Background Educational interventions are increasingly used to promote peritoneal dialysis (PD), the most common form of home therapy for end-stage renal disease. A systematic review of the evidence ...in support of dialysis modality education is needed to inform the design of patient-targeted interventions to increase selection of PD. We performed a systematic review and meta-analysis to characterize the relationship between patient-targeted educational interventions and choosing and receiving PD. Study Design Systematic review and meta-analysis. Setting & Population Published original studies and abstracts. Selection Criteria for Studies We searched MEDLINE, EMBASE, CINAHL and EBMR. We included controlled observational studies and randomized trials of educational interventions designed to increase PD selection. Intervention Predialysis educational interventions. Outcomes The primary outcome was choosing PD, defined as intention to use PD regardless of whether PD was ever used. The secondary outcome, receiving PD, was defined as an individual receiving PD as his or her treatment. Results Of 3,540 citations, 15 studies met our inclusion criteria, including 1 randomized trial. In the single randomized trial (N = 70), receipt of an educational intervention was associated with a more than 4-fold increase in the odds of choosing PD (OR, 4.60; 95% CI, 1.19-17.74). Based on results from 4 observational studies (N = 7,653), patient-targeted educational interventions were associated with a 2-fold increase in the odds of choosing PD (pooled OR, 2.15; 95% CI, 1.07-4.32; I2 = 76.7%). Based on results from 9 observational studies (N = 8,229), patient-targeted educational intervention was associated with a 3-fold increase in the odds of receiving PD as the initial treatment modality (OR, 3.50; 95% CI, 2.82-4.35; I2 = 24.9%). Limitations Most studies were observational studies, which can establish an association between education and choosing PD or receiving PD, but does not establish causality. Conclusions This systematic review demonstrates a strong association between patient-targeted education interventions and the subsequent choice and receipt of PD.
Summary Atheroembolic renal disease develops when atheromatous aortic plaques rupture, releasing cholesterol crystals into the small renal arteries. Embolisation often affects other organs, such as ...the skin, gastrointestinal system, and brain. Although the disease can develop spontaneously, it usually develops after vascular surgery, catheterisation, or anticoagulation. The systemic nature of atheroembolism makes diagnosis difficult. The classic triad of a precipitating event, acute or subacute renal failure, and skin lesions, are strongly suggestive of the disorder. Eosinophilia further supports the diagnosis, usually confirmed by biopsy of an affected organ or by the fundoscopic finding of cholesterol crystals in the retinal circulation. Renal and patient prognosis are poor. Treatment is mostly preventive, based on avoidance of further precipitating factors, and symptomatic, aimed to the optimum treatment of hypertension and cardiac and renal failure. Statins, which stabilise atherosclerotic plaques, should be offered to all patients. Steroids might have a role in acute or subacute progressive forms with systemic inflammation.
Background Preemptive correction of a stenosis in an arteriovenous (AV) access (fistula or graft) that is adequately providing hemodialysis (functional AV access) may prolong access survival as ...compared to waiting for signs of access dysfunction to intervene (deferred salvage). However, the evidence in support of preemptive intervention is controversial. We evaluated benefits and harms of preemptive versus deferred correction of AV access stenosis. Study Design Systematic review and meta-analysis of randomized controlled trials. Setting & Population Adults receiving hemodialysis by a functional AV access. Selection Criteria for Studies We searched the Cochrane Kidney and Transplant Specialised Register and EMBASE to October 15, 2015. Intervention Active access surveillance (flow measurement and Doppler or venous pressure) and preemptive correction of a newly identified stenosis versus routine clinical monitoring and deferred salvage, or preemptive correction of a known stenosis versus deferred salvage. Outcomes Access loss (primary outcome) and thrombosis (overall and by access type), infection, mortality, hospitalization, and access-related procedures. Results We included 14 trials (1,390 participants; follow-up, 6-38 months). Relative to deferred salvage, preemptive correction of AV access stenosis had a nonsignificant effect on risk for access loss (risk ratio RR, 0.81; 95% CI, 0.65-1.02; I2 = 0%) and a significant effect on risk for thrombosis (RR, 0.79; 95% CI, 0.65-0.97; I2 = 30%). Treatment effects were larger in fistulas than in grafts for both risk for access loss (subgroup difference, P = 0.05) and risk for thrombosis (subgroup difference, P = 0.002). Results were heterogeneous or imprecise for mortality, rates of access-related infections or procedures, and hospitalization. Limitations Small number and size of primary studies limited analysis power. Conclusions Preemptive stenosis correction in a functional AV access does not improve access longevity. Although preemptive stenosis correction may be promising in fistulas, existing evidence is insufficient to guide clinical practice and health policy.
