Nephrology Care Research Articles

MO854: Implementation of a Geriatric Assessment in Elderly Hemodialysis Patients

Abstract BACKGROUND AND AIMS Elderly patients who are on hemodialysis (HD) have a higher burden of multimorbidity and geriatric syndromes, that are underdiagnosed. These aspects affect quality of life and may lead to higher hospitalization rates and mortality rates. Despite guideline recommendations, geriatric assessment is not part of standard clinical care. The aim of this study was to assess the prevalence of geriatric impairments and frailty in patients ≥ 65 years old on maintenance HD by means of a geriatric assessment (GA). METHOD Cross-sectional study involving patients ≥ 65 years old on maintenance HD at a secondary Hospital in Ecuador between March and April 2021. Baseline demographic data, clinical and dialysis characteristics were collected from the medical charts and during the baseline assessment. All participants underwent a GA, including 5 domains: (1) comorbidity burden: Charlson comorbidity Index, (2) assessment of basic and instrumental activities of daily living (ADL: Barthel Index and iADL: Lawton and Brody index), (3) cognition: Pfeiffer Short Portable Mental Status Questionnaire, (4) mood: 5-item version of the Geriatric Depression Scale and (5) nutrition: Mini Nutritional Assessment (MNA) score. In addition, 3 frailty screening tools were applied: Frail-VIG Index (IF-VIG), Clinical Frailty Scale (CFS) and the clinical judgment of the nephrologist (surprise question). For the clinical judgment, the treating physician was asked to indicate if he would be surprised if the patient died in the next 6 months. Data were summarized using means with standard deviation or proportions when appropriate. Differences regarding baseline characteristics and outcomes between fit and frail patients stratified according to the Frail-VIG Index were assessed using Chi-squared tests and t-tests as appropriate. RESULTS Thirty-two patients were included, mean age 72.2 ± 5.83 years and 78.1% (n = 25) were men. Geriatric impairments were highly prevalent. Most frequently impaired geriatric domains were: functional performance (ADL 71.9% and iADL 75%), depression (40,6%), risk for malnutrition (68.8%), symptoms of cognitive decline (25%) and severe comorbidity (Charlson Index = 5.6 ± 2.3). The prevalence of frailty differed widely according to the different frailty screening tools. According to the IF-VIG, CFS and the clinical judgment, 56.2%, 37.7% and 35% of the patients were found frail, respectively. No differences between frail and fit patients were found in demographics nor in the prevalence of impairment in cognition, symptoms of depression, malnutrition, severe comorbidity or impairment in basic activities of daily living. Frail patients were more care dependent in their instrumental iADL compared with the fit group (P = 0.024) (Figure 1). CONCLUSION Geriatric impairments are highly prevalent in patients ≥ 65 years old on chronic HD. Since impairments can be missed when not searched for in regular dialysis care, the first step of improving nephrologic care is awareness of the extensiveness of geriatric impairment.

MO562: Prevalence and Determinants of Predialysis Dietitian Follow-Up-Results From the Brazilian Dialysis Registry

Abstract BACKGROUND AND AIMS There are lacking of data regarding predialysis dietitian follow-up of CKD patients considering large populational datasets. We aimed to evaluate the prevalence and socio-demographic determinants of predialysis dietitian follow-up in a large cohort of Brazilian dialysis patients. METHOD We evaluated retrospectively data from all incident adult dialysis patients included in the Brazilian Dialysis Registry from January 2011 to September 2021. Predialysis dietitian follow-up was said to be present when a period >6 months of dietitian care was reported. Gender, age, skin color, education, body mass index, chronic kidney disease (CKD) etiology, first chronic dialysis program, healthcare provider and geographic regions were considered in the logistic regression model. RESULTS A total of 10 382 patients met the inclusion criteria and 1254 (12.1%) reported predialysis dietitian follow-up, and most of them referred by nephrologist (94.2%). The independent determinants of dietitian follow-up were older age, white skin color, higher education level, not having diabetes, living in North/Northeast and South (compared with Southeast), and having a nonpublic healthcare provider. When considered only patients with predialysis nephrologic care, higher education, hemodialysis as the first dialysis modality and living in the North/Northeast and South regions (compared with Southeast) were associated with dietitian follow-up. CONCLUSION Predialysis dietitian follow-up for more than 6 months in a country in which the public health system is the main dialysis provider is still very low. The nephrologist is pivotal for referral to dietitians but socioeconomic factors also seem to play a role in this regard.

