Care Of Chronic Kidney Disease Patients Research Articles

#950 Conservative care management in chronic kidney disease: a value for the money?

Abstract Background and Aims In Portugal, in 2021 the Directorate General of Health proposed the implementation of conservative care management (or kidney palliative care) as an option to handle frail Chronic Kidney Disease (CKD) patients or those who opt not to proceed to Kidney Replacement Therapy Options (KRT). A guideline regulated the clinical framework for this proposal but its socioeconomic evaluation and subsequent reimbursement has not been established. This has become a barrier to its application by public and private providers. This work intends to evaluate the limitations of costs and outcomes analysis in context of end-of-life care in CKD patients and propose indicators to compare cost effectiveness in dialysis and conservative care management. Method A narrative review from the literature have been made to evaluate epidemiological, social, individual and economic burden of ESKD and its treatment modalities. A reflection has been made on the benefits of Conservative Care (CC) and the limitations to evaluate cost effectiveness for this option compared to dialysis. Results Cost-effectiveness analysis is a method of comparing costs and effects of two or more alternatives in health or social care interventions to an outcome. Conceptual models of cost-effectiveness analysis evaluate outcomes compared to costs. Quality-adjusted life-years (QALYs) is a popular measure of outcome, but its use is problematic in ESKD. Costs of care are mostly elevated at the end of life and the way they are calculated is also debatable (Fig. 1). Some indicators may be used to compare CC and dialysis (Fig. 2). Conclusion The health policies should guarantee access to the health care, with quality, effectiveness and safety in the provision of services with efficiency but at the same time to assure financial sustainability and patients’ satisfaction. For some patients CC may embody an option that represents value for the money. To prove this reality, a cost-effectiveness evaluation must be implemented based on pre-specified indicators that override the limitations of this analysis in this specific context.

Inappropriate prescribing in patients with kidney disease: A rapid review of prevalence, associated clinical outcomes and impact of interventions.

The prevalence of patients with chronic kidney disease (CKD) and polypharmacy is increasing and has amplified the importance of examining inappropriate prescribing (IP) in CKD. This review focuses on the latest research regarding the prevalence of IP in CKD and the related adverse clinical effects and explores new interventions against IP. A literature search was performed using PubMed, EMBASE and the Cochrane Library searching articles published between June 2016 and March 2022. Twenty-seven studies were included. An IP prevalence of 12.6% to 96% and 0.3% to 66% was reported in hospital and outpatient settings, respectively. In nonhospital settings, the prevalence of IP varied between 3.9% and 60%. IP was associated with higher risk of hospitalisation (HR 1.46, 95% CI 1.17-1.81), higher bleeding rate (HR 2.34, 95% CI 1.32 to 3.37) and higher risk of all-cause mortality (OR 1.07, 95% CI 1.02 to 1.13). Three studies reported the impact of interventions on IP. This review highlights widespread IP in CKD patients across healthcare settings, with varying prevalence rates. IP is substantially linked to adverse outcomes in patients. While limited interventions show promise, urgent research is needed to develop effective strategies addressing IP and improving CKD patient care.

