Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely ...used in some European countries for many years, it remains unavailable or poorly utilised in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries.
Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow, and their top 3 priorities.
Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD with all respondents mentioning need for nephrology team education and/or patient education and involvement in dialysis modality decision making.
Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and for all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policy makers and healthcare providers to develop and support assistance for PD.
Urinary Soluble CD163 in Active Renal Vasculitis O'Reilly, Vincent P; Wong, Limy; Kennedy, Claire ...
Journal of the American Society of Nephrology,
09/2016, Letnik:
27, Številka:
9
Journal Article
Recenzirano
Odprti dostop
A specific biomarker that can separate active renal vasculitis from other causes of renal dysfunction is lacking, with a kidney biopsy often being required. Soluble CD163 (sCD163), shed by monocytes ...and macrophages, has been reported as a potential biomarker in diseases associated with excessive macrophage activation. Thus, we hypothesized that urinary sCD163 shed by crescent macrophages correlates with active glomerular inflammation. We detected sCD163 in rat urine early in the disease course of experimental vasculitis. Moreover, microdissected glomeruli from patients with small vessel vasculitis (SVV) had markedly higher levels of CD163 mRNA than did those from patients with lupus nephritis, diabetic nephropathy, or nephrotic syndrome. Both glomeruli and interstitium of patients with SVV strongly expressed CD163 protein. In 479 individuals, including patients with SVV, disease controls, and healthy controls, serum levels of sCD163 did not differ between the groups. However, in an inception cohort, including 177 patients with SVV, patients with active renal vasculitis had markedly higher urinary sCD163 levels than did patients in remission, disease controls, or healthy controls. Analyses in both internal and external validation cohorts confirmed these results. Setting a derived optimum cutoff for urinary sCD163 of 0.3 ng/mmol creatinine for detection of active renal vasculitis resulted in a sensitivity of 83%, specificity of 96%, and a positive likelihood ratio of 20.8. These data indicate that urinary sCD163 level associates very tightly with active renal vasculitis, and assessing this level may be a noninvasive method for diagnosing renal flare in the setting of a known diagnosis of SVV.
Background
Peritoneal dialysis provides several benefits for patients and should be offered as first line kidney replacement therapy, particularly for fragile patients. Limitation to self-care drove ...assisted peritoneal dialysis to evolve from family-based care to institutional programs, with specialized care givers. Some European countries have mastered this, while others are still bound by the availability of a volunteer to become responsible for treatment.
Methods
A group of leading nephrologists from 13 European countries integrated real-life application of such therapy, highlighting barriers, lessons learned and practical solutions. The objective of this work is to share and summarize several different approaches, with their intrinsic difficulties and solutions, which might helpperitoneal dialysis units to develop and offer assisted peritoneal dialysis.
Results
Assisted peritoneal dialysis does not mean 4 continuous ambulatory peritoneal dialysis exchanges, 7 days/week, nor does it exclude cycler. Many different prescriptions might work for our patients. Tailoring PD prescription to residual kidney function, thereby maintaining small solute clearance, reduces dialysis burden and is associated with higher technique survival. Assisted peritoneal dialysis does not mean assistance will be needed permanently, it can be a transitional stage towards individual or caregiver autonomy. Private care agencies can be used to provide assistance; other options may involve implementing PD training programs for the staff of nursing homes or convalescence units. Social partners may be interested in participating in smaller initiatives or for limited time periods.
Conclusion
Assisted peritoneal dialysis is a valid technique, which should be expanded. In countries without structural models of assisted peritoneal dialysis, active involvement by the nephrologist is needed in order for it to become a reality.
Graphical abstract
Peritoneal dialysis (PD) is the preferred available option of renal replacement therapy for a significant number of end-stage kidney disease patients. A major limiting factor to the successful ...continuation of PD is the long-term viability of the PD catheter (PDC). Bedside percutaneous placement of the PDC is not commonly practiced despite published data encouraging use of this technique. Its advantages include faster recovery and avoidance of general anesthesia.
We carried out a retrospective analysis of the outcomes of 313 PDC insertions at our center, comparing all percutaneous PDC insertions between July 1998 and April 2010 (group P, n = 151) with all surgical PDC insertions between January 2003 and April 2010 (group S, n = 162).
