Multidisciplinary Chronic Kidney Disease Research Articles

#989 Fund and incentivize multidisciplinary CKD care: what can we learn from the French CKD bundled payment program?

Abstract Background and Aims Multidisciplinary care (MDC) is crucial to slow down the progression of Chronic Kidney Disease (CKD) and prevent or post-pone kidney replacement therapy. To incentivize the development of that care, France launched a nationwide bundled payment program (CKD-BP) targeted to patients with CKD G4 and G5. In this study, we review the implementation of the program, 3 years into its launch. Method First, using the CKD-BP program data collected by participating facilities, we described the characteristics and trajectories of patients enrolled from 2020 through 2022. Second, from exploratory interviews with medical and management staff, we performed a thematic analysis to identify the obstacles encountered during implementation and the changes introduced by the program. Results Since 2020, 157,863 patients were reported by 408 facilities (median age 75 y-o, 40% women, 77% G4). Missing data frequencies were high for comorbidities. Each year, around 4200 dialysis start (5% of patients) and 2600 deaths (3% of patients) were reported. On average, 47% and 40% of patients visited nurses and dietitians at least once a year respectively. From 22 interviews across 7 facilities, we identified challenges of implementation: adapting information systems, gathering the support of facility management and organizing the care in a context of workforce shortage, specifically nurses. Despite those challenges, facilities welcomed positively the new model, notably with increased time between nurses and patients and affirmation of dietitian's role. Conclusion We estimate the exhaustiveness of the CKD-BP program at 40% of all French patients with G5 CKD (around 4,600 dialysis start reported in 2021, compared to 11,000 from the national exhaustive REIN registry data). The results of this study suggest that interventions to accompany facilities in adapting their information systems are a priority to ensure efficient allocation of medical time and quality of the data. The results also suggest the need for increased flexibility regarding what professional is considered in the CKD-BP program, beyond nurses and dietitians. These challenges remain to be addressed in order to complete a successful shift from fee-for-service to assessable value-based care for CKD in France.

Oral Nutritional Supplement Prescription and Patient-Reported Symptom Burden Among Patients With Late-Stage Non-Dialysis Chronic Kidney Disease.

Malnutrition and protein-energy wasting (PEW) are nutritional complications of advanced chronic kidney disease (CKD) that contribute to morbidity, mortality, and decreased quality of life. No previous studies have assessed the effect of oral nutritional supplements (ONSs) on patient-reported symptom burden among patients with non-dialysis CKD (CKD-ND) who have or are at risk of malnutrition/PEW. The objective of this study was (1) to quantify the associations between baseline nutritional parameters and patient-reported symptom scores for wellbeing, tiredness, nausea, and appetite and (2) to compare the change in symptom scores among patients prescribed ONS with patients who did not receive ONS in a propensity-score-matched analysis. This study conducted observational cohort analysis using provincial registry data. This study was done in multidisciplinary CKD clinics in British Columbia. Adult patients >18 years of age with CKD-ND entering multidisciplinary CKD clinics between January 1, 2010-July 31, 2019 who had at least 2 Edmonton Symptom Assessment System Revised: Renal (ESASr:Renal) assessments. The measurements include nutrition-related parameters such as body mass index (BMI), serum albumin, serum phosphate, serum bicarbonate, neutrophil-to-lymphocyte ratio (NLR), and ESASr:Renal scores (overall and subscores for wellbeing, tiredness, nausea, and appetite). Multivariable linear regression was applied to assess associations between nutritional parameters and ESASr:Renal scores. Propensity-score matching using the greedy method was used to match patients prescribed ONS with those not prescribed ONS using multiple demographic, comorbidity, health care utilization, and temporal factors. Linear regression was used to assess the association between first ONS prescription and change in ESASr:Renal overall score and subscores for wellbeing, tiredness, nausea, and appetite. Of total, 2076 patients were included. Higher baseline serum albumin was associated with lower overall ESASr:Renal score (-0.20, 95% confidence interval [CI] = -0.40 to -0.01 per 1 g/L increase in albumin), lower subscores for tiredness (-0.04, 95% CI = -0.07 to -0.01), nausea (-0.03, 95% CI = -0.04 to -0.01), and appetite (-0.03, 95% CI = -0.06 to -0.01). Higher BMI was associated with higher overall ESASr:Renal score (0.32, 95% CI = 0.16 to 0.48 per 1 kg/m2 increase in BMI), higher symptom subscores for wellbeing (0.02, 95% CI = 0.00 to 0.04) and tiredness (0.05, 95% CI = 0.02 to 0.07). Higher baseline NLR was associated with higher overall score (0.21, 95% CI = 0.03 to 0.39 per 1 unit increase in NLR), higher symptom subscores for wellbeing (0.03, 95% CI = 0.01 to 0.05) and nausea (0.03, 95% CI = 0.02 to 0.05). In the propensity-score-matched analysis, there were no statistically significant associations between ONS prescription and change in overall ESASr:Renal (beta coefficient for change in ESASr:Renal = 0.17, 95% CI = -2.64 to 2.99) or for subscores for appetite, tiredness, nausea, and wellbeing. Possible residual confounding. The ESASr:Renal assessments were obtained routinely only in patients with G5 CKD-ND and/or experiencing significant CKD-related symptoms. This exploratory observational analysis of patients with advanced non-dialysis CKD demonstrated BMI, serum albumin, and NLR were modestly associated with patient-reported symptoms, but we did not observe an association between ONS use and change in ESASr:Renal scores.

