≤ 1.5 mg/dL) was analyzed. Estimated dry weight was considered accurate if it was within ± 2% of the week 2 post-transplant weight. RESULTS Fifty seven patients with good allograft function were identified: mean age 54 ± 14 years, 32 (58%) from deceased donors, 22 (38.6%) females. 38 were Caucasian (66.7%), 11 Hispanic (19.3%), 3 black (5.3%), and 5 others (8.8%). 2-week mean post transplantation serum creatinine was 1.2 ± 0.2 mg/dL. Mean (SD) estimated dry weight was 71.4 ± 15.9. Before transplantation, only 14 (24.6%) patients were within ± 2% of the 2-week post-transplant weight; 23 (40.3%) were above and 20 (35.1%) were below. CONCLUSIONS Our point of view, based on the assumption that the weight of patients with good allograft function at 2 weeks post-transplant approaches their accurate dry weight, is that a majority of maintenance hemodialysis patients (75.4%) are hypervolemic or hypovolemic prior to renal transplantation. This highlights the importance of finding novel tools to achieve euvolemia in patients undertaking dialysis. Timely feedback regarding achieved weight 2 weeks post-transplant to treating nephrologists and dialysis centers may be a starting point for assessing accuracy of dry weight.
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Affiliation(s)
- Michael J Germain
- Renal and Transplant Associates of New England, PC, Springfield, MA, 01107, USA.,Baystate Medical Center, Springfield, MA, 01199, USA
| | - Barbara A Greco
- Renal and Transplant Associates of New England, PC, Springfield, MA, 01107, USA.,Baystate Medical Center, Springfield, MA, 01199, USA
| | - Spencer Hodgins
- Kidney Care and Transplant Service of New England, Springfield, MA, 01104, USA
| | - Bikash Chapagain
- MidState Nephrology Associates, 85 Church St, Middletown, CT, 06457, USA
| | - Ravi Thadhani
- Massachusetts General Brigham, Boston, MA, 02199, USA
| | | | | | | | - Yossi Chait
- University of Massachusetts, Amherst, MA, 01106, USA. .,MIE Department, University of Massachusetts, 160 Governors Drive, Amherst, MA, 01003-2210, USA.
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Nadim MK, Forni LG, Mehta RL, Connor MJ, Liu KD, Ostermann M, Rimmelé T, Zarbock A, Bell S, Bihorac A, Cantaluppi V, Hoste E, Husain-Syed F, Germain MJ, Goldstein SL, Gupta S, Joannidis M, Kashani K, Koyner JL, Legrand M, Lumlertgul N, Mohan S, Pannu N, Peng Z, Perez-Fernandez XL, Pickkers P, Prowle J, Reis T, Srisawat N, Tolwani A, Vijayan A, Villa G, Yang L, Ronco C, Kellum JA. COVID-19-associated acute kidney injury: consensus report of the 25th Acute Disease Quality Initiative (ADQI) Workgroup. Nat Rev Nephrol 2020. [PMID: 33060844 DOI: 10.37473/fic/10.1038/s41581-020-00372-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Kidney involvement in patients with coronavirus disease 2019 (COVID-19) is common, and can range from the presence of proteinuria and haematuria to acute kidney injury (AKI) requiring renal replacement therapy (RRT; also known as kidney replacement therapy). COVID-19-associated AKI (COVID-19 AKI) is associated with high mortality and serves as an independent risk factor for all-cause in-hospital death in patients with COVID-19. The pathophysiology and mechanisms of AKI in patients with COVID-19 have not been fully elucidated and seem to be multifactorial, in keeping with the pathophysiology of AKI in other patients who are critically ill. Little is known about the prevention and management of COVID-19 AKI. The emergence of regional 'surges' in COVID-19 cases can limit hospital resources, including dialysis availability and supplies; thus, careful daily assessment of available resources is needed. In this Consensus Statement, the Acute Disease Quality Initiative provides recommendations for the diagnosis, prevention and management of COVID-19 AKI based on current literature. We also make recommendations for areas of future research, which are aimed at improving understanding of the underlying processes and improving outcomes for patients with COVID-19 AKI.
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Affiliation(s)
- Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lui G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK.,Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Ravindra L Mehta
- Division of Nephrology, Department of Medicine, University of California, San Diego, CA, USA
| | - Michael J Connor
- Divisions of Pulmonary, Allergy, Critical Care, & Sleep Medicine, Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California, San Francisco, CA, USA
| | - Marlies Ostermann
- Department of Intensive Care, Guy's & St Thomas' NHS Foundation Hospital, London, UK
| | - Thomas Rimmelé
- Department of Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Samira Bell
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Eric Hoste
- Intensive Care Unit, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Faeq Husain-Syed
- Division of Nephrology, Pulmonology and Critical Care Medicine, Department of Medicine II, University Hospital Giessen and Marburg, Giessen, Germany
| | - Michael J Germain
- Division of Nephrology, Renal Transplant Associates of New England, Baystate Medical Center U Mass Medical School, Springfield, MA, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jay L Koyner
- Division of Nephrology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Matthieu Legrand
- Department of Anesthesiology and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Nuttha Lumlertgul
- Department of Intensive Care, Guy's & St Thomas' NHS Foundation Hospital, London, UK.,Division of Nephrology, Excellence Center for Critical Care Nephrology, Critical Care Nephrology Research Unit, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons and New York Presbyterian Hospital, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Neesh Pannu
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Zhiyong Peng
- Division of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xose L Perez-Fernandez
- Servei de Medicina Intensiva, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - John Prowle
- Critical Care and Peri-operative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Thiago Reis
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute of Vicenza, Vicenza, Italy.,Department of Nephrology, Clínica de Doenças Renais de Brasília, Brasília, Brazil
| | - Nattachai Srisawat
- Division of Nephrology, Excellence Center for Critical Care Nephrology, Critical Care Nephrology Research Unit, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand.,Academy of Science, Royal Society of Thailand, Bangkok, Thailand
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama, Birmingham, AL, USA
| | - Anitha Vijayan
- Division of Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gianluca Villa
- Section of Anaesthesiology and Intensive Care, Department of Health Science, University of Florence, Florence, Italy
| | - Li Yang
- Renal Division, Peking University First Hospital, Beijing, China
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute of Vicenza, Vicenza, Italy.,Department of Medicine, University of Padova, Padova, Italy
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA.
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Nadim MK, Forni LG, Mehta RL, Connor MJ, Liu KD, Ostermann M, Rimmelé T, Zarbock A, Bell S, Bihorac A, Cantaluppi V, Hoste E, Husain-Syed F, Germain MJ, Goldstein SL, Gupta S, Joannidis M, Kashani K, Koyner JL, Legrand M, Lumlertgul N, Mohan S, Pannu N, Peng Z, Perez-Fernandez XL, Pickkers P, Prowle J, Reis T, Srisawat N, Tolwani A, Vijayan A, Villa G, Yang L, Ronco C, Kellum JA. COVID-19-associated acute kidney injury: consensus report of the 25th Acute Disease Quality Initiative (ADQI) Workgroup. Nat Rev Nephrol 2020; 16:747-764. [PMID: 33060844 PMCID: PMC7561246 DOI: 10.1038/s41581-020-00356-5] [Citation(s) in RCA: 362] [Impact Index Per Article: 90.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 01/08/2023]
Abstract
Kidney involvement in patients with coronavirus disease 2019 (COVID-19) is common, and can range from the presence of proteinuria and haematuria to acute kidney injury (AKI) requiring renal replacement therapy (RRT; also known as kidney replacement therapy). COVID-19-associated AKI (COVID-19 AKI) is associated with high mortality and serves as an independent risk factor for all-cause in-hospital death in patients with COVID-19. The pathophysiology and mechanisms of AKI in patients with COVID-19 have not been fully elucidated and seem to be multifactorial, in keeping with the pathophysiology of AKI in other patients who are critically ill. Little is known about the prevention and management of COVID-19 AKI. The emergence of regional 'surges' in COVID-19 cases can limit hospital resources, including dialysis availability and supplies; thus, careful daily assessment of available resources is needed. In this Consensus Statement, the Acute Disease Quality Initiative provides recommendations for the diagnosis, prevention and management of COVID-19 AKI based on current literature. We also make recommendations for areas of future research, which are aimed at improving understanding of the underlying processes and improving outcomes for patients with COVID-19 AKI.
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Affiliation(s)
- Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lui G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK
- Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Ravindra L Mehta
- Division of Nephrology, Department of Medicine, University of California, San Diego, CA, USA
| | - Michael J Connor
- Divisions of Pulmonary, Allergy, Critical Care, & Sleep Medicine, Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California, San Francisco, CA, USA
| | - Marlies Ostermann
- Department of Intensive Care, Guy's & St Thomas' NHS Foundation Hospital, London, UK
| | - Thomas Rimmelé
- Department of Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Samira Bell
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Eric Hoste
- Intensive Care Unit, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Faeq Husain-Syed
- Division of Nephrology, Pulmonology and Critical Care Medicine, Department of Medicine II, University Hospital Giessen and Marburg, Giessen, Germany
| | - Michael J Germain
- Division of Nephrology, Renal Transplant Associates of New England, Baystate Medical Center U Mass Medical School, Springfield, MA, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jay L Koyner
- Division of Nephrology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Matthieu Legrand
- Department of Anesthesiology and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Nuttha Lumlertgul
- Department of Intensive Care, Guy's & St Thomas' NHS Foundation Hospital, London, UK
- Division of Nephrology, Excellence Center for Critical Care Nephrology, Critical Care Nephrology Research Unit, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons and New York Presbyterian Hospital, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Neesh Pannu
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Zhiyong Peng
- Division of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xose L Perez-Fernandez
- Servei de Medicina Intensiva, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - John Prowle
- Critical Care and Peri-operative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Thiago Reis
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute of Vicenza, Vicenza, Italy
- Department of Nephrology, Clínica de Doenças Renais de Brasília, Brasília, Brazil
| | - Nattachai Srisawat
- Division of Nephrology, Excellence Center for Critical Care Nephrology, Critical Care Nephrology Research Unit, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
- Academy of Science, Royal Society of Thailand, Bangkok, Thailand
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama, Birmingham, AL, USA
| | - Anitha Vijayan
- Division of Nephrology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gianluca Villa
- Section of Anaesthesiology and Intensive Care, Department of Health Science, University of Florence, Florence, Italy
| | - Li Yang
- Renal Division, Peking University First Hospital, Beijing, China
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute of Vicenza, Vicenza, Italy
- Department of Medicine, University of Padova, Padova, Italy
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA.