MO464: Long-Term Renal Outcomes After ST-Elevation Myocardial Infarction Treated by Percutaneaous Coronary Intervention

Abstract BACKGROUND AND AIMS Among patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI), short- and long-term renal function evaluations are of prime importance. Most studies have focused on short-term renal dysfunction and acute kidney injury (AKI) occurrence after STEMI treated by PCI, which is associated with major adverse cardiovascular events (MACE) and especially the occurrence of heart failure. However, few studies have focused on long-term renal outcomes. We aimed to describe renal function evolution and to determine predictors of estimated glomerular filtration rate (eGFR) decline one year after STEMI is treated by PCI. METHOD From May 2016 to July 2020, 322 consecutive patients with STEMI who underwent PCI revascularization were enrolled prospectively. Serum creatinine (SCr) concentration was routinely measured at patient admission, after 48 h or hospital discharge, then during systematic 1-month and 1-year clinical check-ups, AKI was determined according to the Acute Kidney Injury Network (AKIN) definition. The estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD EPI) formula. The evolution of renal function was evaluated by the difference between admission and 1-month or 1-year eGFR. Rapid progression was defined as a decline in eGFR of more than 5 mL/min/1.73m² per year. Determinants of eGFR decline ≥ 10 mL/min/1.73m² per year were analyzed with multivariate logistic regressions. RESULTS The mean age was 59.6 years, 29.5% of patients had a medical history of hypertension, 13.8% had diabetes and 52.8% presented with anterior myocardial infarction. Median admission SCr concentration was 71 µmol/L, with an eGFR of 96.5 mL/min/1.73m² [inter quartile range (IQR): 84.4–105.1]. A total of 38 patients (11.8%) developed AKI. In the whole population median eGFR decline was 7.7 mL/min/1.73 m² (1.2–14.4) and 8 mL/min/1.73 m² [1.3–15.9] 1-month and 1-year after STEMI respectively (Figure 1). Rapid eGFR decline was found in 59.7% of the total population and 44.6% of patients presented a 1-year eGFR decline of at least 10 mL/min/1.73 m². AKI patients had significant lower eGFR at 1-month and 1-year follow up (median 1-year eGFR of 74.5 mL/min/1.73m² (52.4–96.4) versus 88.1 mL/min/1.73m² (74.0–100.3) in non-AKI patients, P = 0.01). There was no significant difference between AKI and non-AKI patients regarding rates of eGFR decline at both 1-month and 1-year after inclusion. Multivariate analysis (Table 1) showed that age and 1-month eGFR decline was significantly associated with 1-year eGFR decline ≥ 10 mL/min/1.73m². Especially, 1-month eGFR decline greater than 10 mL/min/1.73m² was an independent and stratified predictor of 1-year eGFR decline with an odds ratio (OR) of 7.45 [95% confidence interval (CI): 2.76–22.81, P < 0.01). AKI occurrence and peak hs-I troponin were not found as predictors of 1-year eGFR decline. CONCLUSION Among STEMI patients treated by PCI, a large majority of patients present a significant decline in renal function 1-year after STEMI, regardless of AKI occurrence or infarct size. One-month eGFR decline is a strong predictor of 1-year eGFR evolution and could help identify high-risk patients and adjust nephrological care. Our findings bear important clinical implications and underline the need for longitudinal follow-up of renal function after STEMI is treated by PCI.

An evaluation of patient's knowledge about acute kidney injury pre- and post-follow-up clinic

Acute kidney injury (AKI) is a common occurrence among hospital patients, with patients being cared for by a wide range of health care specialties, rather than purely under the care of nephrologists. Patients with severe AKI are known to have poorer outcomes if they do not receive appropriate follow-up and medication reviews. Following the successful implementation of a nurse-led AKI follow-up clinic, a service evaluation was undertaken to assess whether there had been any impact on patients' knowledge of AKI. Patients were asked to assess their perceived knowledge about AKI before and after attending an AKI nurse-led clinic appointment. The results found that patients were more knowledgeable following attendance at clinic and felt reasonably confident in preventing future AKI.