Patient-Centered Outcomes With a Multidisciplinary CKD Care Team Approach: An Observational Study.

Multidisciplinary chronic kidney disease (CKD) care has been associated with improved clinical outcomes in comparison to general nephrology care. However, there is little research examining the impact of multidisciplinary care on patient-centered outcomes. We examined if a multidisciplinary approach to CKD care was associated with 4 patient-centered outcomes. Cross-sectional study design using previously established surveys to assess patient-centered outcomes in participants with nondialysis CKD. Adults with CKD stages 1-5 who had not undergone transplant or were not on dialysis. General nephrology care or multidisciplinary care. Patients receiving multidisciplinary care were seen by a pharmacist, social worker, dietitian, and nephrologist, whereas patients receiving general nephrology care only saw a nephrologist. Four patient-centered outcomes: CKD-specific knowledge, disease-related stress, perception of overall health, and perception of health status compared to 1 year ago. Differences were examined using a Welch 2-sample t test and linear regression model. Mean age of participants was 60 years with standard deviation of 17 years. 182 (77%) patients were White, and 230 (96%) had formal education greater than or equal to high school. 121 (49%) were women, and 215 (88%) had CKD stage 3-5. 77 (31%) received multidisciplinary care. We did not identify any significant differences in patient knowledge, stress, or perception of health between multidisciplinary and general nephrology care. However, notably, patients in multidisciplinary care were older and had more advanced CKD than those in general nephrology care. Cross-sectional study designs only identify associations. Study was conducted at clinics located within 30 miles of each other, limiting generalizability. Our results suggest that a team-based approach to care can better support sicker, more vulnerable patients so that they can achieve similar patient-centered outcomes compared to patients who are younger and with less advanced CKD.

Implementing a Formalized Risk-Based Approach to Determine Candidacy for Multidisciplinary CKD Care: A Descriptive Cohort Study.

The kidney failure risk equation (KFRE) can be used to predict progression to end-stage kidney disease in a clinical setting. Evaluate implementation of a formalized risk-based approach in nephrologists' outpatient clinics and multidisciplinary chronic kidney disease (CKD) clinics to determine candidacy for multidisciplinary care, and the impact of CKD care selection on clinical outcomes. Population-based descriptive cohort study. Alberta Kidney Care South. Adults attending or considered for a multidisciplinary CKD clinic between April 1, 2017, and March 31, 2019. Exposure-The course of CKD care assigned by the nephrologist: management at multidisciplinary CKD clinic; management by a nephrologist or primary care physician. Primary Outcome-CKD progression, defined as commencement of kidney replacement therapy (KRT). Secondary Outcomes-Death, emergency department visits, and hospitalizations. We linked operational data from the clinics (available until March 31, 2019) with administrative health and laboratory data (available until March 31, 2020). Comparisons among patient groups, courses of care, and clinical settings with negative binomial regression count models and calculated unadjusted and fully adjusted incidence rate ratios. For the all-cause death outcome, we used Cox survival models to calculate unadjusted and fully adjusted hazard ratios. Of the 1748 patients for whom a KFRE was completed, 1347 (77%) remained in or were admitted to a multidisciplinary CKD clinic, 310 (18%) were managed by a nephrologist only, and 91 (5%) were referred back for management by their primary care physician. There was a much higher kidney failure risk among patients who remained at or were admitted to a multidisciplinary CKD clinic (median 2-year risk of 34.7% compared with 3.6% and 0.8% who remained with a nephrologist or primary care physician, respectively). None of the people managed by their primary care physician alone commenced KRT, while only 2 (0.6%) managed by a nephrologist without multidisciplinary CKD care commenced KRT. The rates of emergency department visits, hospitalizations, and death were lower in those assigned to management outside the multidisciplinary CKD clinics when compared with those managed in the multidisciplinary care setting. The follow-up period may not have been long enough to determine outcomes, and potentially limited generalizability given variability of care in multidisciplinary clinics. Our findings indicate that a portion of patients can be directed to less resource-intensive care without a higher risk of adverse events. Not applicable.