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11
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Headley SA, Chapman DJ, Germain MJ, Evans EE, Hutchinson J, Madsen KL, Ikizler TA, Miele EM, Kirton K, O'Neill E, Cornelius A, Martin B, Nindl B, Vaziri ND. The effects of 16-weeks of prebiotic supplementation and aerobic exercise training on inflammatory markers, oxidative stress, uremic toxins, and the microbiota in pre-dialysis kidney patients: a randomized controlled trial-protocol paper. BMC Nephrol 2020; 21:517. [PMID: 33243160 PMCID: PMC7689649 DOI: 10.1186/s12882-020-02177-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/18/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is characterized by dysbiosis, elevated levels of uremic toxins, systemic inflammation, and increased markers of oxidative stress. These factors lead to an increased risk of cardiovascular disease (CVD) which is common among CKD patients. Supplementation with high amylose maize resistant starch type 2 (RS-2) can change the composition of the gut microbiota, and reduce markers of inflammation and oxidative stress in patients with end-stage renal disease. However, the impact of RS-2 supplementation has not been extensively studied in CKD patients not on dialysis. Aerobic exercise training lowers certain markers of inflammation in CKD patients. Whether combining aerobic training along with RS-2 supplementation has an additive effect on the aforementioned biomarkers in predialysis CKD patients has not been previously investigated. METHODS The study is being conducted as a 16-week, double-blind, placebo controlled, parallel arm, randomized controlled trial. Sixty stage 3-4 CKD patients (ages of 30-75 years) are being randomized to one of four groups: RS-2 & usual care, RS-2 & aerobic exercise, placebo (cornstarch) & usual care and placebo & exercise. Patients attend four testing sessions: Two baseline (BL) sessions with follow up visits 8 (wk8) and 16 weeks (wk16) later. Fasting blood samples, resting brachial and central blood pressures, and arterial stiffness are collected at BL, wk8 and wk16. A stool sample is collected for analysis of microbial composition and peak oxygen uptake is assessed at BL and wk16. Blood samples will be assayed for p-cresyl sulphate and indoxyl sulphate, c-reactive protein, tumor necrosis factor α, interleukin 6, interleukin 10, monocyte chemoattractant protein 1, malondialdehyde, 8-isoprostanes F2a, endothelin-1 and nitrate/nitrite. Following BL, subjects are randomized to their group. Individuals randomized to conditions involving exercise will attend three supervised moderate intensity (55-65% peak oxygen uptake) aerobic training sessions (treadmills, bikes or elliptical machine) per week for 16 weeks. DISCUSSION This study has the potential to yield information about the effect of RS-2 supplementation on key biomarkers believed to impact upon the development of CVD in patients with CKD. We are examining whether there is an additive effect of exercise training and RS-2 supplementation on these key variables. TRIAL REGISTRATION Clinicaltrials.gov Trial registration# NCT03689569 . 9/28/2018, retrospectively registered.
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Affiliation(s)
- Samuel A Headley
- Exercise Science & Athletic Training Department at Springfield College, 263 Alden Street, Springfield, MA, 01109, USA.
| | - Donna J Chapman
- Exercise Science & Athletic Training Department at Springfield College, 263 Alden Street, Springfield, MA, 01109, USA
| | | | - Elizabeth E Evans
- Exercise Science & Athletic Training Department at Springfield College, 263 Alden Street, Springfield, MA, 01109, USA
| | - Jasmin Hutchinson
- Exercise Science & Athletic Training Department at Springfield College, 263 Alden Street, Springfield, MA, 01109, USA
| | - Karen L Madsen
- Department of Gastroenterology, University of Alberta, Edmonton, Canada
| | | | - Emily M Miele
- Exercise Science & Athletic Training Department at Springfield College, 263 Alden Street, Springfield, MA, 01109, USA
| | - Kristyn Kirton
- Exercise Science & Athletic Training Department at Springfield College, 263 Alden Street, Springfield, MA, 01109, USA
| | - Elizabeth O'Neill
- Exercise Science & Athletic Training Department at Springfield College, 263 Alden Street, Springfield, MA, 01109, USA
| | | | - Brian Martin
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition University of Pittsburgh, Pittsburgh, USA
| | - Bradley Nindl
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition University of Pittsburgh, Pittsburgh, USA
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12
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Ju A, Teixeira-Pinto A, Tong A, Smith AC, Unruh M, Davison SN, Dapueto J, Dew MA, Fluck R, Germain MJ, Jassal SV, Obrador GT, O'Donoghue D, Viecelli AK, Strippoli G, Ruospo M, Timofte D, Sharma A, Au E, Howell M, Costa DSJ, Anumudu S, Craig JC, Rutherford C. Validation of a Core Patient-Reported Outcome Measure for Fatigue in Patients Receiving Hemodialysis: The SONG-HD Fatigue Instrument. Clin J Am Soc Nephrol 2020; 15:1614-1621. [PMID: 33093215 PMCID: PMC7646231 DOI: 10.2215/cjn.05880420] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/03/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Fatigue is a very common and debilitating symptom and identified by patients as a critically important core outcome to be included in all trials involving patients receiving hemodialysis. A valid, standardized measure for fatigue is needed to yield meaningful and relevant evidence about this outcome. This study validated a core patient-reported outcome measure for fatigue in hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A longitudinal cohort study was conducted to assess the validity and reliability of a new fatigue measure (Standardized Outcomes in Nephrology-Hemodialysis Fatigue [SONG-HD Fatigue]). Eligible and consenting patients completed the measure at three time points: baseline, a week later, and 12 days following the second time point. Cronbach α and intraclass correlation coefficient were calculated to assess internal consistency, and Spearman rho was used to assess convergent validity. Confirmatory factor analysis was also conducted. Hemodialysis units in the United Kingdom, Australia, and Romania participated in this study. Adult patients aged 18 years and over who were English speaking and receiving maintenance hemodialysis were eligible to participate. Standardized Outcomes in Nephrology-Hemodialysis, the Visual Analog Scale for fatigue, the 12-Item Short Form Survey, and Functional Assessment of Chronic Illness Therapy-Fatigue were used. RESULTS In total, 485 participants completed the study across the United Kingdom, Australia, and Romania. Psychometric assessment demonstrated that Standardized Outcomes in Nephrology-Hemodialysis is internally consistent (Cronbach α =0.81-0.86) and stable over a 1-week period (intraclass correlation coefficient =0.68-0.74). The measure demonstrated convergence with Functional Assessment of Chronic Illness Therapy-Fatigue and had moderate correlations with other measures that assessed related but not the same concept (the 12-Item Short Form Survey and the Visual Analog Scale). Confirmatory factor analysis supported the one-factor model. CONCLUSIONS SONG-HD Fatigue seems to be a reliable and valid measure to be used in trials involving patients receiving hemodialysis.
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Affiliation(s)
- Angela Ju
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia .,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Faculty of Science, Quality of Life Office, School of Psychology, University of Sydney, Sydney, Australia
| | - Armando Teixeira-Pinto
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Allison Tong
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Alice C Smith
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Mark Unruh
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Sara N Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Juan Dapueto
- Departamento de Psicología Médica, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard Fluck
- Department of Renal Medicine, Royal Derby Hospital, Derby, United Kingdom
| | - Michael J Germain
- Division of Nephrology, Renal and Transplant Associates of New England, Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, Massachusetts
| | - Sarbjit V Jassal
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Gregorio T Obrador
- Department of Epidemiology, Biostatistics, and Public Health, Universidad Panamericana School of Medicine, Mexico City, Mexico
| | - Donal O'Donoghue
- Department of Renal Medicine, Salford Royal Hospital, Salford, United Kingdom
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Australasian Kidney Trials Network, Centre for Health Services Research, University of Queensland, Brisbane, Queensland, Australia
| | - Giovanni Strippoli
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Marinella Ruospo
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Delia Timofte
- Department of Dialysis, Emergency University Hospital, Bucharest, Romania
| | - Ankit Sharma
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Eric Au
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia .,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Martin Howell
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Daniel S J Costa
- Faculty of Medicine and Health, Pain Management Research Institute, Royal North Shore Hospital, New South Wales, Sydney, Australia
| | - Samaya Anumudu
- Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Claudia Rutherford
- Faculty of Science, Quality of Life Office, School of Psychology, University of Sydney, Sydney, Australia.,The University of Sydney, Susan Wakil School of Nursing and Midwifery, Cancer Nursing Research Unit, Faculty of Medicine and Health, Sydney, Australia
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13
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Eneanya ND, Percy SG, Stallings TL, Wang W, Steele DJR, Germain MJ, Schell JO, Paasche-Orlow MK, Volandes AE. Use of a Supportive Kidney Care Video Decision Aid in Older Patients: A Randomized Controlled Trial. Am J Nephrol 2020; 51:736-744. [PMID: 32791499 DOI: 10.1159/000509711] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/24/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND There are few studies of patient-facing decision aids that include supportive kidney care as an option. We tested the efficacy of a video decision aid on knowledge of supportive kidney care among older patients with advanced CKD. METHODS Participants (age ≥ 65 years with advanced CKD) were randomized to receive verbal or video education. Primary outcome was knowledge of supportive kidney care (score range 0-3). Secondary outcomes included preference for supportive kidney care, and satisfaction and acceptability of the video. RESULTS Among all participants (n = 100), knowledge of supportive kidney care increased significantly after receiving education (p < 0.01); however, there was no difference between study arms (p = 0.68). There was no difference in preference for supportive kidney care between study arms (p = 0.49). In adjusted analyses, total health literacy score (aOR 1.08 [95% CI: 1.003-1.165]) and nephrologists' answer of "No" to the Surprise Question (aOR 4.87 [95% CI: 1.22-19.43]) were associated with preference for supportive kidney care. Most felt comfortable watching the video (96%), felt the content was helpful (96%), and would recommend the video to others (96%). CONCLUSIONS Among older patients with advanced CKD, we did not detect a significant difference between an educational verbal script and a video decision aid in improving knowledge of supportive kidney care or preferences. However, patients who received video education reported high satisfaction and acceptability ratings. Future research will determine the effectiveness of a supportive kidney care video decision aid on real-world patient outcomes. TRIAL REGISTRATION NCT02698722 (ClinicalTrials.gov).