No additional benefit of prescribing a very low-protein diet in patients with advanced chronic kidney disease under regular nephrology care: a pragmatic, randomized, controlled trial

Whether a very low-protein diet supplemented with ketoanalogues (sVLPD), compared with a standard low-protein diet (LPD), improves outcomes in patients with chronic kidney disease (CKD) under stable nephrology care is undefined. To compare the effectiveness of sVLPD compared with LPD in patients regularly seen in tertiary nephrology care. Participants were patients with CKD stages 4-5, followed for at least 6 mo, randomly allocated to receive sVLPD or LPD [0.35 or 0.60g/kg ideal body weight (IBW)/d, respectively], stratified by center and CKD stage. The primary outcome was time to renal death, defined as the first event between end-stage renal disease (ESRD) and all-cause mortality; secondary outcomes were the single components of the primary outcome, cardiovascular outcome, and nutritional status. We analyzed 223 patients (sVLPD, n=107; LPD, n=116). Mean age was 64 y, 61% were male, and 35% had diabetes. Median protein intake (PI), which was 0.8g/kg IBW/d at baseline in both groups, was 0.83 and 0.60g/kg IBW/d in LPD and sVLPD, respectively, during the trial with a large decrease only in sVLPD (P = 0.011). During a median of 74.2 mo, we recorded 180 renal deaths (141 dialysis and 39 deaths before dialysis). Risk of renal death did not differ in sVLPD compared with LPD (HR: 1.17; 95% CI: 0.88, 1.57; P = 0.28). No difference was observed for ESRD (HR: 1.12; 95% CI: 0.81, 1.56; P = 0.51), mortality (HR: 0.95; 95% CI: 0.62, 1.45; P = 0.82), or time to fatal/nonfatal cardiovascular events (P=0.2, log-rank test). After 36 mo, still active patients were 45 in sVLPD and 56 in LPD. No change of nutritional status emerged during the study in any arm. This long-term pragmatic trial found that in patients with CKD under stable nephrology care, adherence to protein restriction is low. Prescribing sVLPD compared with standard LPD is safe but does not provide additional advantage to the kidney or patient survival.

Provider Perspectives and Clinical Outcomes with Inpatient Telenephrology.

Despite the dramatic increase in the provision of virtual nephrology care, only anecdotal reports of outcomes without comparators to usual care exist in the literature. This study aimed to provide objective determination of clinical noninferiority of hybrid (telenephrology plus face-to-face) versus standard (face-to-face) inpatient nephrology care. This retrospective study compares objective outcomes in patients who received inpatient hybrid care versus standard nephrology care at two Mayo Clinic Health System community hospitals. Outcomes were then additionally compared with those patients receiving care at another Mayo Clinic Health System site where only standard care is available. Hospitalized adults who had nephrology consults from March 1, 2020 to February 28, 2021 were considered. Regression was used to assess 30-day mortality, length of hospitalization, readmissions, odds of being prescribed dialysis, and hospital transfers. Sensitivity analysis was performed using patients who had ≥50% of their care encounters via telenephrology. Structured surveys were used to understand the perspectives of non-nephrology hospital providers and telenephrologists. In total, 850 patients were included. Measured outcomes that included the number of hospital transfers (odds ratio, 1.19; 95% confidence interval, 0.37 to 3.82) and 30-day readmissions (odds ratio, 0.97; 95% confidence interval, 0.84 to 1.06), among others, did not differ significantly between controls and patients in the general cohort. Telenephrologists (n=11) preferred video consults (82%) to phone for communication. More than half (64%) of telenephrologists spent less time on telenephrology compared with standard care. Non-nephrology hospital providers (n=21) were very satisfied (48%) and satisfied (29%) with telenephrology response time and felt telenephrology was as safe as standard care (67%), while providing them enough information to make patient care decisions (76%). Outcomes for in-hospital nephrology consults were not significantly different comparing hybrid care versus standard care. Non-nephrology hospital providers and telenephrologists had favorable opinions of telenephrology and most perceived it is as safe and effective as standard care. This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_04_11_CJN13441021.mp3.

The European Green Deal and nephrology: a call for action by the European Kidney Health Alliance.

The world faces a dramatic man-made ecologic disaster and healthcare is a crucial part of this problem. Compared with other therapeutic areas, nephrology care, and especially dialysis, creates an excessive burden via water consumption, greenhouse gas emission and waste production. In this advocacy article from the European Kidney Health Alliance we describe the mutual impact of climate change on kidney health and kidney care on ecology. We propose an array of measures as potential solutions related to the prevention of kidney disease, kidney transplantation and green dialysis. For dialysis, several proactive suggestions are made, especially by lowering water consumption, implementing energy-neutral policies, waste triage and recycling of materials. These include original proposals such as dialysate regeneration, dialysate flow reduction, water distillation systems for dialysate production, heat pumps for unit climatization, heat exchangers for dialysate warming, biodegradable and bio-based polymers, alternative power sources, repurposing of plastic waste (e.g. incorporation in concrete), registration systems of ecologic burden and platforms to exchange ecologic best practices. We also discuss how the European Green Deal offers real potential for supporting and galvanizing these urgent environmental changes. Finally, we formulate recommendations to professionals, manufacturers, providers and policymakers on how this correction can be achieved.