MO187: Healthcare Costs based on Risk of Progression in Patients with Chronic Kidney Disease

Abstract BACKGROUND AND AIMS Nephrologists follow patients with chronic kidney disease (CKD) stage G3 and G4 as a homogeneous group with the assumption that everyone had similar rates of progression with scheduled visits and lab investigations based on the stage of the disease. We now recognize that not all patients progress at similar rates to kidney failure and treatment and follow-up needs vary. The Kidney Failure Risk Equation (KFRE) identifies patients at different risks of progression to kidney failure (low, medium and high risk) in each stage of the disease. Previous studies had looked at resource utilization of patients based on the stage of the CKD. The purpose of our analysis was to examine resource utilization and associated costs based on the risk of progression by KFRE in the setting of a universal healthcare system. METHOD We conducted a retrospective cohort study of adults with CKD G3 and G4 enrolled in multidisciplinary CKD clinics in the province of Saskatchewan, Canada. Data was collected from January 2004 through December 2012 and patients were followed for 5 years. The predicted risk of kidney failure for each patient was calculated using the 8-variable KFRE. The equation used clinical and routine laboratory data, to stratify patients into three risk categories (low, medium and high risk) of progression. We compared the number and cost of hospital admissions, physician visits and prescription drugs by risk within G3 and G4. Negative binomial regression and generalized linear model were used to compare healthcare utilization and cost between the groups respectively (α = 0.05). RESULTS A total of 1003 adults with CKD G3 and G4 were included in the study. In patients with stage G3 CKD, 311 (59%), 150 (28%) and 68 (13%) were in low, medium and high-risk categories, respectively. Amongst patients with CKD stage G4, 275 (58%), 86 (18%) and 113 (24%) were in similar categories respectively. The cost of hospital admissions, physician visits and drug dispensations in stage G4 high risk in comparison to low risk over the 5-year study period was CAD $89 265 versus $48 374 (P = .008), $23 423 versus $11 231 (P < .001) and $21 853 versus $16 757 (P = .01), respectively. In stage G3, the cost of hospital admissions was CAD $55 944 versus $36 740 (P = 0.10), physician visits $13 414 versus $10 370 (P = .08) and prescription drugs $20 394 versus $14 902 (P = .02) in high-risk patients in comparison to low-risk patients (Figure 1). CONCLUSION In patients followed in multidisciplinary clinics with CKD stages G3 and G4, the cost of hospital admissions, physician visits and prescription drugs were higher in high-risk patients compared to patients in low-risk category. In our study, the KFRE, designed to predict the risk of progression to dialysis in patients with CKD, also assisted in identifying patients with higher health resource utilization and healthcare costs compared to those with lower health resource use. We additionally suggest that patients who are in medium and high-risk categories be followed in multidisciplinary clinics rather than individual physician offices to delay the trajectory of decline to kidney failure.

'It's the empathy'-defining a role for peer support among people living with chronic kidney disease: a qualitative study.

ObjectivesPersons with advanced chronic kidney disease (CKD) have unique support needs associated with managing a chronic yet often silent condition, complex treatment-related decisions and care transitions. The aim of this study was to explore perspectives on how peer support could address CKD support needs and augment care.DesignThis study employed a qualitative descriptive methodology. Data were collected through focus groups (cofacilitated by patient partners) and semistructured interviews.SettingFour multidisciplinary CKD clinics across Southern Alberta, Canada.ParticipantsWe purposively sampled among adult patients with advanced, non-dialysis CKD and their caregivers, as well as trained peer mentors from The Kidney Foundation of Canada’s Kidney Connect programme.AnalysisTranscripts were coded in duplicate, and themes were generated inductively through a thematic analysis approach.ResultsWe conducted seven focus groups with a total of 39 patient and caregiver participants. Seven patients and caregivers who were unable to attend a focus group and 13 peer mentors participated in a telephone interview. Although patients and caregivers had limited awareness of peer support, participants acknowledged its central role in affirming their experiences and enabling confidence to live well with kidney disease. We identified four themes related to the anticipated role of peer support in addressing support needs for people with non-dialysis CKD: (1) creating connection; (2) preparing for uncertainty; (3) adapting to new realities; and (4) responsive peer support delivery. Aligning peer support access with patient readiness and existing CKD management supports can promote optimism, community and pragmatic adaptations to challenges.ConclusionsPatients, caregivers and peer mentors highlighted a unique value in the shared experiences of CKD peers to anticipate and manage disease-related challenges and confidently face a future living with kidney disease.