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Affiliation(s)
- Nwamaka D Eneanya
- Renal-Electrolyte Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA,
| | - Shananssa G Percy
- Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School Center, Boston, Massachusetts, USA
| | - Taylor L Stallings
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wei Wang
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J R Steele
- Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School Center, Boston, Massachusetts, USA
| | - Michael J Germain
- Division of Nephrology, Baystate Medical Center, University of Massachusetts Medical School - Baystate, Springfield, Massachusetts, USA
| | - Jane O Schell
- Division of Renal-Electrolyte, Department of General Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Angelo E Volandes
- Division of General Medicine, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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14
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Abstract
In patients with advanced-stage chronic kidney disease (CKD), progressive kidney function decline leads to increased risk for hyperkalemia (serum potassium > 5.0 or >5.5 mEq/L). Medications such as renin-angiotensin-aldosterone system inhibitors pose an additional hyperkalemia risk, especially in patients with CKD. When hyperkalemia develops, clinicians often recommend a diet that is lower in potassium content. This review discusses the barriers to adherence to a low-potassium diet and the impact of dietary restrictions on adverse clinical outcomes. Accumulating evidence indicates that a diet that incorporates potassium-rich foods has multiple health benefits, which may also be attributable to the other vitamin, mineral, and fiber content of potassium-rich foods. These benefits include blood pressure reductions and reduced risks for cardiovascular disease and stroke. High-potassium foods may also prevent CKD progression and reduce mortality risk in patients with CKD. Adjunctive treatment with the newer potassium-binding agents, patiromer and sodium zirconium cyclosilicate, may allow for optimal renin-angiotensin-aldosterone system inhibitor therapy in patients with CKD and hyperkalemia, potentially making it possible for patients with CKD and hyperkalemia to liberalize their diet. This may allow them the health benefits of a high-potassium diet without the increased risk for hyperkalemia, although further studies are needed.
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Affiliation(s)
- Deborah J. Clegg
- Drexel College of Nursing and Health Professions, Philadelphia, PA
| | - Samuel A. Headley
- Department of Exercise Science and Athletic Training, Springfield College, Springfield, MA
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15
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Germain MJ, Paul SK, Broumand V, Fadda G, Nguyen A, McGarvey N, Gitlin M, Ashfaq A. P0901REAL-WORLD ASSESSMENT: CLINICAL EFFECTIVENESS AND SAFETY OF VITAMIN D THERAPIES IN ND-CKD PATIENTS. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p0901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and Aims
Extended-release calcifediol (ERC), active vitamin D analogs (VDA), and nutritional vitamin D (NVD) are the predominant vitamin D therapies (VDTs) commonly used for treatment (Tx) of secondary hyperparathyroidism (SHPT) in adults with stage 3 or 4 non-dialysis chronic kidney disease (ND-CKD) and vitamin D insufficiency (VDI). Clinical trials have demonstrated varying efficacy on serum total 25-hydroxyvitamin D (25D) and intact parathyroid hormone (iPTH) across VDTs. This study aimed to descriptively assess the real-world experience of various VDTs in increasing 25D, reducing iPTH, and modifying serum calcium (Ca).
Method
Medical records of the first 376 adult patients with stage 3 or 4 CKD and a history of SHPT and VDI who met study criteria from 18 geographically representative United States nephrology clinics were reviewed from 1 year before through 1 year after initiation of VDT. Key study variables included patient demographics, medication usage, and laboratory results. The study population had a mean age of 69.5 years with gender and racial distributions representative of the US ND-CKD population. Patients were stratified into cohorts based on their index therapy at index date: ERC (n=174), VDA (n=55) and NVD (n=147).
Results
Patients treated with NVD were predominantly CKD Stage 3 (69.4%), while CKD Stage 4 were the majority of those treated with ERC (53.4%) and VDA (61.8%). The ERC Tx’ed subjects demonstrated an increase in 25D by 23.7 ± 1.6 ng/mL (p<0.001) and a decrease iPTH by 35 ± 6.2 pg/mL (p<0.001) without statistically significant impact on serum calcium (Ca) and phosphorus (P) levels. The VDA Tx’ed group demonstrated an increase in 25D by 5.5 ± 1.3 ng/mL (p<0.001) without statistically significant impact on iPTH and serum phosphorus levels. Additionally, serum Ca increased by 0.2 ± 0.1 pg/mL (p<0.001) among VDA recipients. The NVD Tx’ed group demonstrated an increase in 25D by 9.7 ± 1.6 ng/mL (p<0.001) without statistically significant impact on iPTH and serum Ca and P levels (Table 1).
Conclusion
Clinical effectiveness and safety varied across VDTs. ERC was the only VDT which significantly reduced mean iPTH in the real world setting despite highest mean levels at baseline among the three cohorts. Additionally, subjects treated with ERC demonstrated the largest mean increase in 25D and ERC was the only VDT which raised mean 25D to the normal range (>30 ng/mL). Patients treated with ERC and NVD saw no statistically significant impact on serum Ca and P levels; however, those treated with VDAs saw a small, but statistically significant increase in serum Ca levels.
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Affiliation(s)
- Michael J Germain
- Renal and Transplant Associates of New England, PC, Springfield, United States of America
| | - Subir K Paul
- Shoals Kidney & Hypertension Center, Florence, United States of America
| | | | - George Fadda
- California Institute of Renal Research, San Diego, United States of America
| | - Andy Nguyen
- BluePath Solutions, Los Angeles, United States of America
| | | | - Matthew Gitlin
- BluePath Solutions, Los Angeles, United States of America
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16
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Chait Y, Germain MJ, Hollot CV, Horowitz J. The Role of Feedback Control Design in Developing Anemia Management Protocols. Ann Biomed Eng 2020; 49:171-179. [PMID: 32383041 DOI: 10.1007/s10439-020-02520-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/24/2020] [Indexed: 11/27/2022]
Abstract
The optimal use of erythropoiesis stimulating agents to treat anemia of end-stage renal disease remains difficult due to reported associations with adverse events. A patient's hemoglobin response to these agents cannot be accurately described using population-level models due to many individual factors including chronic inflammation, red blood cell lifespan, and acute blood loss. As a consequence, it is generally understood that current one-size-fits-all anemia management protocols result in suboptimal outcomes. In this paper, we report on our collaboration with the medical community in designing anemia management protocols. In clinical implementation, these new dosing protocols have led to improved outcomes due to their use of control-relevant modelling, model parameter identification, and principles of feedback control. This is an example of medical professionals and control engineers working together to positively affect the performance of anemia management protocols in end-stage renal disease.
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Affiliation(s)
- Yossi Chait
- Mechanical and Industrial Engineering Department, University of Massachusetts, Amherst, MA, 01003, USA.
| | - Michael J Germain
- Renal and Transplant Associates of New England, PC, Springfield, MA, 01107, USA
- Division of Nephrology, Baystate Medical Center, Springfield, MA, 01199, USA
- University of Massachusetts Medical School, Worcester, MA, 01655, USA
| | - Christopher V Hollot
- Electrical and Computer Engineering Department, University of Massachusetts, Amherst, MA, 01003, USA
| | - Joseph Horowitz
- Mathematics and Statistics Department, University of Massachusetts, Amherst, MA, 01003, USA
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Schmidt RJ, Landry DL, Cohen L, Moss AH, Dalton C, Nathanson BH, Germain MJ. Derivation and validation of a prognostic model to predict mortality in patients with advanced chronic kidney disease. Nephrol Dial Transplant 2020; 34:1517-1525. [PMID: 30395311 DOI: 10.1093/ndt/gfy305] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Guiding patients with advanced chronic kidney disease (CKD) through advance care planning about future treatment obliges an assessment of prognosis. A patient-specific integrated model to predict mortality could inform shared decision-making for patients with CKD. METHODS Patients with Stages 4 and 5 CKD from Massachusetts (749) and West Virginia (437) were prospectively evaluated for clinical parameters, functional status [Karnofsky Performance Score (KPS)] and their provider's response to the Surprise Question (SQ). A predictive model for 12-month mortality was derived with the Massachusetts cohort and then validated externally on the West Virginia cohort. Logistic regression was used to create the model, and the c-statistic and Hosmer-Lemeshow statistic were used to assess model discrimination and calibration, respectively. RESULTS In the derivation cohort, the SQ, KPS and age were most predictive of 12-month mortality with odds ratios (ORs) [95% confidence interval (CI)] of 3.29 (1.87-5.78) for a 'No' response to the SQ, 2.09 (95% CI 1.19-3.66) for fair KPS and 1.41 (95% CI 1.15-1.74) per 10-year increase in age. The c-statistic for the 12-month mortality model for the derivation cohort was 0.80 (95% CI 0.75-0.84) and for the validation cohort was 0.74 (95% CI 0.66-0.83). CONCLUSIONS Our integrated prognostic model for 12-month mortality in patients with advanced CKD had good discrimination and calibration. This model provides prognostic information to aid nephrologists in identifying and counseling advanced CKD patients with poor prognosis who are facing the decision to initiate dialysis or pursue medical management without dialysis.