Changes in patient activation in people starting dialysis: A prospective longitudinal, observational study.

IntroductionIncreased patient activation is associated with improved health outcomes; however, little is known about patient activation in people with end‐stage kidney disease at the start of their dialysis journey. This study aimed to measure activation status changes over the first 4 months of dialysis.MethodsProspective, longitudinal, and observational study. Incident patients initiating dialysis at 25 in‐center hemodialysis and 17 home dialysis programs across three US states managed by the same dialysis provider completed the 13‐item Patient Activation Measure (PAM‐13) survey at baseline (month 1 after commencement of dialysis) and follow‐up (month 4). The survey yields a score (0–100) that corresponds to four levels (1–4), with higher scores or levels indicating higher activation.FindingsOne hundred eighty‐two participants (139 center, 43 home) completed both baseline and follow‐up surveys. Mean age was 60 ± 15 years, 40% female. Mean PAM‐13 scores were 65.1 ± 16.8 and 64.8 ± 17.8 at baseline and follow‐up, respectively; mean intraindividual change: −0.3 ± 17.3. The proportions of patients at levels 1–4 at baseline were 11%, 23%, 35%, and 31% respectively. At follow‐up, 50%, 64%, 52%, and 37% of participants at levels 1–4, respectively, changed to a different PAM level (Spearman correlation = 0.47; p < 0.001). Home dialysis was associated with higher PAM scores when compared to in‐center hemodialysis in multivariable analyses, adjusted for sociodemographic variables, comorbidities, and predialysis nephrology care (β = 5.74, 95% confidence intervals [CI]: 0.11–11.37 and 9.02, 95% CI: 3.03–15.02, at baseline and follow–up, respectively).DiscussionAlthough aggregated group scores and levels remained stable, intra‐individual patient activation changed significantly during the first 4 months of dialysis. This novel finding is foundational to future projects aiming to design interventions to improve patient activation.

Four decades of urolithiasis: What has changed in our practice?

Urolithiasis is the most common urologic disease in Pakistan, which is treated and managed by urologists throughout their careers.1 Its exact prevalence and incidence has never been investigated in the country, but a few rough estimates show the disease prevalence to be 9-15%.2 The oldest study on urolithiasis on 400 patients, was published in 1975, which showed predominantly bladder stone disease accounting for 60% of all cases.3 After the first publication, about 35 papers have been published on this subject from Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan. SIUT is a major tertiary care urology and nephrology center with a catchment area extending to almost the entire country.&#x0D; In this resume the subject of stone disease from 1971 onwards will be presented to note the changes in its epidemiology and management. Collectively, 83,107 adult stone patients were treated during the above period. The number of stone patients has increased enormously from 2,345 between 1971-1982 to 8,905 during 1983-1993, and 27,541 during 1994-2004 period. Finally, during the years, 2005-2014, 45,318 patients were managed.4 This tremendous increase in the number of patients could be attributed to increasing free facilities of minimally invasive surgery including Extracorporeal shock wave lithotripsy (ESWL), Percutaneous Nephrolithonomy (PCNL) and Ureteroscopy (URS) at this institute, availability of ultrasound at tehsil and district level hospitals, or due to increasing incidence and prevalence of stone disease in the country.&#x0D; Similarly, if the peak age and gender differences at different periods in the four decades are studied, then it can be seen that from 1972-1974, the peak age was 21-40 years with M:F ratio of 4.5:1.3, in 1987-1990, it was 31-40 years with M:F ratio 4.1:1, in 1991-1993, it was 21-30 years with M:F ratio of 4.8:1, in 2001-2004, it was 31-40 years with M:F ratio of 1.7:1.4&#x0D; Continue...