Healthcare provider perspectives on integrating peer support in non-dialysis-dependent chronic kidney disease care: a mixed methods study

BackgroundPeer support complements traditional models of chronic kidney disease (CKD) care through sharing of peer experiences, pragmatic advice, and resources to enhance chronic kidney disease self-management and decision-making. As peer support is variably offered and integrated into multi-disciplinary CKD care, we aimed to characterize healthcare providers’ experiences and views on peer support provision for people with non-dialysis-dependent CKD within Canada.MethodsIn this concurrent mixed methods study, we used a self-administered online survey to collect information from multi-disciplinary CKD clinic providers (e.g., nurses, nephrologists, allied health professionals) on peer support awareness, program characteristics and processes, perceived value, and barriers and facilitators to offering peer support in CKD clinics. Results were analyzed descriptively. We undertook semi-structured interviews with a sample of survey respondents to elaborate on perspectives about peer support in CKD care, which we analyzed using inductive, content analysis.ResultsWe surveyed 113 providers from 49 clinics. Two thirds (66%) were aware of formal peer support programs, of whom 19% offered in-house peer support through their clinic. Peer support awareness differed by role and region, and most referrals were made by social workers. Likert scale responses suggested a high perceived need of peer support for people with CKD. Top cited barriers to offering peer support included lack of peer support access and workload demands, while facilitators included systematic clinic processes for peer support integration and alignment with external programs. Across 18 interviews, we identified themes related to peer support awareness, logistics, and accessibility and highlighted a need for integrated support pathways.ConclusionsOur findings suggest variability in awareness and availability of peer support among Canadian multi-disciplinary CKD clinics. An understanding of the factors influencing peer support delivery will inform strategies to optimize its uptake for people with advanced CKD.

Independent External Validation and Comparison of Death and Kidney Replacement Therapy Prediction Models in Advanced CKD

Rationale & ObjectiveThe Kidney Failure Risk Equation (KFRE) is widely used to predict the risk of kidney replacement therapy (KRT) initiation in chronic kidney disease (CKD) stages G3-G5. The new Grams calculator developed for advanced CKD (stage G4+) predicts KRT initiation, cardiovascular events, and death by uniquely incorporating the competing risk of death. We aimed to validate this tool in a stage G4+ cohort for death and KRT.Study DesignRetrospective cohort study.Setting & Participants442 patients with CKD stage G4+ (mean ± SD age, 73 ± 12 years; mean ± SD estimated glomerular filtration rate, 20 ± 6.2 mL/min/1.73 m2) who visited the multidisciplinary CKD clinic at Kingston Health Sciences Center in Ontario, Canada.Outcomes & Analytical ApproachDiscrimination and calibration were examined for the outcome of death using the 2- and 4-year Grams scores. The 2- and 5-year KFRE and 2- and 4-year Grams scores were compared in terms of discrimination and calibration for KRT.ResultsThere were 91, 161, and 206 death events and 90, 145, and 159 KRT events in our cohort at 2, 4, and 5 years, respectively. The Grams model demonstrated modest discrimination for death at 4 years (area under the curve [AUC] 0.70; 95% CI, 0.65-0.75) and performed worse at 2 years (AUC, 0.63; 95% CI, 0.57-0.70). It only overpredicted death by approximately 10% across most of the predicted range. Both models had similar discrimination for KRT at 2 years (KFRE AUC, 0.83; 95% CI, 0.78-0.88 and Grams AUC, 0.8; 95% CI, 0.76-0.87), 4 years (Grams AUC, 0.82; 95% CI, 0.77-0.86), and 5 years (KFRE AUC, 0.81; 95% CI, 0.76-0.85). There was excellent calibration for KRT using the 2-year KFRE and Grams values for predicted risk thresholds of ≤15% and using the 5-year KFRE and 4-year Grams values for predicted risk thresholds of ≤20%. At higher risk ranges, KFRE overpredicts and Grams underpredicts the KRT risk.LimitationsThis is a single-center study with a primarily White cohort limited by smaller sample sizes at the higher ranges of the predicted risks, particularly for the Grams calculator.ConclusionsThe Grams model provides moderately accurate death predictions, and consideration should be given to its incorporation into patient education and advanced care planning. Both the Grams and KFRE models remain clinically useful for determining KRT risks in advanced CKD.

POS-307 HEALTHCARE COSTS BASED ON RISK-BASED APPROACH IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Multidisciplinary Chronic Kidney Disease (CKD) Clinics were established to offer support from other disciplines (diabetic educators, social workers, pharmacists, dietitians, specialty trained nurses) to monitor and delay progression in conjunction with the Nephrologist. Most CKD clinics followed patients with CKD stage G3 and G4 as a homogeneous group with the assumption that everyone had similar rates of progression with scheduled visits and lab investigations based on the stage of the disease.

Older Patients with Advanced Chronic Kidney Disease and Their Perspectives on Prognostic Information: a Qualitative Study.