Digital Health Interventions for Quality Improvements in Chronic Kidney Disease Primary Care: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Chronic kidney disease (CKD) is a significant public health issue globally. The importance of its timely identification and early intervention is paramount. However, a systematic approach for early CKD management in the primary care setting is currently lacking, receiving less attention compared to upstream risk factors such as diabetes and hypertension. This oversight may lead to a failure in meeting quality-of-care indicators. Digital health interventions (DHIs), which leverage digital tools to enhance healthcare delivery, have shown effectiveness in managing chronic diseases and improving the quality, safety, and efficiency of primary care. Our research aimed to evaluate the effectiveness of DHIs in the care process, focusing on their reach, uptake, and feasibility. In this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov for randomized controlled trials (RCTs) assessing DHIs' effectiveness in CKD patient care among adults in primary care settings. The search, conducted on 30 June 2023, included studies published in English from 1 January 2009. Screening was conducted using Covidence, adhering to Cochrane's guidelines for data extraction. We primarily evaluated changes in care processes (testing, documentation, medication use, etc.) and the use of renin-angiotensin-aldosterone system inhibitors (RAASi), referrals, among others. Multilevel meta-analysis was employed to address within-study clustering, and meta-regression analyzed the impact of study characteristics on heterogeneity in effect sizes. Clinical endpoints were recorded where available. Bias risk was assessed using the Cochrane Risk of Bias 2 tool. Data on reach, uptake, and feasibility were narratively summarized. The study is registered with PROSPERO (CRD42023449098). From 679 records, 12 RCTs were included in the narrative synthesis, and 6 studies (encompassing 7 trials) in the meta-analysis. The trials indicated a -0.85% change (95%CI, -5.82% to 4.11%) in the proportion of patients receiving desired care. This result showed considerable heterogeneity (I2 = 91.9%). One study characteristic (co-intervention, education) correlated with larger effects. Although including co-intervention in multivariable meta-regression was significant, it did not diminish heterogeneity. The reported reach varied and was not high, while the uptake was relatively high. Most studies did not explicitly address feasibility, though some statements implied its evaluation. The current literature on the impact of DHIs in community-based CKD care is limited. The studies suggest a non-significant effect of DHIs on enhancing CKD management in community settings, marked by significant heterogeneity. Future research should focus on rigorous, methodologically sound implementations to better assess the effectiveness of DHIs in the primary care management of CKD.

Pharmacological Nephroprotection in Non-Diabetic Chronic Kidney Disease-Clinical Practice Position Statement of the Polish Society of Nephrology.

Chronic kidney disease (CKD) is a modern epidemic worldwide. Introducing renin-angiotensin system (RAS) inhibitors (i.e., ACEi or ARB) not only as blood-pressure-lowering agents, but also as nephroprotective drugs with antiproteinuric potential was a milestone in the therapy of CKD. For decades, this treatment remained the only proven strategy to slow down CKD progression. This situation changed some years ago primarily due to the introduction of drugs designed to treat diabetes that turned into nephroprotective strategies not only in diabetic kidney disease, but also in CKD unrelated to diabetes. In addition, several drugs emerged that precisely target the pathogenetic mechanisms of particular kidney diseases. Finally, the role of metabolic acidosis in CKD progression (and not only the sequelae of CKD) came to light. In this review, we aim to comprehensively discuss all relevant therapies that slow down the progression of non-diabetic kidney disease, including the lowering of blood pressure, through the nephroprotective effects of ACEi/ARB and spironolactone independent from BP lowering, as well as the role of sodium-glucose co-transporter type 2 inhibitors, acidosis correction and disease-specific treatment strategies. We also briefly address the therapies that attempt to slow down the progression of CKD, which did not confirm this effect. We are convinced that our in-depth review with practical statements on multiple aspects of treatment offered to non-diabetic CKD fills the existing gap in the available literature. We believe that it may help clinicians who take care of CKD patients in their practice. Finally, we propose the strategy that should be implemented in most non-diabetic CKD patients to prevent disease progression.

Assessment of Hydration, Nutritional Status and Arterial Stiffness in Hypertensive Chronic Kidney Disease Patients

The aim of this cross-sectional study was to determine the body fluid volume in patients diagnosed with both chronic kidney disease (CKD) and arterial hypertension (AH), and to investigate the relationship between fluid overload (FO), nutritional status and arterial stiffness in this specific patient population. A total of 169 participants with CKD and AH were enrolled in the study, and data on general parameters, comorbidities, medication use, and laboratory parameters were collected. Body composition was assessed with a Tanita MC 780 device, and data on the central and peripheral systolic and diastolic blood pressure, as well as pulse wave velocity (PWV) and the augmentation index (AIx) were collected with an IEM Mobil-O-Graph 24 h ambulatory blood pressure monitor, which was based on oscillometry. The Mediterranean Diet Serving Score (MDSS) questionnaire was used to determine the adherence to the Mediterranean diet (MeDi). Our results showed that the significant positive predictors of hydration status were the use of diuretics and oral hypoglycemic agents, whereas the negative predictors were female sex, higher body mass index level and use of two or more antihypertensives in the form of a single-pill combination. We also found differences in blood pressure and arterial stiffness parameters in relation to volume status, along with differences based on the presence of diabetes mellitus (DM). In conclusion, these results call for a higher awareness of volume status in the care of CKD patients with AH, especially in those with diabetes mellitus.