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Affiliation(s)
- Rebecca J Schmidt
- Department of Medicine, Sections of Nephrology and Supportive Care, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Daniel L Landry
- Division of Nephrology, Baystate Medical Center, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - Lewis Cohen
- Department of Psychiatry, Baystate Medical Center, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - Alvin H Moss
- Department of Medicine, Sections of Nephrology and Supportive Care, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Cheryl Dalton
- Department of Medicine, Sections of Nephrology and Supportive Care, West Virginia University School of Medicine, Morgantown, WV, USA
| | | | - Michael J Germain
- Division of Nephrology, Baystate Medical Center, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
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Polk D, Madden RL, Lipkowitz GS, Braden GL, Germain MJ, Mulhern JG, O'Shea MH. Use of Computerized Tomography in the Evaluation of a Capd Patient with a Foramen of Morgagni Hernia: A Case Report. Perit Dial Int 2020. [DOI: 10.1177/089686089601600315] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Donna Polk
- Departments of Surgery and Medicine Baystate Medical Center Tufts University School of Medicine Springfield, Massachusetts, U.S.A
| | - Robert L. Madden
- Departments of Surgery and Medicine Baystate Medical Center Tufts University School of Medicine Springfield, Massachusetts, U.S.A
| | - George S. Lipkowitz
- Departments of Surgery and Medicine Baystate Medical Center Tufts University School of Medicine Springfield, Massachusetts, U.S.A
| | - Gregory L. Braden
- Departments of Surgery and Medicine Baystate Medical Center Tufts University School of Medicine Springfield, Massachusetts, U.S.A
| | - Michael J. Germain
- Departments of Surgery and Medicine Baystate Medical Center Tufts University School of Medicine Springfield, Massachusetts, U.S.A
| | - Jeffrey G. Mulhern
- Departments of Surgery and Medicine Baystate Medical Center Tufts University School of Medicine Springfield, Massachusetts, U.S.A
| | - Michael H. O'Shea
- Departments of Surgery and Medicine Baystate Medical Center Tufts University School of Medicine Springfield, Massachusetts, U.S.A
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Fishbane S, Mathur V, Germain MJ, Shirazian S, Bhaduri S, Munera C, Spencer RH, Menzaghi F. Randomized Controlled Trial of Difelikefalin for Chronic Pruritus in Hemodialysis Patients. Kidney Int Rep 2020; 5:600-610. [PMID: 32405581 PMCID: PMC7210745 DOI: 10.1016/j.ekir.2020.01.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 01/13/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction There is an unmet medical need for pruritus associated with chronic kidney disease, a distressing complication characterized by generalized and persistent itch affecting 20% to 40% of patients undergoing hemodialysis. Here we report the results of a phase 2 trial evaluating the efficacy and safety of a novel peripherally restricted kappa opioid receptor agonist, difelikefalin, in adult patients undergoing hemodialysis with pruritus. Methods In this study, 174 hemodialysis patients with moderate-to-severe pruritus were randomly assigned to receive difelikefalin (0.5, 1.0, or 1.5 μg/kg) or placebo intravenously thrice weekly after each hemodialysis session for 8 weeks in a double-blind, controlled trial. The primary endpoint was the change from baseline at week 8 in the weekly mean of the 24-hour Worst Itching Intensity Numerical Rating Scale score. The secondary efficacy endpoint was the change in itch-related quality of life measured by the Skindex-10 questionnaire. Other endpoints included safety, sleep quality, and additional measures including the 5-D itch scale. Results A significant reduction from baseline in itch intensity scores at week 8 favored all difelikefalin doses combined versus placebo (P = 0.002). Difelikefalin also showed improvement over placebo in Skindex-10, 5-D itch, and sleep disturbance scores (P ≤ 0.005). Overall, 78% of patients receiving difelikefalin reported treatment-emergent adverse events versus 42% of patients given placebo, with diarrhea, dizziness, nausea, somnolence, and fall being the most frequent (≥5%). Conclusion In this trial, difelikefalin effectively reduced itching intensity and improved sleep and itch-related quality of life.
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Affiliation(s)
- Steven Fishbane
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | | | - Michael J Germain
- Baystate Medical Center and Tufts University, Springfield, Massachusetts, USA
| | - Shayan Shirazian
- Columbia University Medical Center, Division of Nephrology, Department of Medicine, College of Physicians and Surgeons at Columbia University, New York, New York, USA
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Momb BA, Headley SA, Matthews TD, Germain MJ. Intradialytic exercise increases cardiac power index. J Nephropathol 2019. [DOI: 10.15171/jnp.2020.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: Mortality rates are high in end-stage renal disease due to cardiovascular complications. Perfusion of the myocardium declines during and after hemodialysis sessions with the potential for aerobic exercise to mitigate these during hemodialysis. Objectives: The purpose of this study was to investigate acute changes in hemodynamics in subjects with end-stage renal disease (ESRD) during exercise. Patients and Methods: Subjects (n = 10) were monitored for 1.5 hours during hemodialysis treatment during a control (CON) and an exercise (EX) session. Subjects cycled using an ergometer strapped to the reclining dialysis chair at an RPE of 11-13 for 30 minutes during the EX session beginning at 30 min into dialysis and ending at 60 minutes. Data for systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were collected using an automated blood pressure cuff attached to the hemodialysis machine. Data for cardiac output (Q̇ ), cardiac power index (CPI), stroke volume (SV), systemic vascular resistance (SVR), and heart rate (HR) were collected using the NICaS bioelectrical impedance device. Results: During the EX session, CPI, Q̇ , SV, and HR were significantly greater (P<0.05) than the CON session. Additionally, Q̇ was significantly (P< 0.05) greater at 45 minutes and 60 minutes compared to 15 minutes. HR was significantly (P<0.05) greater at 45 minutes compared to 90 minutes. No significant interactions were found for MAP, CPI, Q̇ , HR, SV, SBP, DBP, or SVR. Conclusion: In conclusion, exercise during dialysis may decrease the likelihood of experiencing ischemic or hypotensive events by enhancing myocardial perfusion through increasing CPI and Q̇ .
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Affiliation(s)
- Brent A. Momb
- Department of Kinesiology, University of Massachusetts, Amherst, MA, USA
| | - Samuel A.E Headley
- Department of Exercise Science and Athletic Training, Springfield College, Springfield, MA, USA
| | - Tracey D. Matthews
- Department of Exercise Science and Athletic Training, Springfield College, Springfield, MA, USA
| | - Michael J. Germain
- Department of Nephrology, Renal and Transplant Associates, Springfield, MA, USA
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Levy AR, Xing S, Brunelli SM, Cooper K, Finkelstein FO, Germain MJ, Kimel M, Platt RW, Belozeroff V. Symptoms of Secondary Hyperparathyroidism in Patients Receiving Maintenance Hemodialysis: A Prospective Cohort Study. Am J Kidney Dis 2019; 75:373-383. [PMID: 31629575 DOI: 10.1053/j.ajkd.2019.07.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 07/17/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Although multiple lines of evidence suggest a negative impact of secondary hyperparathyroidism on patients with kidney failure treated by hemodialysis, it is uncertain whether patients can detect associated symptoms. The objective was to determine whether changes in parathyroid hormone (PTH) levels are associated with changes in symptoms within this patient population. STUDY DESIGN Prospective cohort. SETTING & PARTICIPANTS 165 adults with hyperparathyroidism secondary to kidney failure diagnosed, a range of dialysis vintages, and receiving regular hemodialysis from a US single-provider organization. EXPOSURE Change in PTH levels over 24 weeks. OUTCOMES 19 putative symptoms of secondary hyperparathyroidism measured up to 4 times using a self-administered questionnaire that assessed severity on a 5-level ordinal scale. ANALYTICAL APPROACH Longitudinal associations between changes in PTH levels and symptom severity were assessed using generalized additive models. RESULTS The 165 participants studied represented 81% of enrollees (N=204) who had sufficiently complete data for analysis. Mean age was 56 years and 54% were women. Increases in PTH levels over time were associated (P<0.1) with worsening of bone aches and stiffness, joint aches, muscle soreness, overall pain, itchy skin, and tiredness, and the effects were more pronounced with larger changes in PTH levels. LIMITATIONS Findings may have been influenced by confounding by unmeasured comorbid conditions, concomitant medications, and multiple testing coupled with a P value threshold of 0.10. CONCLUSIONS In this exploratory study, we observed that among patients with secondary hyperparathyroidism, increases in PTH levels over time were associated with worsening of 1 or more cluster of symptoms. Replication of these findings in other populations is needed before concluding about the magnitude and shape of these associations. If replicated, these findings could inform clinically useful approaches for measuring patient-reported outcomes related to secondary hyperparathyroidism.
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Affiliation(s)
| | - Shan Xing
- Takeda Pharmaceuticals U.S.A, Cambridge, MA
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22
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Guzzi LM, Bergler T, Binnall B, Engelman DT, Forni L, Germain MJ, Gluck E, Göcze I, Joannidis M, Koyner JL, Reddy VS, Rimmelé T, Ronco C, Textoris J, Zarbock A, Kellum JA. Clinical use of [TIMP-2]•[IGFBP7] biomarker testing to assess risk of acute kidney injury in critical care: guidance from an expert panel. Crit Care 2019; 23:225. [PMID: 31221200 PMCID: PMC6585126 DOI: 10.1186/s13054-019-2504-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/04/2019] [Indexed: 12/16/2022]
Abstract
Background The first FDA-approved test to assess risk for acute kidney injury (AKI), [TIMP-2]•[IGFBP7], is clinically available in many parts of the world, including the USA and Europe. We sought to understand how the test is currently being used clinically. Methods We invited a group of experts knowledgeable on the utility of this test for kidney injury to a panel discussion regarding the appropriate use of the test. Specifically, we wanted to identify which patients would be appropriate for testing, how the results are interpreted, and what actions would be taken based on the results of the test. We used a modified Delphi method to prioritize specific populations for testing and actions based on biomarker test results. No attempt was made to evaluate the evidence in support of various actions however. Results Our results indicate that clinical experts have developed similar practice patterns for use of the [TIMP-2]•[IGFBP7] test in Europe and North America. Patients undergoing major surgery (both cardiac and non-cardiac), those who were hemodynamically unstable, or those with sepsis appear to be priority patient populations for testing kidney stress. It was agreed that, in patients who tested positive, management of potentially nephrotoxic drugs and fluids would be a priority. Patients who tested negative may be candidates for “fast-track” protocols. Conclusion In the experience of our expert panel, biomarker testing has been a priority after major surgery, hemodynamic instability, or sepsis. Our panel members reported that a positive test prompts management of nephrotoxic drugs as well as fluids, while patients with negative results are considered to be excellent candidates for “fast-track” protocols. Electronic supplementary material The online version of this article (10.1186/s13054-019-2504-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Louis M Guzzi
- Florida Hospital, 601 E. Rollins Street, Orlando, FL, 32803, USA
| | - Tobias Bergler
- University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Brian Binnall
- Baystate Medical Center, 759 Chestnut Street, Springfield, MA, 01107, USA
| | - Daniel T Engelman
- Baystate Medical Center, 759 Chestnut Street, Springfield, MA, 01107, USA
| | - Lui Forni
- The Royal Surrey County Hospital NHS Foundation Trust, Egerton Rd, Guildford, Surrey, GU2 7XX, UK.,University of Surrey, 388 Stag Hill, Guildford, Surrey, GU2 7XH, UK
| | - Michael J Germain
- Baystate Medical Center, 759 Chestnut Street, Springfield, MA, 01107, USA
| | - Eric Gluck
- Swedish Covenant Hospital, 5145 N California Ave, Chicago, IL, 60625, USA
| | - Ivan Göcze
- University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, 5841 South Maryland Ave, Suite S-507, MC5100, Chicago, IL, 60637, USA
| | - V Seenu Reddy
- Tristar Centennial Medical Center, 2400 Patterson St #307, Nashville, TN, 37203, USA
| | - Thomas Rimmelé
- Hospices Civils de Lyon, Edouard Herriot Hospital, 5 Place d'Arsonval, 69003, Lyon, France
| | - Claudio Ronco
- Department of Nephrology University of Padua, Padua Italy; San Bortolo Hospital, Vicenza, Italy; International Renal Research Institute Vicenza, Vicenza, Italy
| | - Julien Textoris
- Hospices Civils de Lyon, Edouard Herriot Hospital, 5 Place d'Arsonval, 69003, Lyon, France.,bioMérieux, 5 Place d'Arsonval, 69003, Lyon, France
| | - Alexander Zarbock
- University Hospital Münster, Albert-Schweitzer Campus 1, Building A1, 48149, Münster, Germany
| | - John A Kellum
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, 3347 Forbes Avenue, Suite 220, Pittsburgh, PA, 15213, USA. .,Critical Care Medicine, Clinical & Translational Science, and Bioengineering, Center for Critical Care Nephrology, 3347 Forbes Avenue, Suite 220, Pittsburgh, PA, 15213, USA.