Compared with group P patients, significantly more group S patients had undergone previous abdominal surgery or PDC insertion (41.8% vs 9.3% and 33.3% vs 3.3% respectively, p = 0.00). More exit-site leaks occurred in group P than in group S (20.5% vs 6.8%, p = 0.002). The overall incidence of peritonitis was higher in group S than in group P (1 episode in 19 catheter-months vs 1 episode in 26 catheter-months, p = 0.017), but the groups showed no significant difference in the peritonitis rate within 1 month of catheter insertion (5% in group P vs 7.4% in group S, p = 0.4) or in poor initial drainage or secondary drainage failure (9.9% vs 11.7%, p = 0.1, and 7.9% vs 12.3%, p = 0.38, for groups P and S respectively).Technical survival at 3 months was significantly better for group P than for group S (86.6% vs 77%, p = 0.037); at 12 months, it was 77.7% and 68.7% respectively (p = 0.126). No life-threatening complications attributable to the insertion of the PDC occurred in either group.
Our analysis demonstrates further encouraging outcomes of percutaneous PDC placement compared with open surgical placement. However, the members of the percutaneous insertion group were primarily a selected subset of patients without prior abdominal surgery or PDC insertion, therefore limiting the comparability of the groups. Studies addressing such confounding factors are required. Local expertise in catheter placement techniques may affect the generalizability of results.
Highlights • There is a lack of trial evidence directly comparing 2% chlorhexidine gluconate (CHG) in alcohol with other CHG solutions for the prevention of central venous catheter–related infections ...in hemodialysis patients. • Although not statistically significant, there is a possible benefit from 2% chlorhexidine gluconate (CHG) in alcohol compared with routinely used CHG solutions. • Findings add to the evidence base and can be used in future meta-analyses of similar studies.
The standard low-phosphorus diet restricts pulses, nuts, and whole grains and other high phosphorus foods to control hyperphosphatemia. We conducted a randomized controlled trial to evaluate the ...effectiveness, safety, and tolerability of the modified diet, which introduced some pulses and nuts, increased the use of whole grains, increased focus on the avoidance of phosphate additives, and introduced the prescription of low-biological-value protein such as bread.
We conducted a multicenter, pragmatic, parallel-arm, open-label, randomized controlled trial of modified versus standard diet in 74 adults on hemodialysis with hyperphosphatemia over 1 month. Biochemistry was assessed using monthly laboratory tests. Dietary intake was assessed using a 2-day record of weighed intake of food, and tolerability was assessed using a patient questionnaire.
There was no significant difference in the change in serum phosphate between the standard and modified diets. Although total dietary phosphorus intake was similar, phytate-bound phosphorus, found in pulses, nuts, and whole grains, was significantly higher in the modified diet (P < 0.001). Dietary fiber intake was also significantly higher (P < 0.003), as was the percentage of patients reporting an increase in bowel movements while following the modified diet (P = 0.008). There was no significant difference in the change in serum potassium or in reported protein intake between the 2 diets. Both diets were similarly well tolerated.
The modified low phosphorus diet was well tolerated and was associated with similar phosphate and potassium control but with a wider food choice and greater fiber intake than the standard diet.
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Both physiological- and laboratory-derived variables, alone or in combination, have been used to predict mortality among acute medical admissions. Using the Modification of Diet in Renal Disease ...(MDRD) not as an estimate of glomerular filtration rate but as an outcome predictor for hospital mortality, we examined the relationship between the MDRD value and in-hospital death during an emergency medical admission.
An analysis was performed on all emergency medical patients admitted between 1 January 2002 and 31 December 2008, using the hospital in-patient enquiry system, linked to the patient administration system and laboratory datasets. Hospital mortality (any in-patient death within 30 days) was obtained from a database of deaths occurring during the same period under physicians participating in the 'on-call' roster. Logistic regression was used to calculate unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI) for MDRD value.
Univariate analysis identified those with MDRD value of <60 as possessing increased mortality risk. Their 30-day mortality rate was 21.63 versus 4.35% for patients without an abnormal value (P < 0.0001) with an OR of 6.07 (95% CI's 5.49, 6.73: P < 0.001). After adjustment for 12 other outcome predictors including comorbidity, the OR was 4.63 (4.08, 5.25: P < 0.0001). Using the Kidney Disease Outcomes Quality Initiative (KDOQI) class, the respective mortality rates by 30 days increased with a lower MDRD value, from 2.8% in KDOQI Class 1 to 48.6% in KDOQI Class 5. Outcome prediction of in-hospital death, at 5 and 30 days with the MDRD, yielded areas under the receiver operator curves of 0.84 (0.83, 0.84) and 0.77 (0.77, 0.78).