Prognostic information is key to shared decision-making, particularly in life-limiting illness like advanced chronic kidney disease (CKD). To understand the prognostic information preferences expressed by older patients with CKD. Qualitative study of 28 consecutively enrolled patients over 65years of age with non-dialysis dependent CKD stages 3b-5, receiving care in a multi-disciplinary CKD clinic. Semi-structured telephone or in-person interviews to explore patients' preference for and perceived value of individualized prognostic information. Interviews were analyzed using inductive content analysis. We completed interviews with 28 patients (77.7 ± SD 6.8years, 69% men). Patients varied in their preference for prognostic information and more were interested in their risk of progression to end-stage kidney disease (ESKD) than in life expectancy. Many conflated ESKD risk with risk of death, perceiving a binary choice between dialysis and quick decline and death. Patients expressed that prognostic information would allow them to plan, take care of important business, and think about their treatment options. Patients were accepting of prognostic uncertainty and imagined leveraging it to nurture hope or motivate them to better manage risk factors. They endorsed the desire to receive prognosis of life expectancy even though it may be hard to accept or difficult to talk about but worried it could create helplessness for other patients in their situation. Most, but not all, patients were interested in prognostic information and could see its value in motivating behavior change and allowing planning. Some patients expressed concern that information on life expectancy might cause depression and hopelessness. Therefore, prognostic information is most appropriate as part of a clinical conversation that fosters shared decision-making and helps patients consider treatment risks, benefits, and burdens in context of their lives.

Death and Dialysis Following Discharge From Chronic Kidney Disease Clinic: A Retrospective Cohort Study.

Background:Multidisciplinary care is recommended for patients with advanced chronic kidney disease (CKD). A formalized, risk-based approach to CKD management is being adopted in some jurisdictions. In Ontario, Canada, the eligibility criteria for multidisciplinary CKD care funding were revised between 2016 and 2018 to a 2 year risk of kidney replacement therapy (KRT) greater than 10% calculated by the 4-variable Kidney Failure Risk Equation (KFRE). Implementation of the risk-based approach has led to the discharge of prevalent CKD patients.Objective:The primary objective of this study was to determine the frequency of occurrence of death and KRT initiation in patients discharged from CKD clinic.Design:Retrospective cohort studySetting:Single center multidisciplinary CKD clinic in Ontario, CanadaPatients:Four hundred and twenty five patients seen at least once in 2013 at the multidisciplinary CKD clinicMeasurements:Outcomes included discharge status, death, re-referral and KRT initiation. Reasons for discharge were recorded.Methods:Outcomes were extracted from available electronic medical records and the provincial death registry between the patient’s initial clinic visit in 2013 and January 1, 2020. KFRE-2 scores were calculated using the 4-variable KFRE equation. The hazard rates of death and KRT after discharge due to stable eGFR/low KFRE were compared to patients who remained in the clinic.Results:Of the 425 CKD patients, 69 (16%) and 19 (4%) were discharged to primary care and general nephrology, respectively. Of those discharged, 7 (8%) were re-referred to nephrology or CKD clinic, while only 2 (2%) discharged patients required subsequent KRT. The hazard of mortality was reduced after discharge from the clinic due to stable eGFR/low KFRE (adjusted HR = 0.45 [95% CI, 0.25-0.78, P = .005]).Limitations:Single center, observational retrospective study design and unknown kidney function over time post discharge for most patientsConclusions:Discharge of low risk patients from multidisciplinary CKD clinic appears feasible and safe, with fewer than 1 in 40 discharged patients subsequently initiated on KRT over the following 7 years.

Protocol for a Multistage Mixed-Methods Evaluation of Multidisciplinary Chronic Kidney Disease Care Quality Following Integration of Virtual and In-Person Care During the COVID-19 Pandemic.

Background:Multidisciplinary care of patients with chronic kidney disease (CKD) as it previously existed was predicated on an evidence and experience base of improved patient outcomes within an established and well-described service delivery model. The onset of the COVID-19 pandemic brought with it a departure from this established care delivery model toward integration of virtual care and in-person care.Objective:To develop an evaluation framework to determine whether this shift in service delivery models has affected quality of multidisciplinary kidney care and/or patient-clinician interactions and relationships.Design:A sequential multiphase, mixed-methods evaluation.Setting:All 15 British Columbia (BC) multidisciplinary kidney care clinics (KCCs).Participants:All patients and all clinicians in all KCCs across BC will be invited to participate in the planned evaluation.Measurements:Qualitative and quantitative feedback from patients and families living with CKD and KCC clinicians.Methods:The planned multiphase evaluation of virtual care integration in KCCs will be conducted across all 15 KCCs in the province of BC, Canada. The following phases are proposed: (1) review of current virtual care integration and practices, (2) assessment of patient and clinician experiences and perspectives via semi-structured interviews, (3) validation of those patient and clinician perspectives via survey of a larger sample, (4) compilation and analysis of all phases to provide informed recommendations for patient and visit format selection in a mixed in-person and virtual multidisciplinary clinic setting.Limitations:This work will not capture any information about the relationship between differences in virtual usage parameters and clinical outcomes or financial implications.Conclusions:There is no existing framework for either evaluation of multidisciplinary CKD care quality in a virtual setting or evaluation of care quality following a substantial change in service delivery models. The proposed evaluation protocol will enable better understanding of the nuances in kidney care delivery in this new format and inform how best to optimize the integration of virtual and pre-existing formats into kidney clinic care delivery beyond the pandemic. Beyond the current evaluation, this protocol may be of use for other jurisdictions to evaluate their own local instances of virtual care implementation and integration. The model may be adapted to evaluate quality of multidisciplinary kidney care delivery following other changes to clinic service delivery models.