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Affiliation(s)
- Emma Murphy
- University of Southampton and University Hospital Southampton, Southampton, United Kingdom.
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24
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Abstract
OBJECTIVES There are approximately 660 000 end-stage renal disease patients in the USA, with hemodialysis (HD) the primary form of treatment. High ultrafiltration rates (UFRs) are associated with intradialytic hypotension, a complication associated with adverse clinical outcomes including mortality. Individualized UFR profiles could reduce the incidence of intradialytic hypotension. METHODS The patient's fluid dynamics during HD is described by a nonlinear model comprising intravascular and interstitial pools, whose parameters are given by the patient's estimated nominal parameter values with uncertainty ranges; the output measurement is hematocrit. We design UFR profiles that minimize the maximal UFR needed to remove a prescribed volume of fluid within a set time, with hematocrit not exceeding a specified time-varying critical profile. RESULTS We present a novel approach to design individualized UFR profiles, and give theoretical results guaranteeing that the system remains within a predefined physiologically plausible region and does not exceed a specified time-invariant critical hematocrit level for all parameters in the uncertainty ranges. We test the performance of our design using a real patient data example. The designed UFR maintains the system below a time-varying critical hematocrit profile in the example. CONCLUSION Theoretical results and simulations show that our designed UFR profiles can remove the target amount of fluid in a given time period while keeping the hematocrit below a specified critical profile. SIGNIFICANCE Individualization of UFR profiles is now feasible using current HD technology and may reduce the incidence of intradialytic hypotension.
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26
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Germain MJ, Joubert J, O'Grady D, Nathanson BH, Chait Y, Levin NW. Comparison of stroke volume measurements during hemodialysis using bioimpedance cardiography and echocardiography. Hemodial Int 2017; 22:201-208. [PMID: 28796425 DOI: 10.1111/hdi.12589] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Fluid management remains a major challenge of hemodialysis (HD) care, with serious implications for morbidity and mortality. Intradialytic fluid management is typically guided by blood pressure, an indirect resultant of hemodynamics status. Direct measurements of hemodynamic parameters may improve cardiovascular outcomes by providing rational bases for intervention. We compare stroke volume (SV) measurements using a noninvasive, regional biompedance cardiography device (NiCaS) with Doppler echocardiography (Echo) in HD setting. METHODS Stroke volumes were simultaneously measured using the devices in 17 patients receiving maintenance HD. Measurements were made during 2 weekly HD treatments, and twice within each HD treatment during the first and last hour of each treatment, for a total of 64 SV measurements. Agreement between devices was assessed using linear regression, a Pearson's correlation coefficient, and a Bland-Altman plot all adjusted for repeated measures within patients. RESULTS Echo and NiCaS SV mean and 95% CIs were 58.0 (50.1, 65.8) and 56.7 (49.4, 64.0) mL, respectively. NiCaS SV correlated strongly with Echo SV during the first and last hours of treatments (r = 0.93, P < 0.001 and r = 0.92, P < 0.001, respectively). Linear regression of NiCaS on Echo showed a slope of 0.97, 95% CI (0.91, 1.02) which did not differ from 1, P = 0.20. A Bland-Altman plot and 4-Quadrant plot confirmed that the 2 methods produced comparable measurements. CONCLUSION NiCaS SV measurements are similar to and strongly correlated with Echo SV measurements. This suggests that noninvasive NiCaS technology may be a practical method for measuring SV during HD.
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Affiliation(s)
- Michael J Germain
- Baystate Medical Center, Springfield, Massachusetts and University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jyovani Joubert
- Kidney Care and Transplant Associates of New England, Springfield, Massachusetts, USA
| | | | | | - Yossi Chait
- University of Massachusetts, Amherst, Massachusetts, USA
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Morton RL, Webster AC, McGeechan K, Howard K, Murtagh FE, Gray NA, Kerr PG, Germain MJ, Snelling P. Conservative Management and End-of-Life Care in an Australian Cohort with ESRD. Clin J Am Soc Nephrol 2016; 11:2195-2203. [PMID: 27697783 PMCID: PMC5142079 DOI: 10.2215/cjn.11861115] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 07/28/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES We aimed to determine the proportion of patients who switched to dialysis after confirmed plans for conservative care and compare survival and end-of-life care among patients choosing conservative care with those initiating RRT. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A cohort study of 721 patients on incident dialysis, patients receiving transplants, and conservatively managed patients from 66 Australian renal units entered into the Patient Information about Options for Treatment Study from July 1 to September 30, 2009 were followed for 3 years. A two-sided binomial test assessed the proportion of patients who switched from conservative care to RRT. Cox regression, stratified by center and adjusted for patient and treatment characteristics, estimated factors associated with 3-year survival. RESULTS In total, 102 of 721 patients planned for conservative care, and median age was 80 years old. Of these, 8% (95% confidence interval, 3% to 13%), switched to dialysis, predominantly for symptom management. Of 94 patients remaining on a conservative pathway, 18% were alive at 3 years. Of the total 721 patients, 247 (34%) died by study end. In multivariable analysis, factors associated with all-cause mortality included older age (hazard ratio, 1.55; 95% confidence interval, 1.36 to 1.77), baseline serum albumin <3.0 versus 3.7-5.4 g/dl (hazard ratio, 4.31; 95% confidence interval, 2.72 to 6.81), and management with conservative care compared with RRT (hazard ratio, 2.18; 95% confidence interval, 1.39 to 3.40). Of 247 deaths, patients managed with RRT were less likely to receive specialist palliative care (26% versus 57%; P<0.001), more likely to die in the hospital (66% versus 42%; P<0.001) than home or hospice, and more likely to receive palliative care only within the last week of life (42% versus 15%; P<0.001) than those managed conservatively. CONCLUSIONS Survival after 3 years of conservative management is common, with relatively few patients switching to dialysis. Specialist palliative care services are used more frequently and at an earlier time point for conservatively managed patients, a practice associated with better symptom management and quality of life.
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Affiliation(s)
- Rachael L. Morton
- National Health and Medical Research Council Clinical Trials Centre, Sydney Medical School and
| | - Angela C. Webster
- Sydney School of Public Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Kevin McGeechan
- Sydney School of Public Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Kirsten Howard
- Sydney School of Public Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Fliss E.M. Murtagh
- Cicely Saunders Institute, King’s College London, Denmark Hill, United Kingdom
| | - Nicholas A. Gray
- Sunshine Coast Clinical School, The University of Queensland and Renal Unit, Nambour General Hospital, Nambour, Australia
| | - Peter G. Kerr
- Department of Nephrology, Monash Medical Centre, Clayton, Australia
| | - Michael J. Germain
- Department of Medicine, Division of Nephology, Baystate Medical Center, Springfield, Massachusetts; and
| | - Paul Snelling
- Department of Renal Medicine Royal Prince Alfred Hospital, Camperdown, Australia
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Couchoud C, Hemmelgarn B, Kotanko P, Germain MJ, Moranne O, Davison SN. Supportive Care: Time to Change Our Prognostic Tools and Their Use in CKD. Clin J Am Soc Nephrol 2016; 11:1892-1901. [PMID: 27510452 PMCID: PMC5053799 DOI: 10.2215/cjn.12631115] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In using a patient-centered approach, neither a clinician nor a prognostic score can predict with absolute certainty how well a patient will do or how long he will live; however, validated prognostic scores may improve accuracy of prognostic estimates, thereby enhancing the ability of the clinicians to appreciate the individual burden of disease and the prognosis of their patients and inform them accordingly. They may also facilitate nephrologist's recommendation of dialysis services to those who may benefit and proposal of alternative care pathways that might better respect patients' values and goals to those who are unlikely to benefit. The purpose of this article is to discuss the use as well as the limits and deficiencies of currently available prognostic tools. It will describe new predictors that could be integrated in future scores and the role of patients' priorities in development of new scores. Delivering patient-centered care requires an understanding of patients' priorities that are important and relevant to them. Because of limits of available scores, the contribution of new prognostic tools with specific markers of the trajectories for patients with CKD and patients' health reports should be evaluated in relation to their transportability to different clinical and cultural contexts and their potential for integration into the decision-making processes. The benefit of their use then needs to be quantified in clinical practice by outcome studies including health-related quality of life, patient and caregiver satisfaction, or utility for improving clinical management pathways and tailoring individualized patient-centered strategies of care. Future research also needs to incorporate qualitative methods involving patients and their caregivers to better understand the barriers and facilitators to use of these tools in the clinical setting. Information given to patients should be supported by a more realistic approach to what dialysis is likely to entail for the individual patient in terms of likely quality and quantity of life according to the patient's values and goals and not just the possibility of life prolongation.
