Nephrology Care Research Articles

Visual decision aids to support communication and shared decision-making: How are they valued and used in practice?

It is unknown how visual decision aids support communication and shared decision-making in everyday clinical practice, and how they are perceived by patients with varying levels of health literacy and their healthcare providers. Recently, three visual decision aids have been developed for renal replacement treatment, osteoarthritis of the knee, and osteoarthritis of the hip. This study aims to explore how patients and healthcare providers use and value these visual decision aids. The evaluation of the visual decision aids was performed by coding video-recorded outpatient consultations (n = 35), by conducting reflective practice interviews with healthcare providers (n = 9), and through interviews with patients (n = 29). Consultations were coded using the 5-item OPTION instrument to measure shared decision-making, and self-developed items based on the visual decision aids and user guide. Both healthcare providers and patients valued the use of the visual decision aids, especially the overview page with all treatment options. Accordingly, it was observed that most providers mainly used the overview page. However, providers in nephrology discussed the individual treatment pages more often than providers in osteoarthritis care. This study also showed that most providers were unfamiliar with the user guide for the visual decision aids. Visual decision aids for nephrology and osteoarthritis care seem particularly useful for patients with limited health literacy. Healthcare providers in this study mainly used the overview page of the visual decision aids. Although this is valued by both providers and patients, it is also important to discuss the individual treatment pages, including the pros and cons, with patients. This study also points to differences between outpatient clinics or departments in the use and implementation of the visual decision aids. The visual decision aids for osteoarthritis are used to a limited extent. In nephrology clinics, the visual decision aid is implemented.

Towards an effective obstetric nephrology care: the Mansoura experience.

Towards an effective obstetric nephrology care: the Mansoura experience.

Facility-Level Variation in Nephrology Care among Veterans after Urinary Stone Diagnosis.

Prevention is a cornerstone for management of recurrent urinary stone disease. Current guidelines recommend metabolic evaluation, lifestyle modification, and medical treatment for patients with urinary stone disease. Nephrologists are uniquely qualified to evaluate stone risk and formulate treatment strategies to reduce that risk. The objective of this study was to determine the frequency of nephrology visits after a urinary stone diagnosis, a key window of opportunity to assess stone risk. We used nationwide data from the United States Veterans Health Administration to identify patients who had an incident stone diagnosis between 2016 and 2018. We examined the proportion of patients who visited a nephrology clinic within 6 months of stone diagnosis. We identified 42,927 Veterans with urinary stone disease. Only 2432 (5.6%) visited a nephrology clinic within six months of the index diagnosis. The proportion of patients who visited a nephrology clinic after their stone diagnosis ranged between 0.7 and 20.7% across 104 VHA sites, with a median of 4.6% (25%, 75% range 3.4-7.0%). The median rate ratio for a nephrology follow-up visit after a stone diagnosis was 1.72. Veterans with chronic kidney disease were significantly more likely to visit a nephrology clinic relative to Veterans without chronic kidney disease (OR 5.19; 95% CI 4.69, 5.74). Nephrologists are infrequently and variably involved in the care of patients after a urinary stone diagnosis, suggesting potential for quality improvement.

Associations of anaemia and iron deficiency with health-related quality of life in patients with chronic kidney disease stage G3b-5 in Japan: sub analysis of the Reach-J CKD cohort study

BackgroundIron deficiency is a major contributor to anaemia in chronic kidney diseases. The association of anaemia and iron deficiency with health-related quality of life in Japanese patients with non-dialysis chronic kidney disease has not been examined. In this study, we evaluated anaemia and iron deficiency in patients with chronic kidney disease G3b-5 and examined their associations with health-related quality of life.MethodsThis nationwide cohort study included 2,249 patients with advanced chronic kidney disease receiving nephrologist care from 31 representative facilities throughout Japan; they were randomly selected through stratification by region and facility size and aligned with the Chronic Kidney Disease Outcomes and Practice Patterns Study. Using baseline patient data, we assessed the association of anaemia and iron deficiency with health-related quality of life, employing the 36-item Kidney Disease Quality of Life Questionnaire.ResultsThe mean mental and physical component summary scores for all patients were 49 and 47, respectively. Patients with haemoglobin levels < 10 g/dL had worse three kidney disease subscale, mental component summary, physical component summary, and subdomain scores than those with haemoglobin levels > 12 g/dL. Patients with absolute iron deficiency (TSAT < 20% and ferritin < 100 ng/mL) had worse three kidney disease subscale and mental component summary scores than those with functional iron deficiency (TSAT < 20% and ferritin ≥ 100 ng/mL).ConclusionsJapanese patients with chronic kidney disease G3b-5 with anaemia or absolute iron deficiency had worse health-related quality of life. Our results provide clinical evidence of renal anaemia in Japan and will be useful for international comparisons.