The role of Advanced Practice Nurses in creating the Kidney Transplant candidate care map (APN-preKT): a convergent-parallel mixed methods research protocol

BackgroundWaiting time for kidney transplants (KT) is an important health determinant for patients with chronic kidney disease (CKD). During this time, ongoing evaluation and participation is necessary in order to guarantee the quality and suitability of the proposed treatment. There is no existing literature on the potential impact of inclusion of an Advanced Practice Nurse (APN) role in the hospital setting on care for CKD patients who are candidates for KT. The main objectives of this protocol are: to analyse outpatient nursing activity in the care of individuals with KT in Spain; to identify the needs of individuals who are KT candidates; and to measure the impact of the APN role through patient outcomes and experiences. These objectives are fulfilled through 5 specific related substudies.MethodsA convergent parallel mixed methods approach will be conducted between July 2021 and April 2024. Quantitative and qualitative data will be collected and analysed separately to ascertain whether the findings confirm or contradict one another. Each of the 5 substudies of the project require a specific design, sampling method, and data collection procedure in order to meet the overall objectives for the project.DiscussionThe results of the project are expected to inform the design of future nursing roles and contribute to future improvements in the quality of care provided. The data that may be obtained from this protocol are limited to the specific context of the study facility and may be extrapolated but not compared to other settings due to the variability of care pathways for KT candidates internationally.Trial registrationThis project was approved by the Clinical Research Ethics Committee (no.2020/9418/I). The study was supported by the “Strategic Plan for Health Research and Innovation” from the Generalitat de Catalunya, registration number SLT017/20/000001, with a contribution of 57,239 euros.

Clinical practice review: outpatient palliative care for the geriatric chronic kidney disease population.

With a growing geriatric population in the United States, there is an increased need for healthcare resources and collaborative care for serious illnesses. Patients with chronic illnesses including chronic kidney disease (CKD) often experience severe symptoms and face complex decisions, many of which develop or occur in the outpatient setting. Though many of these symptoms overlap between different chronic illnesses, the CKD population remains largely untapped in terms of access to said resources; until recently, the focus in palliative care has been largely in the oncologic population. Older patients with CKD may benefit from additional tools and resources provided from collaborative care models specifically involving palliative care, especially as this population is high risk for experiencing lack of support. In this review, we use case vignettes to discuss the key concepts and roles of outpatient palliative care and how they can be integrated into the nephrology care of older patients with advanced kidney disease. These highlighted concepts include shared decision-making, selective deprescribing and symptom management, psychosocial support, and advance care planning. We also review different outpatient models for integrative palliative care, and the roles and resources of the palliative multidisciplinary team within these models and how these models can potentially be implemented in the care of CKD patients.

Health Care Quality in CKD Subjects: A Cross-Sectional In-Hospital Evaluation

Methods The study was performed in a retrospective and observational manner. All adult (age 18 years or older) in-hospital subjects treated from January until December 2019 were included. CKD was diagnosed according to the KDIGO 2012 CKD Guideline. The following variables were assessed: CKD stage, quantification/analysis (yes/no) of blood pressure, proteinuria, serum phosphate, serum 25-OH-D3, ferritin and transferrin saturation, and blood gas analysis. In addition, recommendations of the following medicines were analyzed (given/not given): ACE inhibitor or sartan, phosphate binder, vitamin D3 (activated or native), iron, erythropoietin, and bicarbonate. It was also evaluated whether discharge letters contained CKD-related diagnoses or not. Results In total, 581 individuals were included in the study. The majority of aspects related to the monitoring and therapeutic management of CKD were either considered in only a small proportion of affected individuals (e.g., quantification of PTH − 5.5%/25-OH-D3 − 6%/transferrin saturation − 13.6%) or avoided nearly at all (e.g., recommendation of erythropoietin—1%, documentation of CKD-MBD diagnosis—0.3%). A reasonable quality of care was identified concerning the blood pressure monitoring (performed in 100%) and blood gas analysis (55% of the patients received analysis). Serum phosphate was measured in 12.9%, particularly in subjects at higher CKD stages. Conclusions The current investigation revealed poor quality of care in CKD patients treated at the Brandenburg University Hospital over the period of one year. Quality improvement must be achieved, most likely via a standardized educational program for physicians and a directer access to CKD management guidelines.