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Affiliation(s)
- Cécile Couchoud
- French End-Stage Renal Disease Registry Renal Epidemiology and Information Network, Agence de la Biomédecine, St. Denis La Plaine, France
| | - Brenda Hemmelgarn
- Departments of Community Health Sciences and
- Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Peter Kotanko
- Renal Research Institute, New York, New York
- Nephrology Department, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael J. Germain
- Division of Nephrology, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts
| | - Olivier Moranne
- Service de Néphrologie-Suppélance rénale, Hôpital Caremeau, Centre Hospitalo-universitaire Nîmes, Nîmes France
- Equipe d'accueil 2415, Biostatistique, Epidémiologie et Santé Publique, Institut Universitaire de Recherche Clinique, Université de Montpellier, Montpellier, France; and
| | - Sara N. Davison
- Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Cukor D, Cohen LM, Cope EL, Ghahramani N, Hedayati SS, Hynes DM, Shah VO, Tentori F, Unruh M, Bobelu J, Cohen S, Dember LM, Faber T, Fischer MJ, Gallardo R, Germain MJ, Ghahate D, Grote N, Hartwell L, Heagerty P, Kimmel PL, Kutner N, Lawson S, Marr L, Nelson RG, Porter AC, Sandy P, Struminger BB, Subramanian L, Weisbord S, Young B, Mehrotra R. Patient and Other Stakeholder Engagement in Patient-Centered Outcomes Research Institute Funded Studies of Patients with Kidney Diseases. Clin J Am Soc Nephrol 2016; 11:1703-1712. [PMID: 27197911 PMCID: PMC5012486 DOI: 10.2215/cjn.09780915] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Including target populations in the design and implementation of research trials has been one response to the growing health disparities endemic to our health care system, as well as an aid to study generalizability. One type of community-based participatory research is "Patient Centered-Research", in which patient perspectives on the germane research questions and methodologies are incorporated into the study. The Patient-Centered Outcomes Research Institute (PCORI) has mandated that meaningful patient and stakeholder engagement be incorporated into all applications. As of March 2015, PCORI funded seven clinically-focused studies of patients with kidney disease. The goal of this paper is to synthesize the experiences of these studies to gain an understanding of how meaningful patient and stakeholder engagement can occur in clinical research of kidney diseases, and what the key barriers are to its implementation. Our collective experience suggests that successful implementation of a patient- and stakeholder-engaged research paradigm involves: (1) defining the roles and process for the incorporation of input; (2) identifying the particular patients and other stakeholders; (3) engaging patients and other stakeholders so they appreciate the value of their own participation and have personal investment in the research process; and (4) overcoming barriers and challenges that arise and threaten the productivity of the collaboration. It is our hope that the experiences of these studies will further interest and capacity for incorporating patient and stakeholder perspectives in research of kidney diseases.
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Affiliation(s)
- Daniel Cukor
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Abstract
Pruritus is a common and distressing symptom in patients with chronic kidney disease. The most recent epidemiologic data have suggested that approximately 40% of patients with end-stage renal disease experience moderate to severe pruritus and that uremic pruritus (UP) has a major clinical impact, being associated strongly with poor quality of life, impaired sleep, depression, and increased mortality. The pathogenesis of UP remains largely unclear, although several theories on etiologic or contributing factors have been proposed including increased systemic inflammation; abnormal serum parathyroid hormone, calcium, and phosphorus levels; an imbalance in opiate receptors; and a neuropathic process. UP can present somewhat variably, although it tends to affect large, discontinuous, but symmetric, areas of skin and to be most symptomatic at night. A variety of alternative systemic or dermatologic conditions should be considered, especially in patients with asymmetric pruritus or other atypical features. Treatment initially should focus on aggressive skin hydration, patient education on minimizing scratching, and optimization of the aspects of chronic kidney disease care that are most relevant to pruritus, including dialysis adequacy and serum parathyroid hormone, calcium, and phosphorus management. Data for therapy specifically for UP remain limited, although topical therapies, gabapentin, type B ultraviolet light phototherapy, acupuncture, and opioid-receptor modulators all may play a role.
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Affiliation(s)
- Sara A Combs
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - J Pedro Teixeira
- Department of Medicine, University of Washington Medical Center, University of Washington, Seattle, WA
| | - Michael J Germain
- Department of Medicine, Baystate Medical Center, Tufts University, Springfield, MA.
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Shrestha RP, Horowitz J, Hollot CV, Germain MJ, Widness JA, Mock DM, Veng-Pedersen P, Chait Y. Models for the red blood cell lifespan. J Pharmacokinet Pharmacodyn 2016; 43:259-74. [PMID: 27039311 PMCID: PMC4887310 DOI: 10.1007/s10928-016-9470-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 03/06/2016] [Indexed: 10/22/2022]
Abstract
The lifespan of red blood cells (RBCs) plays an important role in the study and interpretation of various clinical conditions. Yet, confusion about the meanings of fundamental terms related to cell survival and their quantification still exists in the literature. To address these issues, we started from a compartmental model of RBC populations based on an arbitrary full lifespan distribution, carefully defined the residual lifespan, current age, and excess lifespan of the RBC population, and then derived the distributions of these parameters. For a set of residual survival data from biotin-labeled RBCs, we fit models based on Weibull, gamma, and lognormal distributions, using nonlinear mixed effects modeling and parametric bootstrapping. From the estimated Weibull, gamma, and lognormal parameters we computed the respective population mean full lifespans (95 % confidence interval): 115.60 (109.17-121.66), 116.71 (110.81-122.51), and 116.79 (111.23-122.75) days together with the standard deviations of the full lifespans: 24.77 (20.82-28.81), 24.30 (20.53-28.33), and 24.19 (20.43-27.73). We then estimated the 95th percentiles of the lifespan distributions (a surrogate for the maximum lifespan): 153.95 (150.02-158.36), 159.51 (155.09-164.00), and 160.40 (156.00-165.58) days, the mean current ages (or the mean residual lifespans): 60.45 (58.18-62.85), 60.82 (58.77-63.33), and 57.26 (54.33-60.61) days, and the residual half-lives: 57.97 (54.96-60.90), 58.36 (55.45-61.26), and 58.40 (55.62-61.37) days, for the Weibull, gamma, and lognormal models respectively. Corresponding estimates were obtained for the individual subjects. The three models provide equally excellent goodness-of-fit, reliable estimation, and physiologically plausible values of the directly interpretable RBC survival parameters.
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Affiliation(s)
- Rajiv P Shrestha
- Octet Research Inc., 101 Arch St. Suite 1950, Boston, MA, 02110, USA.
| | - Joseph Horowitz
- Department of Mathematics & Statistics, University of Massachusetts, Amherst, MA, 01003, USA
| | - Christopher V Hollot
- Department of Electrical & Computer Engineering, University of Massachusetts, Amherst, MA, 01003, USA
| | - Michael J Germain
- Renal and Transplant Associates of New England, Division of Nephrology, Baystate Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - John A Widness
- Department of Pediatrics, College of Medicine, The University of Iowa, Iowa City, IA, 52242, USA
| | - Donald M Mock
- Department of Biochemistry and Molecular Biology, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Peter Veng-Pedersen
- Division of Pharmaceutics, College of Pharmacy, The University of Iowa, Iowa City, IA, 52242, USA
| | - Yossi Chait
- Department of Mechanical & Industrial Engineering, University of Massachusetts, Amherst, MA, 01003, USA
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Chait Y, Kalim S, Horowitz J, Hollot CV, Ankers ED, Germain MJ, Thadhani RI. The greatly misunderstood erythropoietin resistance index and the case for a new responsiveness measure. Hemodial Int 2016; 20:392-8. [PMID: 26843352 DOI: 10.1111/hdi.12407] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction The optimal use of erythropoiesis stimulating agents (ESAs) to treat anemia in end stage renal disease remains controversial due to reported associations with adverse events. In analyzing these associations, studies often utilize ESA resistance indices (ERIs), to characterize a patient's response to ESA. In this study, we examine whether ERI is an adequate measure of ESA resistance. Methods We used retrospective data from a nonconcurrent cohort study of incident hemodialysis patients in the United States (n = 9386). ERI is defined as average weekly erythropoietin (EPO) dose per kg body weight (wt) per average hemoglobin (Hgb), over a 3-month period (ERI = (EPO/wt)/Hgb). Linear regression was used to demonstrate the relationship between ERI and weight-adjusted EPO. The coefficient of variation was used to compare the variability of Hgb with that of weight-adjusted EPO to explain this relationship. This analysis was done for each quarter during the first year of dialysis. Findings ERI is strongly linearly related with weight-adjusted EPO dose in each of the four quarters by the equation ERI = 0.0899*(EPO/wt) (range of R(2) = 0.97-0.98) and weakly linearly related to 1/Hgb (range of R(2) = 0.06-0.16). These correlations hold independent of age, sex, hgb level, ERI level, and epo-naïve stratifications. Discussion ERI is strongly linearly related to weight-adjusted (and nonweight-adjusted) EPO dose by a "universal," not patient-specific formula, and thus is a surrogate of EPO dose. Therefore, associations between ERI and clinical outcomes are associations between a confounded EPO dose and those outcomes.