Enhancing Nephrology Care: Comprehensive Training for Nurses in Vascular Access Management

Enhancing Nephrology Care: Comprehensive Training for Nurses in Vascular Access Management

The ABCs of post-preeclampsia outpatient nephrology care: the Le Mans strategy.

Preeclampsia and hypertensive disorders of pregnancy complicate 3 to 5% of all pregnancies. Chronic kidney disease (CKD), at any stage, reportedly affects 3% of women in childbearing age but most of the time is underdiagnosed, especially in asymptomatic early stages. The link between preeclampsia/hypertensive disorders of pregnancy and CKD is bidirectional and women experiencing a preeclampsia/hypertensive disorder of pregnancy episode are at higher risk for developing CKD later in life, as well as metabolic and cardiovascular diseases. In turn, CKD is a risk factor for preeclampsia/hypertensive disorders of pregnancy. Thus, it is important to follow up patients after an episode of preeclampsia/hypertensive disorders of pregnancy in order to make a timely diagnosis of CKD or reduce the risk of another episode of preeclampsia/hypertensive disorder of pregnancy during a subsequent pregnancy. In Le Mans, we set up a dedicated outpatient clinic for women who experienced an episode of preeclampsia/hypertensive disorder of pregnancy. Inthis point of view paper, we present how we manage post-preeclampsia, in the hope that sharing this experience can promote the creation of dedicated outpatient clinics in other settings that will contribute to women's health.

Association between Vitamin D Hypovitaminosis and Sarcopenic Obesity in Patients with Chronic Kidney Disease Stages 3 and 4

The relationship between sarcopenic obesity and hypovitaminosis D in individuals with chronic kidney disease is complex and has significant impacts on muscle and bone health. An observational, cross-sectional, and analytical study was conducted to analyze possible associations between serum vitamin D levels and sarcopenic obesity in patients with chronic kidney disease stages 3 and 4 in a cohort of patients under nephrology care. The presence of sarcopenic obesity was assessed using bioimpedance criteria, and vitamin D levels were measured and recorded for each patient. Statistically significant associations were found between sarcopenic obesity and suboptimal vitamin D levels (p < 0.005) as well as between severe sarcopenia and hypovitaminosis D (p < 0.05) in patients with chronic kidney disease stages 3 and 4. Patients with optimal levels of vitamin D showed better muscle quality and a lower prevalence of sarcopenia and severe sarcopenia. The findings suggest that vitamin D levels play a crucial role in muscle quality in patients with CKD stages 3 and 4. Maintaining optimal levels of vitamin D may help reduce the prevalence of sarcopenic obesity and improve quality of life in these patients.

Assessment and management of emergencies during haemodialysis.

The haemodialysis unit is a complex clinical environment. Medical emergencies complicating haemodialysis treatment are relatively infrequent but are associated with high morbidity and mortality. The management of intradialytic emergencies is challenging and relevant to the practice of all nephrology and critical care clinicians. There are no dedicated resuscitation guidelines for this unique patient population. This review article provides an outline of the assessment and treatment of important intradialytic emergencies(hypotension, hypertension, haemorrhage, hypoxia, neurologic disturbances, cardiac arrest) based on the best available evidence.

Medications for community pharmacists to dose adjust or avoid to enhance prescribing safety in individuals with advanced chronic kidney disease: a scoping review and modified Delphi

BackgroundCommunity pharmacists commonly see individuals with chronic kidney disease (CKD) and are in an ideal position to mitigate harm from inappropriate prescribing. We sought to develop a relevant medication list for community pharmacists to dose adjust or avoid in individuals with an estimated glomerular filtration rate (eGFR) below 30 mL/min informed through a scoping review and modified Delphi panel of nephrology, geriatric and primary care pharmacists.MethodsA scoping review was undertaken to identify higher risk medications common to community pharmacy practice, which require a dose adaptation in individuals with advanced CKD. A 3-round modified Delphi was conducted, informed by the medications identified in our scoping review, to establish consensus on which medications community pharmacists should adjust or avoid in individuals with stage 4 and 5 CKD (non-dialysis).ResultsNinety-two articles and 88 medications were identified from our scoping review. Of which, 64 were deemed relevant to community pharmacy practice and presented for consideration to 27 panel experts. The panel consisted of Canadian pharmacists practicing in nephrology (66.7%), geriatrics (18.5%) and primary care (14.8%). All participants completed rounds 1 and 2 and 96% completed round 3. At the end of round 3, the top 40 medications to adjust or avoid were identified. All round 3 participants selected metformin, gabapentin, pregabalin, non-steroidal anti-inflammatory drugs, nitrofurantoin, ciprofloxacin and rivaroxaban as the top ranked medications.ConclusionMedications eliminated by the kidneys may accumulate and cause harm in individuals with advanced chronic kidney disease. This study provides an expert consensus of the top 40 medications that community pharmacists should collaboratively adjust or avoid to enhance medication safety and prescribing for individuals with an eGFR below 30 mL/min.