257 Factors Associated with Primary Care Provider (PCP) Use Among Home Dialysis Patients

OBJECTIVES/GOALS: Patients utilizing dialysis receive fewer primary care services, especially during the time of initiation of dialysis. This project aims to identify clinical or demographic factors that are associated with either initiation or continuity of PCP use after initiating home dialysis. METHODS/STUDY POPULATION: Using Medicare claims data from the United States Renal Data System (USRDS), we analyzed PCP use for patients aged 67 years or older. We included patients who initiated either peritoneal or home-hemodialysis between 2008-2014. Patients were followed for 2 years: 1 year before and after home dialysis initiation. We used a multivariable logistic model to control for various demographic and clinical factors believed to be confounders and to ascertain factors (i.e. age, race/ethnicity, area of residence, comorbidities, frailty scores) associated with initiation of PCP use or continuity of PCP use. RESULTS/ANTICIPATED RESULTS: Among the 9,854 patients analyzed, 68% of patients used PCP after dialysis initiation. 85% of patients who used PCP before dialysis continued PCP use after home dialysis initiation. Only 29% of patients who had not used PCP before dialysis initiated PCP use after. Employment (vs. unemployment) and use of home-hemodialysis (vs peritoneal) were associated with lower odds of PCP continuity of care. Diabetes and pre-dialysis nephrology care were associated with greater odds of PCP continuity of care. Black race (vs White) and high frailty scores were associated with lower odds of PCP initiation. Those with cardiovascular disease, residence in the South (vs the Northeast), and residence in more urban areas (vs low urban) were associated with greater odds of PCP initiation. DISCUSSION/SIGNIFICANCE: This study highlights the prevalence of PCP use, as well as the factors and subgroups that are associated with lower PCP use among patients receiving home dialysis. These findings will guide future research, interventions and policies in order to improve our understanding of the barriers to PCP use in that population.

Initial Home Dialysis Is Increased for Rural Patients by Accessing Urban Facilities.

The 240,000 rural patients with end stage kidney disease in the United States have less access to nephrology care and higher mortality than those in urban settings. The Advancing American Kidney Health initiative aims to increase the use of home renal replacement therapy. Little is known about how rural patients access home dialysis and the availability and quality of rural dialysis facilities. Incident dialysis patients in 2017 and their facilities were identified in the United States Renal Data System. Facility quality and service availability were analyzed with descriptive statistics. We assessed the availability of home dialysis methods, depending on rural versus urban counties, and then we used multivariate logistic regression to identify the likelihood of rural patients with home dialysis as their initial modality and the likelihood of rural patients changing to home dialysis within 90 days. Finally, we assessed mortality after dialysis initiation on the basis of patient home location. Of the 97,930 dialysis initiates, 15,310 (16%) were rural. Rural dialysis facilities were less likely to offer home dialysis (51% versus 54%, P<0.001). Although a greater proportion of rural patients (9% versus 8%, P<0.001) were on home dialysis, this was achieved by traveling to urban facilities to obtain home dialysis (OR=2.74, P<0.001). After adjusting for patient and facility factors, rural patients had a higher risk of mortality (HR=1.06, P=0.004). Despite having fewer facilities that offer home dialysis, rural patients were more often on home dialysis methods because they traveled to urban facilities, representing an access gap. Even if rural patients accessed home dialysis at urban facilities, rural patients still suffered worse mortality. Future dialysis policy should address this access gap to improve care and overall mortality for rural patients.

Progressive Thrombocytopenia and Clinical Deterioration with Initial Diagnosis of Esophageal Cancer-Secondary Hemophagocytic Lymphohistiocytosis as a Complicating Cause

Gastroenterology Medicine & Research Progressive Thrombocytopenia and Clinical Deterioration with Initial Diagnosis of Esophageal Cancer-Secondary Hemophagocytic Lymphohistiocytosis as a Complicating Cause Mani Nassir1*, Adrian Schreiber2, Georg Hilfenhaus1, Sebastian Stintzing1 and Uwe Pelzer1 1Department of Hematology, Oncology and Tumor Immunology (CCM), Charity-University medicine Berlin, Berlin, Germany 2Department of Nephrology and Medical Intensive Care, Charity-University medicine Berlin, Berlin, Germany *Corresponding author: Mani Nassir, Department of Hematology, Oncology and Tumor Immunology (CCM), Charity- University medicine Berlin, Berlin, Germany Submission:March 18, 2022;Published: March 29, 2022 DOI: 10.31031/GMR.2022.06.000648 ISSN 2637-7632Volume6 Issue5

Influence of formalized Predialysis Education Program (fPEP) on the chosen and definitive renal replacement therapy option.