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Affiliation(s)
- Yossi Chait
- Department of Mechanical and Industrial Engineering, University of Massachusetts, Amherst, MA, USA
| | - Sahir Kalim
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Joseph Horowitz
- Department of Mathematics and Statistics, University of Massachusetts, Amherst, MA, USA
| | - Christopher V Hollot
- Department of Electrical and Computer Engineering, University of Massachusetts, Amherst, MA, USA
| | - Elizabeth D Ankers
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael J Germain
- Baystate Medical Center, Springfield, and Tufts University School of Medicine, MA, USA
| | - Ravi I Thadhani
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Eneanya ND, Goff SL, Martinez T, Gutierrez N, Klingensmith J, Griffith JL, Garvey C, Kitsen J, Germain MJ, Marr L, Berzoff J, Unruh M, Cohen LM. Shared decision-making in end-stage renal disease: a protocol for a multi-center study of a communication intervention to improve end-of-life care for dialysis patients. BMC Palliat Care 2015; 14:30. [PMID: 26066323 PMCID: PMC4464129 DOI: 10.1186/s12904-015-0027-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 05/29/2015] [Indexed: 11/25/2022] Open
Abstract
Background End-stage renal disease carries a prognosis similar to cancer yet only 20 % of end-stage renal disease patients are referred to hospice. Furthermore, conversations between dialysis team members and patients about end-of-life planning are uncommon. Lack of provider training about how to communicate prognostic data may contribute to the limited number of end-of-life care discussions that take place with this chronically ill population. In this study, we will test the Shared Decision-Making Renal Supportive Care communication intervention to systematically elicit patient and caretaker preferences for end-of-life care so that care concordant with patients’ goals can be provided. Methods/design This multi-center study will deploy an intervention to improve end-of-life communication for hemodialysis patients who are at high risk of death in the ensuing six months. The intervention will be carried out as a prospective cohort with a retrospective cohort serving as the comparison group. Patients will be recruited from 16 dialysis units associated with two large academic centers in Springfield, Massachusetts and Albuquerque, New Mexico. Critical input from patient advisory boards, a stakeholder panel, and initial qualitative analysis of patient and caretaker experiences with advance care planning have informed the communication intervention. Rigorous communication training for hemodialysis social workers and providers will ensure that standardized study procedures are performed at each dialysis unit. Nephrologists and social workers will communicate prognosis and provide advance care planning in face-to-face encounters with patients and families using a social work-centered algorithm. Study outcomes including frequency and timing of hospice referrals, patient and caretaker satisfaction, quality of end-of-life discussions, and quality of death will be assessed over an 18 month period. Discussion The Shared Decision-Making Renal Supportive Care Communication intervention intends to improve discussions about prognosis and end-of-life care with end-stage renal disease patients. We anticipate that the intervention will help guide hemodialysis staff and providers to effectively participate in advance care planning for patients and caretakers to establish preferences and goals at the end of life. Trial registration NCT02405312
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Affiliation(s)
- Nwamaka D Eneanya
- Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sarah L Goff
- Division of General Medicine, Department of Internal Medicine, Baystate Medical Center, Springfield, MA, USA. .,Center for Quality of Care Research, Baystate Medical Center, Springfield, MA, USA.
| | - Talaya Martinez
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA.
| | - Natalie Gutierrez
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA.
| | - Jamie Klingensmith
- Department of Psychiatry, Baystate Medical Center, Springfield, MA, USA.
| | - John L Griffith
- Bouve College of Health Sciences, Northeastern University, Boston, MA, USA.
| | - Casey Garvey
- School of Nursing, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA.
| | | | - Michael J Germain
- Division of Nephrology, Department of Internal Medicine, Baystate Medical Center, Springfield, MA, USA.
| | - Lisa Marr
- Division of Geriatrics and Palliative Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA.
| | - Joan Berzoff
- Smith College School for Social Work, Smith College, Northampton, MA, USA.
| | - Mark Unruh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA.
| | - Lewis M Cohen
- Department of Psychiatry, Baystate Medical Center, Springfield, MA, USA.
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Goff SL, Eneanya ND, Feinberg R, Germain MJ, Marr L, Berzoff J, Cohen LM, Unruh M. Advance care planning: a qualitative study of dialysis patients and families. Clin J Am Soc Nephrol 2015; 10:390-400. [PMID: 25680737 DOI: 10.2215/cjn.07490714] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES More than 90,000 patients with ESRD die annually in the United States, yet advance care planning (ACP) is underutilized. Understanding patients' and families' diverse needs can strengthen systematic efforts to improve ACP. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In-depth interviews were conducted with a purposive sample of patients and family/friends from dialysis units at two study sites. Applying grounded theory, interviews were audiotaped, professionally transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized into major themes and subthemes. RESULTS Thirteen patients and nine family/friends participated in interviews. The mean patient age was 63 years (SD 14) and five patients were women. Participants identified as black (n=1), Hispanic (n=4), Native American (n=4), Pacific Islander (n=1), white (n=11), and mixed (n=1). Three major themes with associated subthemes were identified. The first theme, "Prior experiences with ACP," revealed that these discussions rarely occur, yet most patients desire them. A potential role for the primary care physician was broached. The second theme, "Factors that may affect perspectives on ACP," included a desire for more of a connection with the nephrologist, positive and negative experiences with the dialysis team, disenfranchisement, life experiences, personality traits, patient-family/friend relationships, and power differentials. The third theme, "Recommendations for discussing ACP," included thoughts on who should lead discussions, where and when discussions should take place, what should be discussed and how. CONCLUSIONS Many participants desired better communication with their nephrologist and/or their dialysis team. A number expressed feelings of disenfranchisement that could negatively impact ACP discussions through diminished trust. Life experiences, personality traits, and relationships with family and friends may affect patient perspectives regarding ACP. This study's findings may inform clinical practice and will be useful in designing prospective intervention studies to improve patient and family experiences at the end of life.
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Affiliation(s)
- Sarah L Goff
- Divisions of General Medicine and Center for Quality of Care Research, and
| | - Nwamaka D Eneanya
- Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rebecca Feinberg
- Department of Psychiatry, Baystate Medical Center, Springfield, Massachusetts
| | | | - Lisa Marr
- Divisions of Geriatrics and Palliative Medicine and
| | - Joan Berzoff
- Smith College School for Social Work, Smith College, Northampton, Massachusetts
| | - Lewis M Cohen
- Department of Psychiatry, Baystate Medical Center, Springfield, Massachusetts
| | - Mark Unruh
- Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; and
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Abstract
Nephrologist are often faced with the question of the appropriate initiation and withdrawal from dialysis. Many clinicians feel that patient should be offered dialysis when they have ESRD regardless of the potential risks vs. benefits. My position in this debate is that nephrologists have the obligation to order treatments that are indicated and effective for their patients and will provide more benefit that harm. They should not order dialysis in patient that are not likely to benefit from the treatment. Patients have the right to refuse treatments but not the right to demand that a clinician order an ineffective treatment. Shared decision making is the key principle in deciding on the initiation and withdrawal from dialysis. The national guideline; Shared Decision Making: The Appropriate Initiation and Withdrawal from Dialysis supports this approach.
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Affiliation(s)
- Michael J Germain
- Baystate Medical Center and Tufts University, Springfield, Mass., USA
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36
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Abstract
BACKGROUND The CKD population is becoming increasingly elderly with multiple comorbidities. For this reason, accurate predictive information related to the progression into ESRD, mortality, and functional decline is critical to allow for optimal shared decision making (SDM). SUMMARY This review will assess the current literature on the methodologies for the estimation of prognosis and prognostic tools developed for CKD. A practical clinical approach is discussed that involves the estimation of prognosis and integration of prognosis into SDM. KEY MESSAGE There are validated, easy-to-use prognostic tools that help clinicians engage in effective shared decision making with their CKD patients and family.
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Affiliation(s)
- Michael J Germain
- Baystate Medical Center and Tufts University, Springfield, Mass., USA
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Grubbs V, Moss AH, Cohen LM, Fischer MJ, Germain MJ, Jassal SV, Perl J, Weiner DE, Mehrotra R. A palliative approach to dialysis care: a patient-centered transition to the end of life. Clin J Am Soc Nephrol 2014; 9:2203-9. [PMID: 25104274 DOI: 10.2215/cjn.00650114] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
As the importance of providing patient-centered palliative care for patients with advanced illnesses gains attention, standard dialysis delivery may be inconsistent with the goals of care for many patients with ESRD. Many dialysis patients with life expectancy of <1 year may desire a palliative approach to dialysis care, which focuses on aligning patient treatment with patients' informed preferences. This commentary elucidates what comprises a palliative approach to dialysis care and describes its potential and appropriate use. It also reviews the barriers to integrating such an approach into the current clinical paradigm of care and existing infrastructure and outlines system-level changes needed to accommodate such an approach.
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Affiliation(s)
- Vanessa Grubbs
- Division of Nephrology, University of California, San Francisco, San Francisco, California; Division of Nephrology, San Francisco General Hospital, San Francisco, California;
| | - Alvin H Moss
- Section of Nephrology, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Lewis M Cohen
- Department of Psychiatry, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts
| | - Michael J Fischer
- Division of Nephrology, Jesse Brown Veterans Affairs Medical Center, University of Illinois Hospital and Health Sciences Center, Chicago, Illinois
| | - Michael J Germain
- Division of Nephrology, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts
| | | | - Jeffrey Perl
- Division of Nephrology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts; and
| | - Rajnish Mehrotra
- Division of Nephrology, University of Washington, Seattle, Washington
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Gaweda AE, Ginzburg YZ, Chait Y, Germain MJ, Aronoff GR, Rachmilewitz E. Iron dosing in kidney disease: inconsistency of evidence and clinical practice. Nephrol Dial Transplant 2014; 30:187-96. [PMID: 24821751 DOI: 10.1093/ndt/gfu104] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The management of anemia in patients with chronic kidney disease (CKD) is difficult. The availability of erythropoiesis-stimulating agents (ESAs) has increased treatment options for previously transfusion-requiring patients, but the recent evidence of ESA side effects has prompted the search for complementary or alternative approaches. Next to ESA, parenteral iron supplementation is the second main form of anemia treatment. However, as of now, no systematic approach has been proposed to balance the concurrent administration of both agents according to individual patient's needs. Furthermore, the potential risks of excessive iron dosing remain a topic of controversy. How, when and whether to monitor CKD patients for potential iron overload remain to be elucidated. This review addresses the question of risk and benefit of iron administration in CKD, highlights the evidence supporting current practice, provides an overview of standard and potential new markers of iron status and outlines a new pharmacometric approach to physiologically compatible individualized dosing of ESA and iron in CKD patients.