Effectiveness of Self-Regulation Fluid Program on Patients with Hemodialysis Self-Efficacy for Fluid Adherence in Al-Diwaniyah Teaching Hospital

Objectives: to evaluate patient knowledge with hemodialysis and to determine the effectiveness of Self-regulation Fluid Program on Patients with hemodialysis self-efficacy for fluid adherence in Al-Diwaniyah Teaching Hospital.
 Methodology: A quasi-experimental design (two group design: pre-test and post-test) was used. This study was conducted in Al-Diwaniya Teaching Hospital for the period from (15th of October 2018 to 20th of May 2019) on a non-probability (purposive) sample consisting of (60 patients) treatment in hemodialysis units. A questionnaire was built as a data collection tool and consisted of four parts:
 First part: Demographic characteristics of the patient that consisted of (7) items, second part: Clinical information of the patient that consisted of (8) items, third part: the self-efficacy scale of fluid control in hemodialysis patients that consisted of (22) items and fourth part: patients’ knowledge in two axis that consisted of (20) items.
 The validity of the questionnaire and the educational program were verified by presenting it to (18) experts. The sample has received a pre-test, educational program, and post-test. Descriptive and inferential statistics were used to analyze the results of the study using the Statistical Package of Social Sciences (SPSS) version 22 and Microsoft Excel (2010).
 Results: The study finding shows, that all the study sample responses at the pre-test were fair knowledge with a statistical mean of scores (1.35). Other than the post-test, shows (100%) of the study sample have high knowledge at the mean of scores (2.66). Also, the maturity of the patients in both groups (control and study) is female and age group (more than 48) years, most of them not read and write, the maturity of the sample of study marred, regarding to the monthly income is not sufficient and urban residency. The study also confirms that the effectiveness of an instructional program on patients with hemodialysis to enhance self-efficacy fluid control is positive.
 Conclusion: Program helps patients in increasing self-confidence, knowledge of Chronic Kidney Disease patient care including controlling fluid overload.
 Recommendations: The study recommended the necessity of activating the role of instructional program correctly in order to give about end stage renal disease, and conduct future research programs to improve the patient's knowledge about end stage renal disease, fluid adherence and provide small booklist for caring.

Cost-effectiveness of hemodialysis, peritoneal dialysis and kidney transplantation at dr Sadjito General Hospital in 2018-2020

Background: Chronic kidney disease (CKD) is a non-communicable disease with high morbidity and mortality. Treatment options for CKD patients are kidney transplantation, hemodialysis, and peritoneal dialysis. Kidney transplantation remains the best option for CKD patients, which has the best Quality of Life compared to other therapies. The cost of therapy for CKD patients is relatively high. Even in developed countries, renal replacement therapy costs are still a burden on the health system and a public health problem. Therefore, this study aims to compare the cost of care for CKD patients undergoing kidney transplantation, hemodialysis, and peritoneal hemodialysis at dr. Sardjito General Hospital, Indonesia.Methods: This study was a retrospective cohort study of patients who underwent kidney transplantation, continuous ambulatory peritoneal dialysis (CAPD) or hemodialysis from January 2018 to December 2020 at dr. Sardjito General Hospital. We reviewed the medical records, and the data collected was ordinal, numeric, and categorical data. The data was then coded and processed using SPSS version 25.0. The results are presented in descriptive form, tables, or diagrams.Results: In this study, we found 87 CKD samples. Thirty patients underwent kidney transplantation, 27 patients underwent CAPD, and 30 patients were randomly assigned to undergo routine hemodialysis. Based on the data obtained from this study, the average cost incurred in the first year for patients undergoing kidney transplantation at dr. Sardjito General Hospital amounted to 384.6 million IDR. For CAPD patients, it was 93.7 million IDR, and the average cost for patients undergoing outpatient hemodialysis routinely was 104.1 million IDR. The estimated average cost incurred in the third year after the procedure for kidney transplant patients is 393.7 million IDR, CAPD patients 273.7 million IDR, and patients undergoing routine hemodialysis 307.8 million IDR. The estimated average cost incurred for CKD patients undergoing kidney transplantation was 402.7 million IDR in the fifth year. For CAPD patients was 273.7 million IDR, and for patients undergoing routine hemodialysis was 511.5 million IDR.Conclusions: The results showed a difference in costs between kidney transplantation, CAPD and hemodialysis. The kidney transplant cost is much more expensive than CAPD and hemodialysis, but the monthly cost is much cheaper than the other two procedures. In the third year estimation, the costs incurred for CAPD and hemodialysis will be close to the costs incurred for kidney transplantation. In the fifth year, the costs for kidney transplantation will be smaller than the costs for CAPD and hemodialysis.

