Abstract Ambulatory blood pressure monitoring (ABPM) provides an accurate assessment of blood pressure (BP) and cardiovascular risk. BpTRU and other automated oscillometric BP monitors (AOBP) have ...been proposed to replace ABPM. A systematic review was carried out to determine the accuracy of AOBP, as compared to ABPM. A literature search was performed using Medline, EMBASE and CINAHL databases until Oct 28, 2016. We selected all studies that included intra-individual comparisons between AOBP and ABPM. Study selection, demographics and BP values including details of BP measurement techniques were abstracted in duplicate. Quantitative synthesis was performed to report the weighted mean difference between systolic and diastolic BP measured using the two methods. From the 859 non-duplicate citations from the search, 19 full text articles were selected for the systematic review. The median sample size was 226 (range 17 to 654). In the pooled analysis, the weighted mean difference (WMD) between the two methods for systolic BP was -1.52 mm Hg (95% confidence intervals CI -3.29, 0.25 mm Hg, p = 0.09) and for diastolic BP was 0.33 mm Hg (95% CI -0.97 to 1.64, p=0.62) . The study-level difference in means for systolic BP (SBP) ranged from -9.7 to +9 mm Hg with significant heterogeneity (Cochran’s Q = 270, I-squared 93.3, p < 0.001) and for DBP ranged from -4 to +6 mm Hg with significant heterogeneity (Cochran’s Q 382, I2 95.3, p <0.001). Because of the significant heterogeneity we feel that AOBP should not replace AABP (ABPM) as the reference standard.
The insertion of temporary hemodialysis catheters is considered to be a core competency of nephrology fellowship training. Little is known about the adequacy of training for this procedure and the ...extent to which evidence-based techniques to reduce complications have been adopted. We conducted a web-based survey of Canadian nephrology trainees regarding the insertion of temporary hemodialysis catheters. Responses were received from 45 of 68 (66%) eligible trainees. The median number of temporary hemodialysis catheters inserted during the prior 6 months of training was 5 (IQR, 2-11), with 9 (20%) trainees reporting they had inserted none. More than one-third of respondents indicated that they were not adequately trained to competently insert temporary hemodialysis catheters at both the femoral and internal jugular sites. These findings are relevant to a discussion of the current adequacy of procedural skills training during nephrology fellowship. With respect to temporary hemodialysis catheter placement, there is an opportunity for increased use of simulation-based teaching by training programs. Certain infection control techniques and use of real-time ultrasound should be more widely adopted. Consideration should be given to the establishment of minimum procedural training requirements at the level of both individual training programs and nationwide certification authorities.
Manual measurement of blood pressure (BP) in the office (MOBP) is inferior in accuracy when compared with ambulatory BP measurements (ABPM) since it misses white coat and masked effects on BP. BpTRU, ...an automated office BP device (AOBP), has been reported to reduce white coat effect. We performed a retrospective review of the diagnostic accuracy of MOBP (taken by a trained nurse in clinical hypertension) and AOBP using the Bland-Altman method in hypertensive patients referred to a Renal Hypertension Clinic. In 329 hypertensive patients, the 95% limits of agreement between systolic AOBP and ABPM were -31 mm Hg to 33 mm Hg and for MOBP and ABPM were -27.8 mm Hg to 37.4 mm Hg. The bias between systolic MOBP and systolic ABPM was 4.9 mm Hg (95% confidence interval, 3.0-6.6 mm Hg) whereas the bias between the systolic AOBP and the systolic ABPM was -3.2 (95% confidence interval, -1.3 to -5.0). AOBP did not improve treatment relevant classification errors compared with MOBP (28% vs. 23%; P = .052). Our data support findings by others showing that AOBP improves, but does not eliminate, white coat effect. The increased detection of white coat effect appears related to systematic downward bias by BpTRU. As a result, detection of masked effect is undermined by BpTRU.
Hypertension is the most common modifiable risk factor for cardiovascular disease, with an increasing prevalence with age, but with easily available medications to control it. Adverse effects of ...these medications do limit their use, in particular hyponatremia due to thiazide and thiazide-like diuretics. This is more common in the elderly patients due to a combination of inadequate protein intake and impaired urinary dilution capability, made worse by additional thiazide use. Limiting free water intake and increasing protein intake are often not successful resulting in thiazide avoidance. Daily protein supplement is a potential option in this clinical scenario. We describe the protocol for a feasibility study to explore this option.
This is a single-arm, prospective, open-label proof-of-concept trial, including elderly patients with thiazide diuretic-induced hyponatremia. Forty patients will be enrolled and receive a bottle of a protein supplement daily, providing 120 mmol of solutes and permitting an extra 163 mL free water loss, for 4 weeks. The main outcome measures will be (1) feasibility for enrollment, (2) safety of the intervention, and (3) potential efficacy of the intervention in improving hyponatremia. Secondary outcome measures will include changes in urine osmolality, body weight, and urea measurements.
Thiazide diuretic-induced hyponatremia is an important adverse effect, with significant clinical impact, such as delirium and falls, and limits the use of these potent antihypertensive agents. There are little data on the effect or safety of protein supplementation and also on whether a trial of this is feasible. The results of this proof-of-concept feasibility trial will help plan and execute a larger definitive trial to test protein supplementation as an effective strategy in this condition.
The trial is registered with Clinical trials, registration identifier: NCT02614807.
