Background Information on an individual’s risk for death following dialysis therapy initiation may inform the decision to initiate maintenance dialysis for older adults. We derived and validated a ...clinical risk prediction tool for all-cause mortality among older adults during the first 6 months of maintenance dialysis treatment. Study Design Prediction model using retrospective administrative and clinical data. Setting & Participants We linked administrative and clinical data to define a cohort of 2,199 older adults (age ≥ 65 years) in Alberta, Canada, who initiated maintenance dialysis therapy (excluding acute kidney injury) in May 2003 to March 2012. Candidate Predictors Demographics, laboratory data, comorbid conditions, and measures of health system use. Outcomes All-cause mortality within 6 months of dialysis therapy initiation. Analytical Approach Predicted mortality by logistic regression with 10-fold cross-validation. Results 375 (17.1%) older adults died within 6 months. We developed a 19-point risk score for 6-month mortality that included age 80 years or older (2 points), glomerular filtration rate of 10 to 14.9 mL/min/1.73 m2 (1 point) or ≥15 mL/min/1.73 m2 (3 points), atrial fibrillation (2 points), lymphoma (5 points), congestive heart failure (2 points), hospitalization in the prior 6 months (2 points), and metastatic cancer (3 points). Model discrimination (C statistic = 0.72) and calibration (Hosmer-Lemeshow χ2 = 10.36; P = 0.2) were reasonable. As examples, a score < 5 equated to <25% of individuals dying in 6 months, whereas a score > 12 predicted that more than half the individuals would die in the first 6 months. Limitations The tool has not been externally validated; thus, generalizability cannot be assessed. Conclusions We used readily available clinical information to derive and internally validate a 7-variable tool to predict early mortality among older adults after dialysis therapy initiation. Following successful external validation, the tool may be useful as a clinical decision tool to aid decision making for older adults with kidney failure.
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.
We congratulate the KDIGO (Kidney Disease: Improving Global Outcomes) work group on their comprehensive work in a broad subject area and agreed with many of the recommendations in their clinical ...practice guideline on the evaluation and management of chronic kidney disease. We concur with the KDIGO definitions and classification of kidney disease and welcome the addition of albuminuria categories at all levels of glomerular filtration rate (GFR), the terminology of G categories rather than stages to describe level of GFR, the division of former stage 3 into new G categories 3a and 3b, and the addition of the underlying diagnosis. We agree with the use of the heat map to illustrate the relative contributions of low GFR and albuminuria to cardiovascular and renal risk, though we thought that the highest risk category was too broad, including as it does people at disparate levels of risk. We add an albuminuria category A4 for nephrotic-range proteinuria and D and T categories for patients on dialysis or with a functioning renal transplant. We recommend target blood pressure of 140/90 mm Hg regardless of diabetes or proteinuria, and against the combination of angiotensin receptor blockers with angiotensin-converting enzyme inhibitors. We recommend against routine protein restriction. We concur on individualization of hemoglobin A1c targets. We do not agree with routine restriction of sodium intake to <2 g/d, instead suggesting reduction of sodium intake in those with high intake (>3.3 g/d). We suggest screening for anemia only when GFR is <30 mL/min/1.73 m2 . We recognize the absence of evidence on appropriate phosphate targets and methods of achieving them and do not agree with suggestions in this area. In drug dosing, we agree with the recommendation of using absolute clearance (ie, milliliters per minute), calculated from the patient’s estimated GFR (which is normalized to 1.73 m2 ) and the patient’s actual anthropomorphic body surface area. We agree with referral to a nephrologist when GFR is <30 mL/min/1.73 m2 (and for many other scenarios), but suggest urine albumin-creatinine ratio > 60 mg/mmol or proteinuria with protein excretion > 1 g/d as the referral threshold for proteinuria.
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.
NSAID Use and Progression of Chronic Kidney Disease Gooch, Katherine, MSc; Culleton, Bruce F., MD, MSc; Manns, Braden J., MD, MSc ...
The American journal of medicine,
03/2007, Letnik:
120, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Abstract Purpose The effects of nonselective and selective cyclooxygenase-2 specific (COX-2) nonsteroidal anti-inflammatory drug (NSAID) use on the progression of chronic kidney disease (CKD) is ...uncertain. Due to the high prevalence of both CKD and NSAID use in older adults, we sought to determine the association between NSAID use and the progression of CKD in an elderly community-based cohort. Methods All subjects ≥66 years of age who had at least one serum creatinine measurement in 2 time periods (July-December, 2001 and July-December, 2003) were included. Multiple logistic regression analyses, including covariates for age, sex, baseline estimated glomerular filtration rate (eGFR), diabetes, and comorbidity were used to explore the associations of NSAID use on the primary (decrease in eGFR of ≥15 mL/min/1.732 ) and secondary (mean change in eGFR) outcomes. Results A total of 10,184 subjects (mean age 76 years; 57% female) were followed for a median of 2.75 years. High-dose NSAID users (upper decile of cumulative NSAID exposure) experienced a 26% increased risk for the primary outcome (odds ratio OR 1.26, 95% confidence interval CI, 1.04-1.53). A linear association between cumulative NSAID dose and change in mean GFR also was seen. No risk differential was identified between selective and nonselective NSAID users. Conclusions High cumulative NSAID exposure is associated with an increased risk for rapid CKD progression in the setting of a community-based elderly population. For older adult patients with CKD, these results suggest that nonselective NSAIDs and selective COX-2 inhibitors should be used cautiously and chronic exposure to any NSAID should be avoided.