A pharmacist-physician collaborative care model in chronic kidney disease.

A multidisciplinary approach, including pharmacist interventions, has improved clinical outcomes and reduced economic costs in chronic disease management. To our knowledge, this is the first study to describe the incorporation of pharmacist‐driven medication management with partnering nephrologists while capitalizing on technology to improve outcomes in a Chronic kidney disease (CKD) population. The authors created a collaborative drug therapy management agreement to enhance medication management for hypertension and diabetes mellitus. Our metrics aligned with the Healthcare Effectiveness Data and Information Set (HEDIS) measures. Most referrals to the program met the HEDIS definition of suboptimal disease control (Diabetes: 19/25 and Hypertension: 45/70). In patients with multiple pharmacy visits, achievement of diabetes targets increased from 23% to 67% and hypertension from 29% to 58%. Those who used technology tools were more likely to reach goals. The positive impact of a pharmacist‐physician collaboration and utilization of technology tools present an opportunity to improve care for CKD patients.

MO183TELEMEDICINE AS A MODALITY OF HEALTH CARE DELIVERY FOR PATIENTS WITH SEVERE CHRONIC KIDNEY DISEASE DURING COVID-19 PANDEMIC

Background and AimsTelemedicine is a new modality of care delivery. Over the last months, it has been used to deliver health care to outpatients with chronic kidney disease (CKD) during COVID-19 pandemic. However, experience of telemedicine in patients with severe CKD is scarce and there are not reassuring data about its efficacy in improving patients’ outcome. To evaluate the efficacy and the outcome profile of telemedicine in people with severe CKD, we reviewed all data of outpatients with severe kidney impairment who underwent nephrological evaluation during the first wave of this pandemic. In particular, outcomes of the ambulatory activity (urgent-start dialysis, late referral and modalities of dialysis initiation) were compared to 2019 ambulatory activity.MethodOutpatients with severe chronic kidney disease included in the ambulatory program called “Pre-Dialysis Program were enrolled in a retrospective study. We reviewed all electronic charts of patients who underwent nephrological follow-up from 9th March to June 21st, 2020 (15 weeks in total) at the University Hospital of Modena, Italy. Extension of the observation period to 30th September 2020 allowed us to determine the long-term effects of telemedicine on the rate of urgent-star dialysis, late referral, and modalities of dialysis initiation.ResultsDuring 15 weeks of follow-up, 186 nephrological visits were performed (Table) They were subdivided into telemedicine visits (56.5%) and in-person visits (43.5%). Overall, mean age of patients was 71.7±13.1 years with a prevalence of male (60.2%). Patients who received telemedicine visits had a statistically significant lower sCr (3.7±1.2 vs 4.5±1.5 mg/dl; P=0.0001) and higher eGFR level (14.7±6.02 vs 12.16±5.8 ml/min; P=0.002) than patients followed in the ambulatory setting. A high prevalence of patients with CKD stage 5 was monitored by in-person visits (P=0.0001). Patients followed by telemedicine had a clinical profile including a lower weight (P=0.007) and better control of metabolic acidosis (P=0.039) than the counterpart.Changes in domiciliary therapy occurred more frequently in patients monitored in the ambulatory setting (P=0.036). Statistically significant differences were encountered in the prescription of diuretics (P=0.002), sodium bicarbonate (P=0.043), antihypertensive drugs (P=0.001) and uric acid-lowering agents (P=0.046). During the 15-week period in 2019, 214 visits were performed (+13% compared to 2020). The vast majority of these visits were conducted in the hospital setting (210 out of 214; 98.2%). The severity of CKD was similar between patients, without statistically significant difference in the rate of patients in CKD stage III (P=0.7), stage IV (0.388) and stage V (P=0.593).Implementation of telemedicine to in-person visits during COVID-19 pandemic did not change the outcomes of patients. Short-term follow-up showed a similar rate in urgent-start dialysis (P=0.361), late referral (P=1), and HD (P=0.875) or PD initiation (P=0.661). Similar results were seen also at the end of the extended follow-up.ConclusionImplementation of telemedicine has been fundamental to maintain a high level of care in CKD patients during the COVID-19 pandemic. Telemedicine services in combination with in-person visits have contributed to the delivery of clinical monitoring in a group of patients with severe and progressive CKD. No differences have been identified in terms of rate of unplanned dialysis, late referral, and modality of dialysis initiation.