Background:
Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease, with afflicted patients often progressing to end-stage kidney disease (ESKD) requiring ...renal replacement therapy (RRT). As the timelines to ESKD are predictable over decades, it follows that ADPKD patients should be optimized regarding kidney transplantation, home dialysis therapies, and vascular access.
Objectives:
To examine the association of kidney transplantation, dialysis modalities, and vascular access in ADPKD patients compared with a matched, non-ADPKD cohort.
Setting:
Canadian patients from 2001-2012 excluding Quebec.
Patients:
All adult incident ESKD patients who received dialysis or a kidney transplant.
Measurements:
ADPKD as defined by the treating physician.
Methods:
ADPKD and non-ADPKD patients were propensity score (PS) matched (1:4) using demographics, comorbidities, and lab values. Conditional logistic regression and Cox proportional hazards models were used to examine associations with kidney transplantation (preemptive or any), dialysis modality (peritoneal, short daily, home, or in-center hemodialysis HD), vascular access (arteriovenous fistula AVF, permanent or temporary central venous catheter CVC), and dialysis survival.
Results:
We matched 2120 ADPKD (99.9%) with 8283 non-ADPKD with no significant imbalances between the groups. ADPKD was significantly associated with preemptive kidney transplantation (odds ratio OR = 7.13, 95% confidence interval CI = 5.74-8.87), any kidney transplant (OR = 2.37, 95% CI = 2.14-2.63), and initial therapy of nocturnal daily HD (OR = 2.74, 95% CI = 1.38-5.44), whereas in-center intermittent HD was significantly less likely in the ADPKD population (OR = 0.59, 95% CI = 0.54-0.65). There was no difference in peritoneal dialysis (PD) as initial RRT but lower use of any PD among the ADPKD group (OR = 0.85, 95% CI = 0.77-0.95). ADPKD patients were significantly more likely to have an AVF (OR = 3.25, 95% CI = 2.79-3.79) and less likely to have either a permanent (OR 0.68, 95% CI 0.59-0.78) or temporary (OR = 0.49, 95% CI = 0.41-0.59) CVC as compared with the non-ADPKD cohort. Survival on either in-center HD or PD was better for ADPKD patients (HD: hazard ratio HR 0.48, 95% CI 0.44-0.53; PD: HR 0.73, 95% CI 0.60-0.88).
Limitations:
Conservative care patients were not captured; despite PS matching, the possibility of residual confounding remains.
Conclusions:
ADPKD patients were more likely to receive a kidney transplant, use home HD, dialyze with an AVF, and have better survival relative to non-ADPKD patients. Conversely, they were less likely to receive PD either as initial therapy or anytime during ESKD. This may be attributed to higher transplantation or clinical decision-making processes susceptible to education and intervention.
Background:
Simulation-based-mastery-learning (SBML) is an effective method to train nephrology fellows to competently insert temporary, non-tunneled hemodialysis catheters (NTHCs). Previous studies ...of SBML for NTHC-insertion have been conducted at a local level.
Objectives:
Determine if SBML for NTHC-insertion can be effective when provided at a national continuing medical education (CME) meeting. Describe the correlation of demographic factors, prior experience with NTHC-insertion and procedural self-confidence with simulated performance of the procedure.
Design:
Pre-test – post-test study.
Setting:
2014 Canadian Society of Nephrology annual meeting.
Participants:
Nephrology fellows, internal medicine residents and medical students.
Measurements:
Participants were surveyed regarding demographics, prior NTHC-insertion experience, procedural self-confidence and attitudes regarding the training they received. NTHC-insertion skills were assessed using a 28-item checklist.
Methods:
Participants underwent a pre-test of their NTHC-insertion skills at the internal jugular site using a realistic patient simulator and ultrasound machine. Participants then had a training session that included a didactic presentation and 2 hours of deliberate practice using the simulator. On the following day, trainees completed a post-test of their NTHC-insertion skills. All participants were required to meet or exceed a minimum passing score (MPS) previously set at 79%. Trainees who did not reach the MPS were required to perform more deliberate practice until the MPS was achieved.
Results:
Twenty-two individuals participated in SBML training. None met or exceeded the MPS at baseline with a median checklist score of 20 (IQR, 7.25 to 21). Seventeen of 22 participants (77%) completed post-testing and improved their scores to a median of 27 (IQR, 26 to 28; p < 0.001). All met or exceeded the MPS on their first attempt. There were no significant correlations between demographics, prior experience or procedural self-confidence with pre-test performance.
Limitations:
Small sample-size and self-selection of participants. Costs could limit the long-term feasibility of providing this type of training at a CME conference.
Conclusions:
Despite most participants reporting having previously inserted NTHCs in clinical practice, none met the MPS at baseline; this suggests their prior training may have been inadequate.
The prevalence of inter‐arm BP difference is high in hypertension and is associated with adverse cardiovascular outcomes. We performed a retrospective chart review of prevalent patients in the Ottawa ...Hospital Hypertension Center to assess for prevalence, risk factors, and whether finding of inter‐arm BP difference >10 mmHg leads to investigations of the aorta and aortic arch. Inter‐arm BP difference among 493 patients was present in 16.2% (95% confidence interval CI13.3‐19.9%), and it was associated with presence of peripheral arterial disease. Physicians did not investigate ascending aorta and aortic arch for causes of the clinically significant inter‐arm BP difference.
PDF