Background The effectiveness and safety of warfarin use among patients with atrial fibrillation (AF) and reduced kidney function are uncertain. Study Design Community-based retrospective cohort study ...(May 1, 2003, to March 31, 2012) using province-wide laboratory and administrative data in Alberta, Canada. Setting & Participants 14,892 adults 66 years or older with new AF and a measurement of kidney function. Long-term dialysis patients or kidney transplant recipients were excluded. Predictor Propensity scores were used to construct a matched-pairs cohort of patients with AF who did and did not have a warfarin prescription within a 60-day period surrounding their AF diagnosis. Outcomes Within 1 year of initiating warfarin therapy (or the matched date for nonusers): (1) the composite of all-cause death, ischemic stroke, or transient ischemic attack (also assessed as separate end points) and (2) first hospitalization or emergency department visit for a major bleeding episode defined as an intracranial, upper or lower gastrointestinal, or other bleeding. Measurements Baseline glomerular filtration rate (GFR) was estimated using the CKD-EPI creatinine equation. Patients were matched within estimated GFR (eGFR) categories: ≥90, 60 to 89, 45 to 59, 30 to 44, and <30 mL/min/1.73 m2 . Information for baseline characteristics (sociodemographics, comorbid conditions, and prescription drug use) was obtained. Results Across eGFR categories, warfarin therapy initiation was associated with lower risk for the composite outcome compared to nonuse (adjusted HRs 95% CI for eGFR categories ≥ 90, 60-89, 45-59, 30-44, and <30 mL/min/1.73 m2 : 0.59 0.35-1.01, 0.61 0.54-0.70, 0.55 0.47-0.65, 0.54 0.44-0.67, and 0.64 0.47-0.87 mL/min/1.73 m2 , respectively). Compared to nonuse, warfarin therapy was not associated with higher risk for major bleeding except for those with eGFRs of 60 to 89 mL/min/1.73 m2 (HR, 1.36; 95% CI, 1.13-1.64). Limitations Selection bias. Conclusions Among older adults with AF, warfarin therapy initiation was associated with a significantly lower 1-year risk for the composite outcome across all strata of kidney function. The risk for major bleeding associated with warfarin use was increased only among those with eGFRs of 60 to 89 mL/min/1.73 m2.
Background Prognostic criteria to inform women with moderate to severe renal insufficiency who wish to bear children are not well established. Study Design Longitudinal multicenter cohort study. ...Settings & Participants Nondiabetic white women with pregnancies proceeded beyond the 20th week and estimated glomerular filtration rate (GFR) less than 60 mL/min/1.73 m2 (<1 mL/s/1.73 m2 ) before conception. Predictors Baseline GFR and proteinuria (exposure); other clinical characteristics at conception (covariates). Outcomes & Measurements Difference in GFR decreases before conception versus after delivery (mixed linear models); low birth weight (<2,500 g), and maternal renal survival (logistic and Cox regressions). Results 49 women were studied. Mean serum creatinine and GFR at conception were 2.1 ± 1 (SD) mg/dL (186 ± 88 μmol/L) and 35 ± 12 mL/min/1.73 m2 (0.58 ± 0.2 mL/s/1.73 m2 ), respectively. Overall mean GFR after delivery was less than before conception (30 ± 13.8 versus 35 ± 12.2 mL/min/1.73 m2 0.50 ± 0.23 versus 0.58 ± 0.20 mL/s/1.73 m2 ; P < 0.001), but the rate of GFR decrease did not change (0.55 ± 0.8 versus 0.50 ± 0.3 mL/min/mo 0.0092 ± 0.013 versus 0.0083 ± 0.005 mL/s/mo; P = 0.661). Independent of potential confounders, the combined presence of baseline GFR less than 40 mL/min/m2 (<0.67 mL/s/m2 ) and proteinuria with protein greater than 1 g/d, but not either factor alone, predicted faster GFR loss after delivery compared with before conception (1.17 ± 1.23 versus 0.55 ± 0.39 mL/min/mo; difference, 0.62 mL/min/mo; 95% confidence interval CI, 0.27 to 0.96 mL/min/mo 0.020 ± 0.021 versus 0.0092 ± 0.007 mL/s/mo; difference, 0.10 mL/s/mo; 95% CI, 0.005 to 0.016 mL/s/mo). The presence of both risk factors, but not either alone, also predicted shorter time to dialysis therapy or GFR halving (N = 20; hazard ratio, 5.2; 95% CI, 1.7 to 15.9) and low birth weight (N = 29; odds ratio, 5.1; 95% CI, 1.03 to 25.6). Limitations Generalizability to other settings; study power. Conclusion In women with renal insufficiency, the presence of both GFR less than 40 mL/min/1.73 m2 (<0.67 mL/s/m2 ) and proteinuria with protein greater than 1 g/d before conception predicts poor maternal and fetal outcomes.