Background We investigated the association between proteinuria, estimated glomerular filtration rate (eGFR), and risk of mortality and kidney failure in white, Chinese, and South Asian populations. ...Study Design Population-based cohort study. Setting & Participants Participants from Alberta, Canada, with a serum creatinine and urine protein dipstick measurement from January 1, 2005, to December 31, 2005. Predictor White, Chinese, or South Asian ethnicity. Outcomes Prevalence of proteinuria by level of eGFR (estimated using the MDRD Modification of Diet in Renal Disease Study equation) and the association between eGFR, proteinuria, and all-cause mortality and kidney failure. Measurements Rates of all-cause mortality and kidney failure per 1,000 person-years were calculated using Poisson regression by ethnicity, eGFR level, and proteinuria level while adjusting for sociodemographic variables and comorbid conditions. Results Of 491,729 participants, 5.3% were Chinese and 4.7% were South Asian. For participants with eGFR <60 mL/min/1.73 m2 , the prevalence of heavy proteinuria was higher in Chinese and South Asians compared with whites. Compared with whites, adjusted rates of death were significantly lower for Chinese and South Asian populations (rate ratios, 0.67 95% CI, 0.56-0.80 and 0.73 95% CI, 0.59-0.88, respectively); these rate ratios did not vary by eGFR and proteinuria levels. Limitations Using surname to identify ethnicity has the potential for misclassification due to name changes and identical last names from different ethnic groups. Also, to be eligible for inclusion, participants had to have a measurement of serum creatinine and urine dipstick proteinuria. Conclusions Although increasing proteinuria and lower eGFR predicted mortality and progression to kidney failure in all 3 ethnic groups, both Chinese and South Asian populations experienced a lower risk of death and similar risk of kidney failure compared with whites at all eGFR and proteinuria levels. Studies exploring this association further are required.
Chronic kidney disease (CKD) is an important global public health problem that is associated with adverse health outcomes and high health care costs. Effective and cost-effective treatments are ...available for slowing the progression of CKD and preventing its complications, including cardiovascular disease. Although wealthy nations have highly structured schemes in place to support the care of people with kidney failure, less consideration has been given to health systems and policy for the much larger population of people with non–dialysis-dependent CKD. Further, how to integrate such strategies with national and international initiatives for control of other chronic noncommunicable diseases (NCDs) merits attention. We synthesized the various approaches to CKD control across 17 European countries and present our findings according to the key domains suggested by the World Health Organization framework for NCD control. This report identifies opportunities to strengthen CKD-relevant health systems and explores potential mechanisms to capitalize on these opportunities. Across the 17 countries studied, we found a number of common barriers to the care of people with non–dialysis-dependent CKD: limited work force capacity, the nearly complete absence of mechanisms for disease surveillance, lack of a coordinated CKD care strategy, poor integration of CKD care with other NCD control initiatives, and low awareness of the significance of CKD. These common challenges faced by diverse health systems reflect the need for international cooperation to strengthen health systems and policies for CKD care.
Many Canadian patients who receive hemodialysis live far from their attending nephrologist, which may affect clinical outcomes. We investigated whether patients receiving hemodialysis who live ...farther from their attending nephrologist are more likely to die than those who live closer.
We studied a random sample of 18,722 patients who began hemodialysis between 1990 and 2000 in Canada. We calculated the distance between each patient's residence location at the start of dialysis and the practice location of their attending nephrologist. We used Cox proportional hazards models to examine the adjusted relation between distance and clinical outcomes (death from all causes, infectious causes and cardiovascular causes) over a follow-up period of up to 14 years.
During the follow-up period (median 2.5 yr, interquartile range 1.0-4.7 yr), 11,582 (62%) patients died. Compared with patients who lived within 50 km of their nephrologist, the adjusted hazard ratio of death among those who lived 50.1-150 km away was 1.06 (95% confidence interval CI 1.01-1.12), 1.13 (95% CI 1.04-1.22) for those who lived 150.1-300 km away and 1.13 (95% CI 1.03-1.24) for those who lived more than 300 km from their nephrologist (p for trend < 0.001). The risk of death from infectious causes increased with greater distance from the attending nephrologist (p for trend < 0.001). The risk of death from cardiovascular causes did not increase with distance from the attending nephrologist (p for trend = 0.21). Compared with patients who lived within 50 km of their nephrologist, the adjusted hazard ratio of death among those who lived more than 300 km away was 1.75 (95% CI 1.32-2.32) for infectious causes and 0.93 (95% CI 0.79-1.09) for cardiovascular causes.
Mortality associated with hemodialysis was greater among patients who lived farther from their attending nephrologist, as compared with those who lived closer. This was especially evident for death from infectious causes.
More frequent dialysis may improve nutrition and remove dietary restrictions in hemodialysis (HD) patients. We present results from a trial comparing nutritional parameters between nocturnal ...hemodialysis (NHD) and conventional HD patients.
Patients were randomized to conventional thrice weekly HD or NHD for a 6-month study period. Dietary intake was recorded by patients using a 3-day food record at baseline and study exit.
Of 51 patients, 23 completed baseline and exit food records and were included in the analysis. Although dietary intake of calcium, potassium, and lipids increased in the NHD group, serum levels of calcium and potassium remained within target limits. The majority of NHD subjects were able to reduce or discontinue their phosphate binders and maintain serum phosphate levels within target limits. Serum albumin improved among the NHD group (0.7 g/L) and declined for the conventional group (-1.6 g/L). None of the between group differences achieved statistical significance.
As compared with conventional dialysis, NHD was associated with a nonstatistically significant increase in dietary intake for some nutrients, with maintenance of serum levels for potassium, calcium, and phosphorus. Whether increased dietary intake translates into improvement in morbidity and mortality remains to be determined.
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