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Affiliation(s)
| | | | - Yossi Chait
- University of Massachusetts, Amherst, MA, USA
| | - Michael J Germain
- Baystate Medical Center, Tufts University School of Medicine, Boston, MA, USA
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Affiliation(s)
- Lewis M Cohen
- Tufts University School of Medicine, Baystate Medical Center, Springfield, Massachusetts
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Murphy E, Germain MJ, Cairns H, Higginson IJ, Murtagh FEM. International variation in classification of dialysis withdrawal: a systematic review. Nephrol Dial Transplant 2013; 29:625-35. [PMID: 24293659 DOI: 10.1093/ndt/gft458] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In patients with end-stage renal disease (ESRD), the rate of deaths preceded by dialysis withdrawal is high. However, rates vary across studies and national renal registries. This study aimed to (i) determine how dialysis withdrawal mortality is defined in the literature and (ii) whether mortality rates preceded by dialysis withdrawal change over time. METHODS MEDLINE (1946 to March 2012) and EMBASE (1980 to March 2012) databases were searched. We included epidemiological studies that reported data permitting calculation of crude (unadjusted) mortality rates preceded by dialysis withdrawal. Definitions of dialysis withdrawal were also extracted. Crude mortality rates and 95% confidence intervals were calculated using OpenEpi software. Non-English language studies were excluded. RESULTS Twenty-three eligible studies were identified; these included 14 527 885 dialysis patients at risk from six countries. Crude mortality rates preceded by dialysis withdrawal ranged from 3 to 50.2 per 1000 person-years. Seven different definitions of dialysis withdrawal were identified, with no assessment of validity. Crude mortality rates preceded by withdrawal have increased over time across the study period 1966 (3 per 1000 person-years) to 2010 (48.6 per 1000 person-years), although these rates are difficult to interpret because of differences in classification. In the USA crude mortality rates preceded by dialysis withdrawal are higher in the older population and have increased over time in the age group 65+ years. In this age group, the crude mortality rate preceded by dialysis withdrawal was 89.4 per 1000 person-years (2008-10) compared with 26.1 per 1000 person-years in the age group 50-64 years (2008-10). CONCLUSION Mortality rates preceded by dialysis withdrawal over time should be interpreted with caution because of differences in classification. Types of dialysis withdrawal need more careful elucidation, and we propose a unified classification of dialysis withdrawal based on trajectories and causal criteria.
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Affiliation(s)
- Emma Murphy
- NIHR GSTFT/KCL Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Chait Y, Horowitz J, Nichols B, Shrestha RP, Hollot CV, Germain MJ. Control-relevant erythropoiesis modeling in end-stage renal disease. IEEE Trans Biomed Eng 2013; 61:658-64. [PMID: 24235247 DOI: 10.1109/tbme.2013.2286100] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Anemia is prevalent in end-stage renal disease (ESRD). The discovery of recombinant human erythropoietin (rHuEPO) over 30 years ago has shifted the treatment of anemia for patients on dialysis from blood transfusions to rHuEPO therapy. Many anemia management protocols (AMPs) used by clinicians comprise a set of experience-based rules for weekly-to-monthly titration of rHuEPO doses based on hemoglobin (Hb) measurements. In order to facilitate the design of an AMP using model-based feedback control theory, we present a physiologically relevant erythropoiesis model and demonstrate its applicability using clinical data.
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Abstract
The burgeoning population of older dialysis patients presents opportunities to provide personalized care. The older dialysis population has a high burden of chronic health conditions, decrements in quality of life and a high risk of death. In order to address these challenges, this review will recommend routinely establishing prognosis through the use of prediction instruments and communicating these findings to older patients. The challenges to prognosis in adults with end-stage renal disease (ESRD) include the subjective nature of clinical judgment, application of appropriate prognostic tools and communication of findings to patients and caregivers. There are three reasons why we believe these conversations occur infrequently with the dialysis population. First, there have previously been no clinically practical instruments to identify individuals undergoing maintenance hemodialysis (HD) who are at highest risk for death. Second, nephrologists have not been trained to have conversations about prognosis and end-of-life care. Third, other than hospitalizations and accrual of new diagnoses, there are no natural milestone guidelines in place for patients supported by dialysis. The prognosis can be used in shared decision-making to establish goals of care, limits on dialysis support or parameters for withdrawal from dialysis. As older adults with ESRD benefit from kidney transplantation, prognosis can also be used to determine who should be referred for evaluation by a kidney transplant team. The use of prognosis in older adults may determine approaches to optimize well-being and personalize care among older adults ranging from hospice to kidney transplantation.
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Affiliation(s)
- Pooja Singh
- Division of Nephrology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
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Nichols B, Shrestha RP, Horowitz J, Hollot CV, Germain MJ, Gaweda AE, Chait Y. Simplification of an erythropoiesis model for design of anemia management protocols in end stage renal disease. Annu Int Conf IEEE Eng Med Biol Soc 2012; 2011:83-6. [PMID: 22254256 DOI: 10.1109/iembs.2011.6089902] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Many end stage renal disease (ESRD) patients suffer from anemia due to insufficient endogenous production of erythropoietin (EPO). The discovery of recombinant human EPO (rHuEPO) over 30 years ago has shifted the treatment of anemia for patients on dialysis from blood transfusions to rHuEPO therapy. Many anemia management protocols (AMPs) used by clinicians comprise a set of experience-based rules for weekly-to-monthly titration of rHuEPO doses based on hemoglobin (Hgb) measurements. In order to facilitate the design of an AMP based on formal control design methods, we present a physiologically-relevant erythropoiesis model, and show that its nonlinear dynamics can be approximated using a static nonlinearity, a step that greatly simplifies AMP design. We demonstrate applicability of our results using clinical data.
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Affiliation(s)
- B Nichols
- Departments, UMass, Amherst, MA 01003, USA
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Murtagh FE, Cohen LM, Germain MJ. The "no dialysis" option. Adv Chronic Kidney Dis 2011; 18:443-9. [PMID: 22098664 DOI: 10.1053/j.ackd.2011.10.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 10/24/2011] [Accepted: 10/24/2011] [Indexed: 11/11/2022]
Abstract
Increasing numbers of patients are starting dialysis who have limited prognoses for 6-month survival. The presence of multiple comorbidities, aging, and frailty contributes to this phenomenon. The rate of dialysis withdrawal has been accelerating over the past decade, and this calls into question the condition of patients who are initiating dialysis. One option is to consider and discuss the "no dialysis" option with patients and family. Patients need to be identified who may benefit from this option, and their medical management needs to be reviewed.
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Germain MJ, Davison SN, Moss AH. When Enough Is Enough: The Nephrologist's Responsibility in Ordering Dialysis Treatments. Am J Kidney Dis 2011; 58:135-43. [DOI: 10.1053/j.ajkd.2011.03.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 03/18/2011] [Indexed: 11/11/2022]
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Germain MJ, Kurella Tamura M, Davison SN. Palliative care in CKD: the earlier the better. Am J Kidney Dis 2010; 57:378-80. [PMID: 21168946 DOI: 10.1053/j.ajkd.2010.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 12/02/2010] [Indexed: 12/25/2022]
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Abstract
Few dying patients undergoing dialysis receive hospice care. An intervention to facilitate hospice referral was evaluated in a longitudinal prospective cohort study. Five hemodialysis units in Massachusetts were divided into intervention sites (N = 3 clinics) and control sites (N = 2 clinics). Five hundred twelve patients were screened to identify those with indicators of poor prognoses; 133 met the eligibility criteria and consented to participate. Eighty-two intervention subjects and 51 control subjects were followed for a median of 17 months. During that time, 45 died and 16 received hospice services. Directors from the community hospices were approached by the researchers and agreed to provide an educational outreach to the intervention clinics. Renal supportive care teams (RSCTs) consisting mainly of volunteer health-care providers recruited from the dialysis clinics and local hospices were notified about the high-mortality patients. Staff met periodically to discuss their contacts with subjects and/or family members from the intervention clinics, The subjects were encouraged to participate in advance care planning, and they were provided information about hospice resources. The control clinics did not have RSCTs, and their subjects received standard treatment. At the conclusion of the study, hospice services had increased at the intervention sites (p = 0.09), and the subgroup of > or = 65-year-old subjects had undergone a significant increase (p = 0.05) in obtaining hospice care. Greater familiarity between hospice and dialysis staff along with outreach to patients with poor prognoses holds the promise of expanding hospice use--especially for the elderly.
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Affiliation(s)
- Lewis M Cohen
- Department of Psychiatry, Tufts University School of Medicine, Psychiatric Consult Service, Baystate Medical Center, Springfield, Massachusetts, USA
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Gaweda AE, Nathanson BH, Jacobs AA, Aronoff GR, Germain MJ, Brier ME. Determining optimum hemoglobin sampling for anemia management from every-treatment data. Clin J Am Soc Nephrol 2010; 5:1939-45. [PMID: 20671221 DOI: 10.2215/cjn.03540410] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Anemia management protocols in ESRD call for hemoglobin (Hb) monitoring every 2 to 4 weeks. Short-term Hb variability affects the reliability of Hb measurement and may lead to incorrect dosing of erythropoiesis stimulating agents. We prospectively analyzed short-term Hb variability and quantified the relationship between frequency of Hb monitoring and error in Hb estimation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using the Crit-Line III TQA device, we prospectively observed Hb during each dialysis treatment in 49 ESRD patients and quantified long- and short-term Hb variability. We estimated Hb from data sampled at regular intervals; 8×, 4×, 2×, or 1× per month to establish how well we account for short-term variability at different monitoring intervals. We calculated the Hb estimation error (Hb(err)) as a root mean-squared difference between the observed and estimated Hb and compared it with the measurement error. RESULTS The most accurate Hb estimation is achieved when monitoring 8× per month (Hb(err) = 0.23 ± 0.05 g/dl), but it exceeds the accuracy of the measurement device. The estimation error increases to 0.34 ± 0.07 g/dl when monitoring 4× per month, 0.39 ± 0.08 g/dl when monitoring 2× a month, and 0.45 ± 0.09 g/dl when monitoring 1× per month. Estimation error comparable to instrument error information is as follows: 8× per month, 15 patients; 4× per month, 22 patients; 2× per month, 6 patients; 1× per a month, 6 patients. CONCLUSIONS Four times a month is the clinically optimal Hb monitoring frequency for anemia management.
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Affiliation(s)
- Adam E Gaweda
- University of Louisville, Department of Medicine, Louisville, KY 40202, USA.
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Schell JO, Germain MJ, Finkelstein FO, Tulsky JA, Cohen LM. An integrative approach to advanced kidney disease in the elderly. Adv Chronic Kidney Dis 2010; 17:368-77. [PMID: 20610364 DOI: 10.1053/j.ackd.2010.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Revised: 02/03/2010] [Accepted: 03/09/2010] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease (CKD) has increasingly become a "geriatric" disease, with a dramatic rise in incidence in the aging population. Patients aged >75 years have become the fastest growing population initiating dialysis. These patients have increased comorbid diseases and functional limitations which affect mortality and quality of life. This review describes the challenges of dialysis initiation and considerations for management of the elderly subpopulation. There is a need for an integrative approach to care, which addresses management issues, health-related quality of life, and timely discussion of goals of care and end-of-life issues. This comprehensive approach to patient care involves the integration of nephrology, geriatric, and palliative medicine practices.
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