Background Hemodialysis vascular access failure occurs often and increases morbidity for people on hemodialysis therapy. Antiplatelet agents may prevent hemodialysis vascular access failure, but ...potentially may be hazardous in people with end-stage kidney disease who have impaired hemostasis. Study Design Systematic review and meta-analysis of randomized controlled trials. Setting & Population Adults on long-term hemodialysis therapy. Selection Criteria Trials evaluating hemodialysis vascular access outcomes identified by searches in Cochrane CENTRAL and Renal Group Trial Registers and Embase, without language restriction. Intervention Antiplatelet therapy. Outcomes Hemodialysis vascular access failure (thrombosis or loss of patency), failure to attain vascular access suitable for dialysis, need for intervention to attain patency or assist maturation, major bleeding, minor bleeding, and antiplatelet treatment withdrawal. Treatment effects were summarized as RRs with 95% CIs using random-effects meta-analysis. Results 21 eligible trials (4,826 participants) comparing antiplatelet treatment with placebo or no treatment were included. 12 trials (3,118 participants) started antiplatelet therapy around the time of dialysis vascular access surgery and continued treatment for approximately 6 months. Antiplatelet treatment reduced fistula failure (thrombosis or loss of patency) by one-half (6 trials, 1,222 participants; RR, 0.49; 95% CI, 0.30-0.81) but had uncertain effects on graft patency and attaining fistula or graft function suitable for dialysis. Overall, antiplatelet treatment had uncertain effects on major bleeding. Limitations Unclear or high risk of bias in most trials and few trial data, particularly for antiplatelet effects on graft function and vascular access suitability for dialysis. Conclusions Antiplatelet treatment protects fistula from thrombosis or loss of patency, but has little or no effect on graft patency and uncertain effects on vascular access maturation for dialysis and major bleeding. Interventions that demonstrably improve vascular access suitability for dialysis are needed.
ABSTRACT BACKGROUND Guidelines recommend nephrology referral for people with advanced non–dialysis-dependent chronic kidney disease, based mostly on survival benefits seen in retrospective studies of ...dialysis patients, which may not be generalizable to the broader population with chronic kidney disease. We aimed to examine the association between outpatient nephrology consultation and survival in adults with stage 4 chronic kidney disease. METHODS We linked population-based laboratory and administrative data from 2002 to 2014 in Alberta, Canada, on adults with stage 4 chronic kidney disease (sustained estimated glomerular filtration rate ≥ 15 to < 30 mL/min/1.73 m2 for > 90 d), who had never had kidney failure and had had no outpatient nephrology encounter in the 2 years preceding study entry. Participants who had never had an outpatient nephrology visit before renal replacement treatment were considered “unexposed.” Participants who saw a nephrologist during follow-up were considered “unexposed” before the first outpatient nephrology visit and “exposed” thereafter. The primary outcome was all-cause mortality. RESULTS Of the 14 382 study participants (median follow-up 2.7 yr), 64% were aged ≥ 80 years, 35% saw a nephrologist and 66% died during follow-up. Nephrology consultation was associated with lower mortality (hazard ratio HR 0.88, 95% confidence interval CI 0.82–0.93). The association was strongest in people < 70 years (HR 0.78, 95% CI, 0.65–0.92), progressively weaker with increasing age, and absent in people ≥ 90 years (HR 1.05, 95% CI 0.88–1.25). INTERPRETATION The survival benefit of nephrology consultation in adults with stage 4 chronic kidney disease may be smaller than expected and appears to attenuate with increasing age. These findings should inform recommendations for nephrology referral considering the advanced age of the patient population meeting current referral criteria.
