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.
Priorities for Emergency Department Syncope Research Sun, Benjamin C., MD, MPP; Costantino, Giorgio, MD; Barbic, Franca, MD ...
Annals of emergency medicine,
12/2014, Letnik:
64, Številka:
6
Journal Article, Conference Proceeding
Recenzirano
Odprti dostop
Study objectives There is limited evidence to guide the emergency department (ED) evaluation and management of syncope. The First International Workshop on Syncope Risk Stratification in the ...Emergency Department identified key research questions and methodological standards essential to advancing the science of ED-based syncope research. Methods We recruited a multinational panel of syncope experts. A preconference survey identified research priorities, which were refined during and after the conference through an iterative review process. Results There were 31 participants from 7 countries who represented 10 clinical and methodological specialties. High-priority research recommendations were organized around a conceptual model of ED decisionmaking for syncope, and they address definition, cohort selection, risk stratification, and management. Conclusion We convened a multispecialty group of syncope experts to identify the most pressing knowledge gaps and defined a high-priority research agenda to improve the care of patients with syncope in the ED.
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 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.
The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) provides the structural and evidence ...base for the Canadian Society of Nephrology (CSN) commentary on this guideline’s relevancy and application to the Canadian health care system. While in general agreement, we provide commentary on 13 of the 21 KDIGO guideline statements. Specifically, we agreed that nonpharmacological interventions should play a significant role in the management of hypertension in patients with CKD. We also agreed that the approach to the management of hypertension in elderly patients with CKD should be individualized and take into account comorbid conditions to avoid adverse outcomes from excessive BP lowering. In contrast to KDIGO, the CSN Work Group believes there is insufficient evidence to target a lower BP for nondiabetic CKD patients based on the presence and severity of albuminuria. The CSN Work Group concurs with the Canadian Hypertension Education Program (CHEP) recommendation of a target BP for all non–dialysis-dependent CKD patients without diabetes of ≤140 mm Hg systolic and ≤90 mm Hg diastolic. Similarly, it is our position that in diabetic patients with CKD and normal urinary albumin excretion, raising the threshold for treatment from <130 mm Hg systolic BP to <140 mm Hg systolic BP could increase stroke risk and the risk of worsening kidney disease. The CSN Work Group concurs with the CHEP and the Canadian Diabetic Association recommendation for diabetic patients with CKD with or without albuminuria to continue to be treated to a BP target similar to that of the overall diabetes population, aiming for BP levels < 130/80 mm Hg. Consistent with this, the CSN Work Group endorses a BP target of <130/80 mm Hg for diabetic patients with a kidney transplant. Finally, in the absence of evidence for a lower BP target, the CSN Work Group concurs with the CHEP recommendation to target BP < 140/90 mm Hg for nondiabetic patients with a kidney transplant.
Objective To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension. Evidence MEDLINE searches were conducted from November 2008 to October 2009 ...with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed full-text articles only. Recommendations Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Changes to the recommendations for 2010 relate to automated office blood pressure measurements. Automated office blood pressure measurements can be used in the assessment of office blood pressure. When used under proper conditions, an automated office systolic blood pressure of 135 mmHg or higher or diastolic blood pressure of 85 mmHg or higher should be considered analogous to a mean awake ambulatory systolic blood pressure of 135 mmHg or higher and diastolic blood pressure of 85 mmHg or higher, respectively. Validation All recommendations were graded according to strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. To be approved, all recommendations were required to be supported by at least 70% of task force members. These guidelines will continue to be updated annually.
Objective To update the evidence-based recommendations for the prevention and treatment of hypertension in adults for 2010. Options and outcomes For lifestyle and pharmacological interventions, ...randomized trials and systematic reviews of trials were preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the general lack of long-term morbidity and mortality data in this field. Progressive renal impairment was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease. Evidence A Cochrane Collaboration librarian conducted an independent MEDLINE search from 2008 to August 2009 to update the 2009 recommendations. To identify additional studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence. Recommendations For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to 1500 mg (65 mmol) per day in adults 50 years of age or younger, to 1300 mg (57 mmol) per day in adults 51 to 70 years of age, and to 1200 mg (52 mmol) per day in adults older than 70 years of age; perform 30 min to 60 min of moderate aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m2 to 24.9 kg/m2 ) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week for men or nine standard drinks per week for women; follow a diet that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources, and that is low in saturated fat and cholesterol; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in patients with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, considerations for initial therapy should include thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. The combination of ACE inhibitors and ARBs should not be used, unless compelling indications are present to suggest consideration of dual therapy. Agents appropriate for first-line therapy for isolated systolic hypertension include thiazide diuretics, long-acting dihydropyridine CCBs or ARBs. In patients with coronary artery disease, ACE inhibitors, ARBs or beta-blockers are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. In selected high-risk patients in whom combination therapy is being considered, an ACE inhibitor plus a long-acting dihydropyridine CCB is preferable to an ACE inhibitor plus a thiazide diuretic. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian lipid treatment guidelines. Selected patients with hypertension who do not achieve thresholds for statin therapy, but who are otherwise at high risk for cardiovascular events, should nonetheless receive statin therapy. Once blood pressure is controlled, low-dose acetylsalicylic acid therapy should be considered. Validation All recommendations were graded according to the strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 80% consensus. These guidelines will continue to be updated annually. Sponsors The Canadian Hypertension Education Program process is sponsored by the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the College of Family Physicians of Canada, the Canadian Pharmacists Association, the Canadian Council of Cardiovascular Nurses, and the Heart and Stroke Foundation of Canada.
The risk of mortality and graft loss is higher in kidney transplant recipients with reduced estimated glomerular filtration rate (eGFR) and albuminuria. It is unclear whether these markers are also ...associated with cardiovascular events.
We examined linked healthcare databases in Alberta, Canada to identify kidney transplant recipients between 2002 and 2013 who had at least 1 outpatient serum creatinine and albuminuria measurement at 1-year posttransplant. We determined the relationship between categories of eGFR and albuminuria and the risk of subsequent cardiovascular events.
Among 1069 eligible kidney transplant recipients, the median age was 52 years, 37% were female, and 52% had eGFR ≥60 mL/min per 1.73 m
. Over a median follow-up of 6 years, the adjusted rate of all-cause mortality and cardiovascular events was 2.7-fold higher for recipients with eGFR 15-29 mL/min per 1.73 m
and heavy albuminuria compared to recipients with eGFR ≥60 mL/min per 1.73 m
and normal albuminuria (rate ratio, 2.7; 95% confidence interval, 1.3-5.7). Similarly, recipients with heavy albuminuria had a threefold increased risk of all-cause mortality and heart failure compared with recipients with eGFR ≥60 mL/min per 1.73 m
and normal albuminuria.
These findings suggest that eGFR and albuminuria should be used together to determine the risk of cardiovascular outcomes in transplant recipients.
Abstract We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2012. The new recommendations are: (1) use of home blood ...pressure monitoring to confirm a diagnosis of white coat syndrome; (2) mineralocorticoid receptor antagonists may be used in selected patients with hypertension and systolic heart failure; (3) a history of atrial fibrillation in patients with hypertension should not be a factor in deciding to prescribe an angiotensin-receptor blocker for the treatment of hypertension; and (4) the blood pressure target for patients with nondiabetic chronic kidney disease has now been changed to < 140/90 mm Hg from < 130/80 mm Hg. We also reviewed the recent evidence on blood pressure targets for patients with hypertension and diabetes and continue to recommend a blood pressure target of less than 130/80 mm Hg.
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