Feasibility and Acceptability of a Palliative Care Intervention Among Older or Adults with Advanced CKD and their Caregivers.

In non-nephrology settings, specialty Palliative Care (PC) improves decision-making, patient's quality of life (QoL), advance care planning (ACP), and certain indicators of the quality of end-of-life (EoL) care. This pilot RCT explored the feasibility and acceptability of a PC intervention, CKD-EDU, for older adults ≥75 years with eGFR ≤25 ml/min and their caregivers. Participants randomized to the control group received standard nephrology care and routine kidney therapy (KT) education, while those randomized to CKD-EDU received a decision aid and met with a PC clinician up to three times to discuss KT decisions and EoL planning. Patients were assessed at baseline, 4-6, 12-14, and 24-26 weeks. Main outcomes included intervention feasibility and acceptability, decision-conflict, and patient QoL. The mediating effects of reduced decision conflict on improved QOL were explored, as were the effects of CKD-EDU on ACP, EoL treatment intensity and 6-month-hospitalization. Statistical analyses encompassed descriptive analyses, adjusted repeated-measure-models, mediation analyses and logistic-regression models. Among the 127 eligible patients screened, 58 (44%) consented: 30 were randomized to CKD-EUD and 28 to the control arm. All patients completed baseline assessments, and 89% completed at least one intervention session (n=26/29), underscoring intervention adherence and feasibility. Similarly, assessments completion rates at 4 (83%, n=45/54) ), 12 (93%, n=42/45), and 24 (95%, n=40/42) weeks were high. The intervention received over 85% acceptability ratings for all questions. Patients exposed to CKD-EDU exhibited significant improvement in decisional conflict scale scores (P = 0.003) at 4-6 weeks and improvements in QoL at 24-26 weeks (P=0.02). Exploratory analyses were not statistically significant in this pilot, but all effect sizes were in the predicted direction. This study demonstrates the feasibility and acceptability of CKD-EDU. A larger scale trial is warranted to assess its effectiveness in improving key outcomes important to patients and families.

HGGL-01 GLIOBLASTOMA MULTIFORM INVOLVING MULTIPLE BRAIN REGIONS ASSOCIATED WITH MUTATIONS IN EXON 4 OF ISOCITRATE DEHYDROGENASE 1 COMPLICATED BY ACUTE KIDNEY FAILURE: A CASE REPORT

Abstract Glioblastoma multiform (GBM), WHO grade 4, is the most aggressive primary brain tumor in adults associated with poor prognosis. We present a case of a 43-year-old female, Muyira, diagnosed with GBM involving multiple brain regions and harboring mutations in exon 4 of isocitrate dehydrogenase 1, who subsequently developed acute kidney failure. The patient initially presented with progressive neurological symptoms, including headache and cognitive decline. Multiplanar multiecho MRI of the brain was performed with IV contrast in orthogonal plane and revealed a moderate sized multilobulated heterogeneously and predominantly peripherally enhancing mass lesion with irregular margins and central non enhancing areas of necrosis arising from the right corona radiata, insular cortex, external capsule, lentiform nucleus, temporal, and frontal white matter with blood products. Perilesional edema was seen. Effacement of sulcal spaces. Right sylvian fissure, compression over right ventricle and midline shift of 8mm toward left side. There was dilatation of the left lateral ventricle with periventricular cerebrospinal fluid ooze. Uncal herniation was right side. On MR spectroscopy large choline, creatinine levels were seen in the lesion with reduced N-acetyl aspartate levels as compared to the normal parenchyma. Findings were suggestive of neoplastic lesion mostly high-grade glioma. Polymerase chain reaction sequencing confirmed the presence of missense mutation R132H in exon 4 of isocitrate dehydrogenase 1 gene. Despite maximal safe surgical resection, the patient developed acute kidney failure secondary to the nephrotoxic effects of gadolinium. Management of both the primary brain tumor and renal complication necessitated a multidisciplinary approach involving neurosurgery, oncology, nephrology, and supportive care. Despite aggressive interventions, the patient’s condition deteriorated, highlighting the challenges in managing concurrent life-threatening conditions in patients with advanced GBM.