Background Whether low-protein-diet (LPD) as opposed to moderate-protein-diet (MPD) regimens improve the long-term survival of patients with chronic kidney disease (CKD) or induce protein-caloric ...malnutrition is unknown. Study Design Intention-to-treat analysis of follow-up data from a randomized controlled trial. Setting & Participants 423 patients with CKD (stages 4-5) were randomly assigned between January 1999 and January 2003 and followed up until December 2006 or death. The first phase of follow up was from January 1999 to June 2004; additional follow-up was from July 2004 to December 2006. Intervention LPD versus MPD (protein intake, 0.55 vs 0.80 g/kg/d). Outcomes Protein-caloric malnutrition (defined as the occurrence of 1 of the following: loss of body weight > 5% in 1 month or 7.5% in 3 months or body mass index < 20 kg/m2 with serum albumin level < 3.2 g/dL and normal C-reactive protein level <0.5 mg/dL), dialysis, death, or the composite outcome of dialysis and death. Results Baseline mean age was 61 years, estimated glomerular filtration rate was 16 mL/min/1.73 m2 , proteinuria had protein excretion of 1.67 g/d, body mass index was 27.1 kg/m2 , protein intake was 0.95 g/kg/d, and there were 57% men. Duration of follow-up was 32 months (median, 30 months; 25th-75th percentiles, 21-39). Average protein intakes were 0.73 ± 0.04 g/kg/d for the LPD and 0.9 ± 0.06 g/kg/d for the MPD. 3 patients (0.7%) met criteria for protein-caloric malnutrition. 48 patients died (11%), 83 initiated dialysis therapy (20%), and 113 (27%) reached the composite outcome. In unadjusted Cox survival analyses, effects of the LPD on these outcomes were 1.01 (95% CI, 0.57-1.79), 0.96 (95% CI, 0.62-1.48), and 0.98 (95% CI, 0.68-1.42), respectively. Limitations Low event rates for dialysis therapy initiation and death. Conclusions Most patients, who were regularly followed up in CKD clinics, were acceptably adherent to the prescribed dietary protein intake restrictions; the LPD and MPD did not lead to protein wasting; and the LPD did not decrease the risk of death or dialysis therapy initiation compared with the MPD.
Background Bacterial biofilm formation on hemodialysis tunneled cuffed catheters is under-recognized. We studied biofilm characteristics in patients with and without catheter-related bloodstream ...infection, accounting for catheter locking solution (citrate 4% or heparin 1:1,000). Study Design Prospective observational study. Setting & Participants 30 HD patients for whom the tunneled cuffed catheter was removed for either noninfectious reasons (n = 19) or bacteremia (n = 11). Predictors Bacteremia and catheter locking solution. Outcomes & Measurements Bacteria density in the biofilm, catheter luminal surface covered by biofilm, biofilm thickness, and exopolysaccharide content. Results Biofilm was present in all catheters. Overall, bacteria density, catheter surface coverage, biofilm thickness, and exopolysaccharide content were significantly higher in catheters from patients with bacteremia (5.3 95% CI, 3.4-7.2 colony-forming unit CFU/mL; 47% 95% CI, 34%-60%; 41 95% CI, 26-55 μm; and 29.4% 95% CI, 20.1%-38.6%, respectively) than from patients without bacteremia (3.7 95% CI, 3.6-3.8 CFU/mL; 17% 95% CI, 16%-19%; 8.6 95% CI, 7.3-9.8 μm; and 5.3% 95% CI, 3.7%-6.8%, respectively). However, all biofilm parameters were lower in catheters from patients with bacteremia when citrate was used as locking agent. Furthermore, bacteria density (0.08 95% CI, 0.02-0.13 CFU/mL/3 cm), biofilm thickness (1.4 95% CI, 0.8-2.1 μm/3 cm), and surface coverage (2.2% 95% CI, 1.8%-2.7%/3 cm) decreased across the length of the catheter from tip to hub. Limitations Observational study design, small numbers of patients, use of prevalent catheters. Conclusion Biofilms are present in all tunneled cuffed catheters. However, the extent of the biofilm varied by the presence of bacteremia and type of locking solution. This method could be used to explore preventative measures.
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