The path to the standardization of PTH: Is this a realistic possibility? a position paper of the IFCC C-BM

Parathyroid hormone (PTH) determination is of greatest importance for patients suffering from parathyroid gland disorders and for the follow-up of bone turnover in patients suffering from chronic kidney disease (CKD). Two generations of PTH assays are simultaneously present on the market for PTH quantification. As these assays are not yet standardized, this results in a significant level of confusion in the care of CKD patients. One key objective of the IFCC Committee for Bone Metabolism is to improve this situation. In this position paper, we will highlight the current state of PTH testing and propose a pathway to ultimately overcome issues resulting from PTH assay variability.

Kidney supportive care: an update of the current state of the art of palliative care in CKD patients.

ABSTRACTChronic kidney disease (CKD) has become a public health burden worldwide for its increasing incidence and prevalence, high impact on the health related quality of life (HRQoL) and life expectancy, and high personal and social cost. Patients with advanced CKD, in dialysis or not, suffer a burden from symptoms very similar to other chronic diseases and have a life span not superior to many malignancies. Accordingly, in recent years, renal palliative care has been recommended to be integrated in the traditional care delivered to this population. This research provides an updated overview on renal palliative care from the relevant literature.

Physical Activity and Health in Chronic Kidney Disease.

Clinical Background and Epidemiology: Low physical activity is a common phenotype in individuals living with chronic kidney disease (CKD). It increases as renal function declines and is associated with adverse clinical outcomes and a poor quality of life (QOL). Both behavioral and disease-related factors contribute to the low physical activity levels in CKD. CKD has profound negative effects on skeletal muscle structure and function that are related to impairments in mitochondrial function, inflammation, oxidative stress, metabolic acidosis, and other uremia-related factors. These factors promote muscle protein catabolism and wasting, and impair strength, physical performance, and cardiorespiratory fitness. Moreover, the high burden of comorbid disease contributes to patient fatigue, fear of injury, and poor exercise self-efficacy. All of these factors reinforce patient's sedentary behavior, leading to a vicious cycle of disease and disability that further compromises their health and QOL. Data from both observational studies and exercise interventions indicate that increasing levels of physical activity may provide a range of benefits in CKD patients, including attenuating declines in renal function, and improving markers of physical function, cardiovascular disease risk, and QOL. Unfortunately, these results have not led to widespread implementation of exercise programs in CKD, and physical inactivity and poor physical function remain hallmarks of the disease worldwide. Challenges and Solutions: There are many frequently cited barriers to implementing exercise programs in CKD. These include: a lack of training and knowledge about physical activity/exercise prescriptions and interventions among health professionals; inadequate time to implement exercise programs due to other clinical responsibilities; a lack of specific funding and incentives to develop these programs; and a poor quality of the data demonstrating efficacy of exercise. Many CKD patients also are unmotivated to incorporate exercise into their daily lives due to time constraints, depression, and other comorbid diseases, and poor self-efficacy for exercise. Given these barriers, it is not surprising that physical activity/exercise programs have not become a component of standard of care for CKD patients. We discuss several potential solutions to address these barriers, including: (1) providing better education and training for healthcare professionals who provide exercise advise and counselling to individuals with CKD; (2) providing incentives to reimburse payers to develop and maintain exercise programs in CKD; and (3) providing more personalized approaches to exercise prescription and implementation of exercise programs that consider the unique circumstances of individual CKD patients. In summary, low physical activity levels in CKD patients result from a combination of many factors that adversely impact patient's health and QOL. Addressing this problem will require comprehensive intervention strategies that consider both the unique pathophysiology of CKD and the individual circumstances of those living with the disease.