Barriers to pre-dialysis education in hemodialysis patients with end-stage renal disease in Kingdom of Saudi Arabia

Background: Adequate pre-dialysis education was found to help patients select the best modality at the time dialysis is needed. Objectives: To identify the barriers to pre-dialysis education in the nephrology clinics among end-stage renal disease (ESRD) in the Kingdom of Saudi Arabia (KSA). Methods: We did a multi-center, cross-sectional study on 221 patients. A questionnaire was used to collect data about patients’ demographics, the primary cause of renal failure, and barriers to pre-dialysis education in the nephrology clinic. We selected the healthcare providers randomly from the same centers. Results: The leading cause of renal failure was diabetes mellitus (DM) in 24.9% of the Patient participants. About 64.7% were with hemodialysis, and 35.3% had peritoneal dialysis. The distance to the nephrology clinic is more than 50 km, about 63.7%. About 65.2% have followed up in the CKD clinic, and dietitians have seen 64.3% in the clinic. Dialysis educators.s have previously seen 59.7%. About 68.8% of the participants had the chance to understand dialysis modality before the commencement of treatment. The barriers from healthcare participants point out are 43.5 % of participants have no CKD clinic, 74% are without a multidisciplinary team, 61% evaluate more than 15 patients every clinic, and 43.5% assess patients with advanced chronic kidney disease every three months or more. 47.8% found many services in their hospital required to refer patients to another hospital because lack of nephrologists per 74% of participants, and 39% of them indicated no peritoneal dialysis unit. And 47.8% found no sociopsychology services play a role as a barrier. Conclusion: The barriers to pre-dialysis education studied in this paper from patients and healthcare providers points. That included the deficiency of a formal structured multidisciplinary chronic kidney disease clinic, lack of psychosocial support for CKD patients, and patients required to travel between hospitals more than 50 kilometers to get renal services. Key words: barriers, pre-dialysis, education, hemodialysis, ESRD, Saudi Arabia.

Effect of multidisciplinary care of dialysis initiation for outpatients with chronic kidney disease.

The aim of comprehensive multidisciplinary care (MDC) by the chronic kidney disease (CKD) team is not only to prevent worsening renal function, but also provide education on the selection of renal replacement therapy (RRT) by shared decision making (SDM). The purpose of this study was to examine the effects of MDC for predialysis outpatients on dialysis therapy, especially with regard to peritoneal dialysis (PD). This study evaluated 112 CKD patients who underwent dialysis at our hospital starting from 2012, with 53 outpatients receiving MDC from the CKD team and 59 outpatients not receiving MDC. Annual decreases in the estimated glomerular filtration rates (ΔeGFR), the duration from the time of intervention to dialysis initiation, the urgent dialysis rate using a temporary catheter, and the PD selection rate were compared and examined between the two groups. The ΔeGFR, the duration from intervention to PD initiation, and the PD retention rate were compared between 18 PD patients in the MDC group and 10 PD patients in the non-MDC group. The MDC group had a significantly lower ΔeGFR, significantly longer duration, and a significantly lower urgent dialysis initiation rate versus the non-MDC group. Moreover, there was a significantly higher PD selection rate, significantly prolonged duration, and significantly higher PD retention rate. Multidisciplinary CKD team care for outpatients is effective in delaying the progression of CKD and avoiding the initiation of urgent dialysis; contributing to improved PD selectivity and continuity by SDM.

Similar quality in chronic kidney disease multidisciplinary follow-up between kidney.