It is widely accepted that patients with chronic kidney disease (CKD) should play an active role in the selection of renal replacement therapy (RRT) option. However, patients' knowledge about CKD and treatment options is limited. The implementation of structured education program and shared decision-making may result in a better preparation to RRT, more balanced choice of dialysis modalities and better access to kidney transplantation (TX). The aim of this long-term study was to assess the impact of formalized Predialysis Education Program (fPEP) on knowlege on RRT options, as well as on selected and definitive therapy. The study included 435 patients (53% men, mean age 60 years) with CKD stage 4 and 5, participating in fPEP at our center. The program included at least 3 visits, during which balanced information about all RRT options was presented and self-care and informed decision-making were encouraged. The knowledge about RRT options before and after fPEP attendance, and selected and definitive RRT options were assessed. Ninety-two percent of patients received prior nephrology care. After fPEP completion, in most patients, the knowledge about CKD and RRT options and selected preferred modality improved - 40% of participants chose hemodialysis (HD), 32% peritoneal dialysis (PD) and 18% TX. During the observation period, 4% of patients died before commencement of dialysis, 2.7% received preemptive kidney transplant, 8.6% were placed on transplant waiting list, and 94% started dialysis (30% PD and 70% HD). Among those who chose PD, 69% started PD and 24% started HD; the leading causes of the discrepancy between choosing and receiving PD was the deterioration in clinical condition (50%) and change of decision (32%). The fPEP increases CKD patients' knowledge on RRT methods. The implementation of a decision-making process based on fPEP leads to a satisfying distribution between modalities, with a good concordance between chosen and definitive modality.

Interdisciplinary Care and Preparedness for Kidney Failure Management in a High-Risk Population

Rationale & ObjectiveInterdisciplinary care may improve health outcomes in patients with chronic kidney disease (CKD). Few studies have evaluated this model of health care delivery in racial and ethnic minorities.Study DesignRetrospective cohort study.Setting & ParticipantsIncident end-stage kidney disease (ESKD) patients at Montefiore Medical Center from October 1, 2013, to October 31, 2019.ExposurePre-ESKD interdisciplinary care.OutcomesPre-ESKD transplant listing and optimal kidney replacement therapy (KRT) start (use of arteriovenous access at hemodialysis initiation, outpatient hemodialysis start, preemptive transplant, or peritoneal dialysis as the first modality).Analytical ApproachWe constructed multivariable logistic regression models adjusted for sociodemographic and clinical factors to determine the odds of transplant listing and optimal KRT start between interdisciplinary versus the usual care group.ResultsOf the 295 incident ESKD patients included in our study, 84 received interdisciplinary care and 211 received usual nephrology care. The mean age was 59.9 years (standard deviation, 13.9 years), 47% were women, and 87% were African American or Hispanic. Baseline characteristics were similar between the groups, except that the interdisciplinary care group had a lower prevalence of hypertension (60% vs 75%). Compared with usual care, a higher proportion of patients in the interdisciplinary care group were listed for kidney transplant (44% vs 16%) and had an optimal KRT start (53% vs 44%). Receipt of interdisciplinary care was associated with a higher odds (OR, 5.73; 95% CI, 2.78-11.80; P < 0.001) of transplant listing compared with usual care after adjusting for important sociodemographic and clinical factors. The odds of an optimal KRT start also favored interdisciplinary care (OR, 1.60; 95% CI, 0.88-2.89; P = 0.12) but did not achieve statistical significance.LimitationsThe study was non-randomized and had a small sample size.ConclusionsInterdisciplinary care is associated with better ESKD preparedness compared with usual nephrology care alone in racial and ethnic minorities. Larger studies are needed to determine the effectiveness of interdisciplinary care in patients with advanced CKD.

Telehealth versus face-to-face visits: A comprehensive outpatient perspective-based cohort study of patients with kidney disease.