A roadmap for optimizing chronic kidney disease patient care and patient-oriented research in the Eastern European nephrology community.

Chronic kidney disease (CKD) is a major health problem because of its high prevalence, associated complications and high treatment costs. Several aspects of CKD differ significantly in the Eastern European nephrology community compared with Western Europe because of different geographic, socio-economic, infrastructure, cultural and educational features. The two most frequent aetiologies of CKD, DM and hypertension, and many other predisposing factors, are more frequent in the Eastern region, resulting in more prevalent CKD Stages 3–5. Interventions may minimize the potential drawbacks of the high prevalence of CKD in Eastern Europe, which include several options at various stages of the disease, such as raising public, medical personnel and healthcare authorities awareness; early detection by screening high-risk populations; preventing progression and CKD-related complications by training health professionals and patients; promoting transplantation or home dialysis as the preferred modality; disseminating and implementing guidelines and guided therapy and encouraging/supporting country-specific observational research as well as international collaborative projects. Specific ways to significantly impact CKD-related problems in every region of Europe through education, science and networking are collaboration with non-nephrology European societies who have a common interest in CKD and its associated complications, representation through an advisory role within nephrology via national nephrology societies, contributing to the training of local nephrologists and stimulating patient-oriented research. The latter is mandatory to identify country-specific kidney disease–related priorities. Active involvement of patients in this research via collaboration with the European Kidney Patient Federation or national patient federations is imperative to ensure that projects reflect specific patient needs.

2018 Kidney Disease: Improving Global Outcomes (KDIGO) Hepatitis C in Chronic Kidney Disease Guideline Implementation: Asia Summit Conference Report

In 2018, Kidney Disease: Improving Global Outcomes (KDIGO) published a clinical practice guideline on the prevention, diagnosis, evaluation, and treatment of hepatitis C virus (HCV) infection in chronic kidney disease (CKD). The guideline synthesized recent advances, especially in HCV therapeutics and diagnostics, and provided clinical recommendations and suggestions to aid healthcare providers and improve care for CKD patients with HCV. To gain insight into the extent that the 2018 guideline has been adopted in Asia, KDIGO convened an HCV Implementation Summit in Hong Kong. Participants included nephrologists, hepatologists, and nurse consultants from 8 Southeast Asian countries or regions with comparable high-to-middle economic ranking by the World Bank: mainland China, Hong Kong, Japan, Malaysia, Singapore, South Korea, Taiwan, and Thailand. Through presentations and discussions, meeting participants described regional practice patterns related to the KDIGO HCV in CKD guideline, identified barriers to implementing the guideline, and developed strategies for overcoming the barriers in Asia and around the world.

Project of the Health Policy Program: Access to Vessels in Renal Replacement Therapy - Fistula First/Catheter Last.