Introduction:Multidisciplinary clinics are the best approach towards Chronic Kidney Disease (CKD) patients in pre-dialysis phases. The few studies regarding kidney transplant recipients (KTR) compare multidisciplinary and non-multidisciplinary clinics.Methods:In this study, we compared the quality of multidisciplinary CKD care between 101 KTR and 101 propensity score-matched non-transplant pre-dialysis patients (PDP). Prevalence of patients without specific treatment at any time and percent time without specific treatment for CKD complications were the main outcomes and patient and kidney function survival, glomerular filtration rate (GFR) decline, prevalence of CKD-related complications, and percent time within therapeutic goals were the exploratory ones.Results:Time within most goals was similar between the groups, except for diastolic blood pressure (83.4 vs. 77.3%, RR 0.92, CI 0.88-0.97, p = 0.002) and hypertriglyceridemia (67.7 vs. 58.2%, OR 0.85, CI 0.78-0.93, p < 0.001), better in non-transplant PDP, and for proteinuria (92.7 vs. 83.5%, RR 1.1, CI 1.05-1.16, p < 0.001), better in KTR. Patient survival and GFR decline were similar between the groups, although non-transplant PDP tended to progress earlier to dialysis (9.9% vs. 6.9%, HR 0.39, p = 0.07, CI 0.14-1.08).Discussion:The similar findings between non-transplant PDP and KTR suggests that good and comparable quality of multidisciplinary is a valid strategy for promoting optimal clinical management of CKD-related complications in KTR.

78 Literacy and Numeracy Skills Related to Non-Steroidal Anti-Inflammatory Drugs in Patients Receiving Care at a Multidisciplinary Chronic Kidney Disease Clinic

78 Literacy and Numeracy Skills Related to Non-Steroidal Anti-Inflammatory Drugs in Patients Receiving Care at a Multidisciplinary Chronic Kidney Disease Clinic

SUN-125 NUTRITIONAL STATUS AND ORAL NUTRITIONAL SUPPLEMENT USE AMONG PATIENTS WITH NON-DIALYSIS CHRONIC KIDNEY DISEASE IN BRITISH COLUMBIA, CANADA

Undernutrition and protein-energy wasting (PEW) are complications of advanced chronic kidney disease (CKD) that are associated with increased risk of mortality and morbidity. In British Columbia, a Nutritional Supplement Policy is stewarded by renal dietitians and guides prescription of oral nutritional supplements (ONS) for CKD patients of all eGFR levels who have unintentional weight loss >10% in past 6 months, current weight of <90% of desirable body weight, inadequate nutrient intake (<80% of recommended intake), or a hypercatabolic state. Given the paucity of studies assessing ONS use among non-dialysis CKD patients at risk for undernutrition and PEW, we aimed to characterize nutritional status and ONS treatment patterns in this population. This has not been previously evaluated in a Canadian setting. We conducted a retrospective study of non-dialysis CKD patients who entered and were followed at multidisciplinary CKD clinics in the province of British Columbia, Canada between January 2013 and December 2018. We used Wilcoxon signed-rank test to compare baseline nutrition and inflammation parameters within 6 months of entry to the CKD clinics between patients with at least one ONS prescription within 1 year of entry, and patients not prescribed ONS. Using descriptive statistics, longitudinal ONS prescription patterns over 3 years were analyzed in the subset of patients who entered the CKD clinics during 2013 to 2015. 15859 patients who entered the CKD clinic during 2013 to 2018 were included in the analysis of nutritional lab parameters. Of these, 1389 patients (9%) were eligible for and prescribed ONS within 1 year of CKD clinic entry. Patients taking ONS had lower eGFR, greater age, lower body mass index, lower serum albumin, higher phosphate, lower bicarbonate, higher ferritin, higher PTH, lower hemoglobin and higher neutrophil-to-lymphocyte ratio compared with those who did not receive ONS (see Table). Differences in lab parameters between patients prescribed ONS and patients not prescribed ONS persisted when analyzed by age category and eGFR category. In the longitudinal analysis of ONS prescription patterns (N=7611), overall ONS use in the 1st, 2nd, and 3rd year of CKD clinic follow-up remained stable (8.3%, 8.0%, 8.9% of patients, respectively), with approximately 40% new ONS users and 60% previous ONS users during the 2nd and 3rd year of follow-up. Among patients who were prescribed ONS within the first year after entry to CKD clinics and who continued follow-up in the subsequent year, 38% discontinued ONS use, 35% received 1-2 ONS prescriptions/year, and 27% received 3+ ONS prescriptions/year. Among non-dialysis CKD patients in British Columbia, 9% of patients received ONS treatment within 1 year of CKD clinic entry. These patients were identified by dietitian assessment as having undernutrition, and their nutritional status was corroborated by anthropometric and lab parameters. ONS prescription patterns demonstrate responsible prescribing and de-prescribing of ONS in a non-dialysis CKD population within a universal health care system. Future analyses will assess the effect of ONS on patient outcomes including progression to end-stage kidney disease and patient-reported symptom burden.