Facility-Level Variation in Nephrology Care among Veterans after Urinary Stone Events

Facility-Level Variation in Nephrology Care among Veterans after Urinary Stone Events

Advancing Nephrology Care Access for Veterans: Implementation and Insights from a Telenephrology Program

Advancing Nephrology Care Access for Veterans: Implementation and Insights from a Telenephrology Program

Enhancing Access to Nephrology Care: Development of a Telenephrology Dashboard via Human-Centered Design

Enhancing Access to Nephrology Care: Development of a Telenephrology Dashboard via Human-Centered Design

Impact of Predialysis Nephrology Care on Incident Vascular Access Outcome among Hispanic Individuals: A Causal Mediation Analysis

Impact of Predialysis Nephrology Care on Incident Vascular Access Outcome among Hispanic Individuals: A Causal Mediation Analysis

The impact of life events on child and adolescent psychiatry consultations

Purpose: Children are exposed to many adverse life events, and this may cause psychiatric disorders. In this study, we aimed to investigate the effects of two different life events, the COVID-19 pandemic and the earthquake, on the consultations requested. Materials and Methods: 1268 consultations requested from the child and adolescent psychiatry department between March 2019 and March 2023 were reviewed from hospital records. The specified period was divided into four distinct parts with one-year intervals: pre-pandemic, the first year of the pandemic, the second year of the pandemic, and post-pandemic. The age, gender, diagnoses of the cases, the department requesting consultation and the reason for consultation were recorded. Results: There were statistically significant differences between periods in terms of departments requested consultation, consultation reasons, and diagnoses. Compared to previous periods, a decrease was found in pediatric emergency and general pediatric clinic consultations in the post-pandemic period. In contrast, an increase was seen in nephrology and intensive care unit department consultations because of earthquakes. In the first year of the pandemic, more consultations were requested from the hematology &amp; oncology department compared to other years. While the rate of consultations requested for suicide attempts decreased in the post-pandemic period, consultations for psychiatric assessment increased. Conclusion: Consultation-liaison psychiatry, which is at the center of interdisciplinary interaction, maintains its importance in the prevention and early diagnosis of psychological symptoms that can develop due to both organic events and the effect of trauma itself after the life events.

Transition of care from pediatric to adult nephrology post-renal transplant: a review.

Pediatric renal transplant recipients (RTRs) face heightened risks when they transition from a childhood nephrologist to an adult-centered one. The transition of care usually occurs when an individual is between ages 18 and 21 years, although some change providers earlier or later depending on varying circumstances. Turbulence during this shift can significantly impact daily life and, in severe cases, lead to graft loss. Several modern studies have explored the transition from pediatric to adult-centered nephrology care post-renal transplant. In this review, we first provide an overview of the differences between pediatric and adult renal transplant, highlighting unique challenges faced by pediatric patients such as donor-recipient size disparity, growth impairment, and need for additional immunizations. We then emphasize the criticality of a well-planned transition process, identifying factors that can hinder a smooth transition-such as medical and medication nonadherence, lack of health literacy, patient psychosocial challenges, and systemic shortcomings in coordination between care teams. Furthermore, this review outlines existing protocols and risk assessment tools, in addition to highlighting recent advancements aimed at facilitating smoother transitions such as the RISE protocol, readiness assessment, and the use of multidisciplinary teams. Proper implementation of coordinated, evidence-based transition protocols can improve patient outcomes, promote medication and appointment adherence, and reduce graft rejection rates. Efforts from multidisciplinary teams utilizing technology, risk stratification tools, and open communication between providers and patients are key to optimizing the transition process for pediatric RTRs as they transfer to adult-centered care.

First interim results from FINE-REAL: a prospective, non-interventional, phase 4 study providing insights into the use and safety of finerenone in a routine clinical setting.