The number of patients with end-stage renal failure (ESRF) that require inclusion in the renal replacement therapy program (RRT) is steadily increasing. This fact caused an increase in vascular operations involving the production of vascular access. According to the current guidelines, the best and safest option for a patient with chronic kidney disease (CKD) is the early creation of arteriovenous fistula (AVF). An efficient vascular access to haemodialysis determines the procedure and directly affects the quality of life of a patient with CKD. The aim of this paper is to present the author's project of the health policy program "Vascular access in renal replacement therapy - fistula first/catheter last", the essence of which is to assess the practical effectiveness and develop an optimal model of CKD patient care organization qualified for the chronic RRT program. The target population of the program consists of all patients diagnosed with CKD, qualified for the RRT program. The basic measures of the program's effectiveness include: (1) reduction in the number of re-hospitalizations related to vascular access, (2) reduction in the number of complications associated with haemofiltration surgery, (3) reduction in general mortality among patients undergoing dialysis in a 12-month perspective, (4) increasing knowledge in the field of self-care and self-care of arteriovenous anastomosis, and (5) creating a register of vascular access in Poland. To sum up, health policy programme "Vascular access in renal replacement therapy - fistula first/catheter last" covering health care services provided in the scope and on the conditions specified in the regulations issued on the basis of article 31d of the Act of 27 August 2004 on health care benefits financed from public funds, is to check whether planned changes in the organization and delivery of services will improve the situation of patients with CKD eligible for chronic RRT and whether it will be effective the point of view of the health care system.

Assessment of oral health status and inflammatory markers in end stage chronic kidney disease patients: A cross-sectional study

Aim:To assess the oral health status and inflammatory markers in end stage chronic kidney disease (CKD) patients.Objectives:To study and compare oral health status of end stage CKD patients with the control group (matched health individuals) and to study and compare inflammatory biomarkers in study and control groups.Materials and Methods:A cross-sectional study was conducted among 50 patients of end stage CKD and 50 matched healthy individual, who were taken as control in the study. Convenience sampling technique was used. Oral health status was recorded by using WHO proforma (2013). Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP ) were also measured in the both groups. These are inflammatory markers which show systemic inflammation. Statistical analysis was done by using IBM SPSS Statistics-version 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.)Results:The study revealed that patients on dialysis going for transplantation have evidence of increased inflammation as indicated by raised CRP values.Conclusion:The present study concludes that the oral hygiene of the patients is deteriorated who are having chronic kidney disease. Good oral and dental care in CKD patients can improve the transplant outcomes.

SAT-219 IMPROVEMENT OF UNHEALTHY BEHAVIORS AND KEY PERFORMANCE INDICATORS IN PATIENTS WITH CHRONIC KIDNEY DISEASE STAGE 3-4 AT 1-YEAR FOLLOW-UP OF ESCORT-2 STUDY

In the ESCORT-2 study, we have designed multidisciplinary integrative care team (MDIC) to take care of stages 3 and 4 chronic kidney disease (CKD) patients among community hospitals in Kamphaeng Phet province, Thailand. In this study, key performance indicators (KPIs) and individual lifestyle pattern that affecting CKD progression were enlisted for serial monitoring, we presented herein the baseline results of KPIs achievement and incidence of unhealthy behaviors of the study. The ESCORT-2 study was a quasi-experimental study which was designed to evaluate the effect of MDIC approach to delay CKD progression in routine clinical care at five district hospitals in Kamphaeng Phet province, Thailand. It comprised hospital-based multidisciplinary team approach and community-based home visit. Clinical characteristics, blood and urine parameters were monitored during hospital visit every 3 months. Unhealthy behaviors were evaluated annually. 914 patients with CKD stages 3 and 4 were enrolled. In the KPI aspects, the patients at the first year of follow-up who achieved office BP less than 140/90, Hb A1c < 7, Hct > 30%, serum bicarbonate > 22 mEq/L and took ACEI or ARB were 773(84.7%), 153(35.3%), 567(95%), 660(72.2%) and 633(72.9%) compared with 681(74.8%), 240(49.9%), 774(91.8%), 583(63.8%) and 604(66.4%) at the beginning of study, in order as table 1. In the unhealthy behavior aspects, the CKD patients who took NSAIDs or herb in the first year of follow-up were 54(6.2%) and 15(1.7%) compared with 327(35.8%) and 209(23.1%) at the beginning of study, respectively as table 1. After 1-year follow-up, the MDIC approach can facilitate improvement in most of KPIs and unhealthy behaviors among community care for CKD patients.