Telenephrology has become an important health care delivery modality during the COVID-19 pandemic. However, little is known about patient perspectives on the quality of care provided via telenephrology compared to face-to-face visits. We aimed to use objective data to study patients' perspectives on outpatient nephrology care received via telenephrology (phone and video) versus face-to-face visits. We retrospectively studied adults who received care in the outpatient Nephrology & Hypertension division at Mayo Clinic, Rochester, from March to July 2020. We used a standardized survey methodology to evaluate patient satisfaction. The primary outcome was the percent of patients who responded with a score of good (4) or very good (5) on a 5-point Likert scale on survey questions that asked their perspectives on access to their nephrologist, relationship with care provider, their opinions on the telenephrology technology, and their overall assessment of the care received. Wilcoxon rank sum tests and chi-square tests were used as appropriate to compare telenephrology versus face-to-face visits. 3,486 of the patient encounters were face-to-face, 808 phone and 317 video visits. 443 patients responded to satisfaction surveys, and 21% of these had telenephrology encounters. Established patients made up 79.6% of telenephrology visits and 60.9% of face-to-face visits. There was no significant difference in patient perceived access to health care, satisfaction with their care provider, or overall quality of care between patients cared for via telenephrology versus face-to-face. Patient satisfaction was also equally high. Patient satisfaction was equally high amongst those patients seen face-to-face or via telenephrology.

Prescription rate of erythropoietin-stimulating agents is low for patients with renal impairment under non-nephrology care in a tertiary-level academic medical center in Japan.

Erythropoiesis-stimulating agents (ESAs) and iron supplements may be prescribed appropriately under nephrology care. However, there are few reports detailing the differences in prescription rates of these therapies among clinical departments. A total of 39,585 patients with renal impairment were enrolled from a database of 914,280 patients. Patients were selected based on an estimated glomerular filtration rate (eGFR) less than 60ml/min/1.73m2. There were eight clinical departments from internal medicine, including nephrology. We defined a hemoglobin level less than 11.0g/dL as anemia and set 20% of transferrin saturation and 100ng/mL of serum ferritin as cutoff points. We compared the prescription rates of ESAs and iron supplementation based on the hemoglobin level and iron status among the patients seen across the eight clinical departments. The lower the eGFR, the more the number of patients seen under nephrology care. The rates of patients with no prescription were 52.3, 39.9, 45.9, and 54.3% among those with hemoglobin levels of < 8, 8 ≤ < 9, 9 ≤ < 10, and 10 ≤ < 11g/dL, respectively. Of the patients with less than 11.0g/dL of hemoglobin, 77.3% were prescribed ESAs under nephrology care. Meanwhile, only 18.5 and 8.2% of patients were prescribed ESAs in clinical departments of internal medicine, other than nephrology, and non-internal medicine care, respectively. Treatment for anemia has not been sufficiently performed in patients with renal impairment under non-nephrology care in a real-world clinical setting.

Etiology, Clinical Profile, and Short-Term Outcome of Children With Acute Kidney Injury.

Background: Acute kidney injury (AKI) is a common clinical syndrome in hospitalized children and it imposes heavy burden of mortality and morbidity. In resource-constraint settings, management of AKI is very challenging and associated with adverse outcomes. The aim of this study was to determine the clinico-etiological profile and outcome of AKI.Methodology: This prospective observational study was done at the department of pediatric nephrology and pediatric intensive care unit, National Institute of Child Health, Karachi, Pakistan from December 2020 to May 2021. A total of 130 children aged 1 month to 15 years, diagnosed with AKI irrespective of the underlying cause were included. Detailed medical information of each child including medical history, examination, and baseline investigations were obtained. Clinical and etiological profile of patients was noted. The patients were followed up to three months and the outcome was noted.Results: In a total of 130 children, 82 (63.1%) were male. The mean age was 5.5±4.4 years (ranging between 1 month and 15 years). There were 117 (90.0%) children who were referred from other centers for either dialysis or surgical treatment. Prerenal cause of AKI was found in 66 (50.8%) children, followed by renal 53 (40.8%) and postrenal in 11 (8.5%) cases. Fever and shortness of breath were the most common clinical presenting symptoms in 102 (78.5%) and 100 (76%) cases, respectively. There were 45 (34.6%) cases who were managed conservatively, 80 (61.5%) needed dialysis, while three children were managed with plasmapheresis and two required surgical intervention in the emergency department. At three-month follow-up period, 64 (49.2%) children recovered (including nine with partial recovery), 46 (36.1%) expired, 9 (6.9%) developed end-stage renal disease, while 11 (8.5%) had chronic kidney disease.Conclusion: Sepsis, nephrotoxic drugs, and acute glomerulonephritis were the major causes of AKI at our center. Mortality was high among children presenting with AKI. A relatively high proportion of children with younger age, septic AKI, and presentation in critical condition could be the reasons for this high mortality.

Caregiver perspectives of dialysis initiation for children with kidney disease: a qualitative study.