Correlation of sociodemographic profiles with psychological problems among hospitalized patients receiving unplanned hemodialysis

Purpose In this prospective study, we aimed to examine the sociodemographic factors and clinical factors associated with psychological disorders in chronic kidney disease (CKD) patients receiving unplanned hemodialysis (HD). Methods We prospectively enrolled 187 CKD stage 5 patients receiving unplanned HD at a tertiary hospital from January 2015 to December 2016. We used structured questionnaires to gather data about participants’ anxiety, depression, and sleep disturbance. Generalized linear regression analysis was used to examine the relationships between sociodemographic and laboratory parameters, and severity of psychological distress. Results The mean age of the participants was 60 years, and the number of men and women was 97 and 90, respectively. We did not find a significant association between anxiety, depression, and sleep disturbance scores and gender, age, marital status, religion status, education levels, and employment status and number of comorbidities. Generalized linear regression analysis showed that a multidisciplinary CKD care program in outpatient clinic disclosed a significant negative association with psychological disorders in participants. Conclusions CKD patients exhibited psychological distress when receiving unplanned HD, not closely associated with sociodemographic profiles.

Association Between Sex and Opiate and Benzodiazepine Prescription Among Patients With CKD: Research Letter.

Background:Opiate and benzodiazepine use is associated with increased mortality and poorer transplant outcomes in patients with chronic kidney disease (CKD).Objective:To determine the predictors of opiate and benzodiazepine prescription in people with kidney disease.Design:Cross-sectional, observational study.Setting:Outpatient clinics at Kingston Health Sciences Centre or at affiliated sites as of June 2017.Patients:Individuals with CKD being treated at clinics or with various dialysis modalities at Kingston Health Sciences Centre and affiliated sites.Measurements:The total number of regular opioid and benzodiazepine prescriptions was recorded for each patient. Patients were stratified based on clinical (eg, dialysis modality) and demographic (sex, age, diabetes mellitus [DM], ethnicity) characteristics, as elicited below.Methods:We evaluated opiate and benzodiazepine use by chart review in the following patient groups: conventional hemodialysis (HD) (n = 359), home hemodialysis (HHD) (n = 21), peritoneal dialysis (PD) (n = 95), patients attending the multidisciplinary chronic kidney disease clinic (MCKDC) (n = 322), and kidney transplant (KT) recipients (n = 176). Opiates and benzodiazepines were classified according to the American Hospital Formulary Service system. Patients were also stratified as white (n = 855), indigenous (n = 66), or all others (n = 48).Results:The mean age was 66.2 ± 14.9 years, 602 (61.9%) were men, and 439 (45.1%) had DM. Opiates were prescribed to 223 patients (22.9%), most frequently to HD (32.3%), followed by MCKDC (20.8%), HHD (19.0%), PD (14.7%), and KT (12.5%) (P < .001). The independent predictors of opiate prescription included DM (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.4-2.6; P < 0.001), conventional HD (vs all other treatment modalities) (OR, 1.8; 95% CI, 1.3-2.5; P < .001), and female sex (OR, 1.4; 95% CI, 1.0-1.9; P = .041) after adjustment for age and ethnicity (R2 = 0.037, P < .001). Benzodiazepines were prescribed to 106 patients (10.9%), most frequently to HD (15.9%), followed by HHD (9.5%), KT (9.1%), MCKDC (7.5%), and PD (7.4%) (P = .005). The independent predictors of benzodiazepine use included female sex (OR, 2.3; 95% CI, 1.5-3.4; P < .001) and dialysis modality (excluding MCKDC and KT) (OR, 1.8; 95% CI, 1.2-2.8; P = .006) after adjustment for ethnicity, DM, and age (R2 = 0.027, P < .001).Limitations:We were not able to ascertain the indication for prescription of these drugs or patient adherence.Conclusions:Women with kidney disease are significantly more likely to be prescribed opiates and benzodiazepines than men with kidney disease. Further research is required to determine whether these medications contribute to increased morbidity and mortality in women with kidney disease.Trial Registration:This manuscript does not meet the criteria for requiring registration or a statement of written consent from study participants. The previous submission of this manuscript already made mention of Research Ethics Board approval.

SAT-281 PROJECT FOR PREVENTION IN THE PROGRESSION OF RENAL DAMAGE THROUGH THE IMPACT OF NUTRITIONAL AND MEDICAL INTERVENTION AT SANTA AMALIA PRIMARY HEALTH PUBLIC CENTRE.

Chronic kidney disease (CKD) is associated with medical complications and quality of life deterioration. There is a lack of evidence to show that nutritional intervention could delay the progression of kidney damage. However, intervention with timely, frequent and individualized nutritional management (FINM) could be the key to the renal function preservation thus preventing complications. The objective is to apply and evaluate a multidisciplinary CKD care model (CKD-M), belonging to the cardiovascular program1 (CVP) at the primary health centre in Chile, that has predominantly low schooling and a poor socio-economic population.