Finerenone, a selective non-steroidal mineralocorticoid receptor antagonist, improves kidney and cardiovascular outcomes in patients with chronic kidney disease (CKD) associated with type 2 diabetes (T2D). The FINE-REAL study (NCT05348733) aims to evaluate the characteristics and treatment patterns of participants treated with finerenone in clinical practice. FINE-REAL is a prospective, single-arm, non-interventional study of patients initiated on finerenone as part of their routine care in accordance with country-approved labels. The study, initiated in June 2022, is expected to be completed by January 2028. The cutoff for this pre-specified interim analysis was June 13, 2023. Participants were recruited across nephrology, endocrinology, cardiology, and primary care settings. Of 556 participants enrolled in the study by the cut-off date, 504 were included in this analysis (median follow-up duration of 7months [finerenone treatment initiation to last recorded observation]). At baseline, 76.1% of participants were in the high or very high (KDIGO) CKD risk categories. Angiotensin converting enzyme inhibitors/angiotensin receptor blockers and sodium-glucose cotransporter 2 inhibitors were prescribed to 71.8% and 46.6% of participants, respectively. Based on prescribing information, 87.9% and 12.1% of participants initiated finerenone at doses of 10 and 20mg, respectively. Finerenone treatment was uninterrupted in 92.3% of participants after 7months' median follow-up. Treatment-emergent adverse events occurred in 110 (21.8%) participants. Hyperkalemia occurred in 25 (5.0%) participants, with no cases leading to death, dialysis, or hospitalization. At this interim analysis, finerenone was initiated in patients with CKD and T2D across various clinical practices participating in the study. Treatment discontinuation and hyperkalemia occurred infrequently.

Race- and Ethnicity-Related Disparities in Predialysis Nephrology Care, Kidney Disease Education, and Home Dialysis Utilization.

Pre-dialysis nephrology care and kidney replacement therapy (KRT)-directed education (KDE) are essential for incident home dialysis use. However, there are substantial disparities in these care parameters among patients with advanced CKD. The impact of these disparities on home dialysis underuse has not been examined. We analyzed the 2021 US Renal Database System to identify all adult kidney failure patients with over six months of pre-dialysis Medicare coverage initiating their first-ever dialysis between 2010 and 2019. We used a mediation analysis to dissect the attributable influence of disparities in pre-dialysis nephrology care and KDE on incident home dialysis use. Additionally, we conducted sensitivity analyses using graded levels of mediators and sustained impact on home dialysis outcomes. We identified 464,310 Medicare recipients: 428,301 using incenter hemodialysis and 35,416 using home dialysis as their first-ever dialysis modality during the study period. Compared to non-Hispanic White patients (n=294,914), adjusted odds ratio (95% confidence intervals) for receiving pre-dialysis nephrology care, KDE service, and incident home dialysis were 0.62(0.61, 0.64), 0.58(0.52, 0.63) and 0.76(0.73, 0.79) respectively among Hispanic individuals (n=49,734), and 0.74(0.73, 0.76), 0.84(0.79, 0.89), and 0.63(95%CI:0.61, 0.65) respectively among Black individuals (n=98,992). Mediation analyses showed that compared to non-Hispanic White individuals, lack of nephrology care explained 30% and 14% of incident home dialysis underuse among Hispanic and Black individuals, respectively (p<0.001). Sensitivity analyses using a longer duration of nephrology care and KDE services and the sustained impact on home dialysis underuse through the first-year post-kidney failure showed congruent and consolidating findings. Disparities in pre-dialysis nephrology care were significantly associated with lower home dialysis among Hispanic and Black individuals.

The Pattern of Practice in the Management of Early Diabetic Kidney Disease.

Background and objectives Diabetes is a leading cause of kidney failure in various regions worldwide. To detect renal disease in individuals with diabetes, screening typically involves evaluating the glomerular filtration rate and measuring albuminuria. Although there are established guidelines for these screenings, adherence to them varies. This study aims to examine the prevalence of albuminuria screening among adults with diabetes mellitus (DM) and to assess the different practices in managing these patients across primary and tertiary care settings. Methods This cross-sectional observational study involved adult patients with DM attending outpatient clinics in both primary and tertiary care settings. Patient data were gathered using a standardized form, excluding those with established chronic kidney disease (CKD) who were under nephrology care. Results The study included 1,010 patients, with 303 (30%) from primary care clinics and 707 (70%) from tertiary care clinics. The cohort comprised 582 (58%) females, with a median age of 62 years (IQR: 55-70), and approximately 990 (98%) had type 2 DM (T2DM). Annual albumin-to-creatinine ratio (ACR) screening was conducted for 498 out of 1,010 patients (49%) (95% confidence interval {CI}: 46%-52%). Screening compliance was notably higher in primary care settings compared to tertiary care clinics. Older patients (over 60 years) and those with hypertension or cardiac conditions were less likely to undergo screening. Among those screened, 185 of 498 patients (37%) (95% CI: 33%-41%) had abnormal albuminuria (ACR > 3). Conclusion Albuminuria is a significant indicator of progressing renal disease and cardiovascular risk. The annual screening rate for albuminuria in diabetic patients is inadequate. Primary care physicians show better adherence to screening guidelines compared to their tertiary care counterparts. Increasing physician awareness about the importance of screening could improve guideline compliance and mitigate the adverse effects of albuminuria.