To better support family-centered care surrounding dialysis initiation, greater understanding of caregiver experience is necessary. Using thematic analysis, we conducted a secondary analysis of semi-structured interview data from a qualitative study of caregivers of children receiving dialysis recruited from 3 pediatric centers. Prominent themes in caregiver experience of caring for a child initiating dialysis were identified. Thirty-five caregivers participated. Three major themes emerged from qualitative analysis: (1) parenting disrupted- caregivers experienced an acute disruption in their parenting role due to the unexpected, emergent circumstances and vast information accompanying their child's diagnosis; (2) redefining parenting- caregivers sought to reestablish their innate parental role and foster their evolving medical provider role through reassurance that their child could survive, communication with the medical team, and engaging in care plan development; and (3) leveraging dual identities - to positively impact their child's experience and enable flourishing, caregivers leveraged their established caregiver role and newly realized medical provider role through voicing their perspectives, watching over their child's care, and preparing for future changes in their child's health. If caregivers' evolution was not nurtured and enabled, acute fluctuations in their child's care could contribute to future disruption and need to restore their parental role. However, if caregiver development was fostered, caregivers acquired increased ability to prepare for vacillations in their child's care. Improving delivery of family-centered care and support of caregivers at dialysis initiation will require directed efforts by nephrology care teams to foster caregiver evolution and resilience and respond to the family's changing experience of kidney disease. A higher resolution version of the Graphical abstract is available as Supplementary information.

Impact of nephrology care trajectories pre-CKD stage 5 on initiation of kidney replacement therapy in children.

To improve pre-emptive kidney transplantation (PKT) in children and limit starting dialysis in an emergency, we aimed to describe nephrology care trajectories pre-CKD stage 5. We included all children in France who, between 2010 and 2016, started kidney replacement therapy (KRT): standard dialysis (reference group) and emergency dialysis or PKT. We identified four pre-CKD stage 5 nephrology care trajectories before KRT that were extracted from the national exhaustive medical-administrative database and used logistic regression to explore associations between patient characteristics, care trajectories, and KRT initiation. Six hundred forty-three pediatric patients started KRT in France; 406 started dialysis and 30.5% emergency dialysis. The "optimal" care trajectory encompassed 179 patients, 82.7% with at least 18months nephrology follow-up. Conversely, the "no care" trajectory encompassed 118 patients with no nephrology follow-up before KRT. The "severe" trajectory encompassed 128 patients; 93% hospitalized more than once a year and 18% in an intensive care unit. Finally, the "irregular" trajectory encompassed 127 patients, 77% and 46% with irregular laboratory monitoring and CKD drug delivery, respectively. With the "optimal" trajectory as the reference, probability of emergency dialysis was higher with the "irregular" and "no care" trajectories (odds ratio 3.02 [95% confidence interval 1.18-7.66] and 26.5 [10.8-64.8], respectively), and PKT was reduced with the "severe" trajectory (0.43 [0.23-0.82]). We identified a group of patients with irregular follow-up who may benefit the most from interventions aiming at improving adherence to treatment and earlier diagnosis of their CKD to improve access to PKT. A higher resolution version of the Graphical abstract is available as Supplementary information.

KDOQI US Commentary on the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in CKD

In October 2020, KDIGO (Kidney Disease: Improving Global Outcomes) published its first clinical practice guideline directed specifically to the care of patients with diabetes and chronic kidney disease (CKD). This commentary presents the views of the KDOQI (Kidney Disease Outcomes Quality Initiative) work group for diabetes in CKD, convened by the National Kidney Foundation to provide an independent expert perspective on the new guideline. The KDOQI work group believes that the KDIGO guideline takes a major step forward in clarifying glycemic targets and use of specific antihyperglycemic agents in diabetes and CKD. The purpose of this commentary is to carry forward the conversation regarding optimization of care for patients with diabetes and CKD. Recent developments for prevention of CKD progression and cardiovascular events in people with diabetes and CKD, particularly related to sodium/glucose cotransporter 2 (SGLT2) inhibitors, have filled a longstanding gap in nephrology's approach to the care of persons with diabetes and CKD. The multifaceted benefits of SGLT2 inhibitors have facilitated interactions between nephrology, cardiology, endocrinology, and primary care, underscoring the need for innovative approaches to multidisciplinary care in these patients. We now have more interventions to slow kidney disease progression and prevent or delay kidney failure in patients with diabetes and kidney disease, but methods to streamline their implementation and overcome barriers in access to care, particularly cost, are essential to ensuring all patients may benefit.