Many factors predict survival following an emergency medical admission. The MDRD value offers a novel readily available and reliable estimate of mortality risk.
Background
Chronic kidney disease (CKD) is becoming increasingly prevalent and there are increasing numbers of older patients with advanced CKD. Peritoneal dialysis (PD) is a potential treatment. ...This study aims to compare PD outcomes in age-defined populations in the largest PD centre in the Republic of Ireland over 10 years.
Methods
We retrospectively identified all adult patients, over the age of 50 years, who commenced PD as their first modality of renal replacement therapy (RRT) between 1 January 1998 and 31 December 2008 at our institution. Primary outcome was patient survival; secondary outcomes were technique failure, peritonitis-free survival, transplantation and hospitalisations.
Results
One hundred and forty-eight patients with a mean age of 63 years were included. Twenty-two patients were on assisted PD, the majority of whom were aged 70 years or over (
P
= 0.001). There were no differences in patient survival or technique failure by age group, Charlson Co-Morbidity Index (CCI), modified-CCI or adjusted CCI. Renal transplantation occurred predominantly in younger patients (
P
= 0.001) with lower m-CCI (
P
= 0.001) and a-CCI (
P
= 0.002) who performed PD independently (
P
= 0.004). Older patients required longer hospital stays to initiate PD (
P
= 0.004). Assisted PD was not associated with an increase in early complications or technique failure but death rates were higher (
P
= 0.002).
Conclusion
This study shows PD to be an acceptable modality of renal replacement therapy in elderly patients, with no observed differences in survival, technique survival or complication rates. Co-morbidities appear to play a stronger role in predicting survival than age alone. Assisted PD is a viable option in those unable to undergo PD independently.
Abstract
BACKGROUND AND AIMS
Haemodialysis (HD) units in Ireland operate a national electronic Kidney Disease Clinical Patient Management System (KDCPMS). KDCMPS is not always used as the primary ...electronic patient record (EPR) but in conjunction with other electronic and paper record systems across the healthcare setting.
HD patients on average have 6 comorbidities and have the largest pill burden for any chronic disease; consuming 19 oral doses/day, comprising of 12 different medicines 1, 2. Frequent medication changes, polypharmacy, comorbidities and non-adherence, increase the risk of drug-related problems (DRPs). In the HD population, DRPs are prevalent at a rate of 1 for every three medication exposures and can elicit negative outcomes, including worsening morbidity, mortality and increased healthcare expenditure 3.
In this study setting, KDCPMS information accuracy has not been examined to date. This study aims to describe medication discrepancies within KDCPMS records of HD outpatients.
METHOD
This prospective, observational study was conducted in the HD unit of Tallaght University Hospital, Dublin.
Medicine reconciliation was conducted to identify KDCPMS discrepancies, followed by medication review to document DRPs. Recommendations were issued by the clinical pharmacist to resolve DRPs.
RESULTS
All KDCPMS records examined contained intentional and unintentional discrepancies (n = 36). Unintentional discrepancies corresponding to 8.8 discrepancies per patient (5.13SD) were observed.
A total of 143 DRPs were identified in 34 patients (94.4%) (Table 1). Out of these, 65% of pharmacist recommendations were accepted (n = 93), 22.4% were rejected (n = 32), 8.4% (n = 12) were referred to the renal multidisciplinary team (MDT) and 4.2% were not actioned (n = 6).
Discrepancies and DRPs by therapeutic area are shown in Fig. 1. Parenteral anticoagulants and thrombolytics were the most common undocumented intentional discrepancies (48.6%, n = 50/103) followed by iron (32%, n = 33/103).
A total of 16 (44.4%) patients had at least one medicine de-prescribed. New prescriptions were issued for 26 patients (72.2%) for 81 medicines.
CONCLUSION
KDCPMS contains inaccuracies that could lead to systemic error. Robust clinical governance supported by the national policy is required to improve the accuracy of information contained in KDCPMS and support its use as the primary platform for renal patients. Specialist clinical pharmacists working collaboratively within the renal MDT reduce discrepancies, improve KDCPMS accuracy and resolve DRPs. Enhanced pharmaceutical care by specialist pharmacists should be supported within national models of care for chronic disease management to enhance patient outcomes.
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