689. Streptococcus suis Endocarditis: Echocardiographic Features and Clinical Outcomes

Abstract Background Streptococcus suis (S. suis) is a zoonotic pathogen that transmits to the human with direct contact of pig or raw pork ingestion. This infection has been described in Asia, especially Thailand, Vietnam, and China. S. suis could cause wide range of infection, including endocarditis. This study aimed to describe the clinical features, echocardiogram findings, and outcomes of S. suis endocarditis. Methods A single center, ten-year (January 2009 to December 2018), retrospective cohort was conducted among patients who were diagnosed with S.suis endocarditis in 1,200-bed hospital in Northern, Thailand. Results Forty-three patients of S.suis endocarditis were identified during the study period. Of those, 28 (65%) patients had positive blood culture and 15 (35%) was diagnosed by 16SRNA bacterial identification from heart valve tissue. Majority (81%) were male with median age of 35. There were 62 affected valves in 43 patients. Twenty patients (48%) had vegetation larger than 10 mm in diameter and 35 (81.4%) patients had moderately severe or severe valvular regurgitation. Valvular perforation was described in 23 patients (53%). Perivalvular complications were founded in 15 patients (35%). Systemic embolism occurred in 17 (40%) patients. Cardiac operation was undertaken in 35 (81%) patients. There were 2 in-hospital deaths (5%) and 6 patients (14%) had disabilities. Moderately severe/severe regurgitation, systemic embolism, and no cardiac operation were significantly associated with disability or death from univariate analysis. By logistic regression analysis, systemic embolism was the only risk factor for disability or death (OR = 12.6, 95% CI 1.3-123.5, p = 0.029). Presenting signs/symptoms, prediction score and laboratory data on admission Conclusion S. suis endocarditis had high rate of valvular damage with complications and resulting systemic embolism. Surgery is required in majority of the patients. Embolism was associated with disability or death. Disclosures All Authors: No reported disclosures

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Use of Proteins Identified through a Functional Genomic Screen To Develop a Protein Subunit Vaccine That Provides Significant Protection against Virulent Streptococcus suis in Pigs

Infection and Immunity ◽

10.1128/iai.00559-17 ◽

2017 ◽

Vol 86 (3) ◽

Cited By ~ 3

Author(s):

Susan L. Brockmeier ◽

Crystal L. Loving ◽

Tracy L. Nicholson ◽

Jinhong Wang ◽

Sarah E. Peters ◽

...

Keyword(s):

Immune Response ◽

Vaccine Trial ◽

Streptococcus Suis ◽

Protein Subunit ◽

Content Type ◽

Degree Of Protection ◽

Wide Range ◽

Associated Proteins ◽

Clinical Protection ◽

Cellular Immune

ABSTRACT Streptococcus suis is a bacterium that is commonly carried in the respiratory tract and that is also one of the most important invasive pathogens of swine, commonly causing meningitis, arthritis, and septicemia. Due to the existence of many serotypes and a wide range of immune evasion capabilities, efficacious vaccines are not readily available. The selection of S. suis protein candidates for inclusion in a vaccine was accomplished by identifying fitness genes through a functional genomics screen and selecting conserved predicted surface-associated proteins. Five candidate proteins were selected for evaluation in a vaccine trial and administered both intranasally and intramuscularly with one of two different adjuvant formulations. Clinical protection was evaluated by subsequent intranasal challenge with virulent S. suis . While subunit vaccination with the S. suis proteins induced IgG antibodies to each individual protein and a cellular immune response to the pool of proteins and provided substantial protection from challenge with virulent S. suis , the immune response elicited and the degree of protection were dependent on the parenteral adjuvant given. Subunit vaccination induced IgG reactive against different S. suis serotypes, indicating a potential for cross protection.

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387. Markers for Mortality in COVID-19 Patients with Atrial Fibrillation or Flutter

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.582 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S262-S262

Author(s):

Kok Hoe Chan ◽

Bhavik Patel ◽

Iyad Farouji ◽

Addi Suleiman ◽

Jihad Slim

Keyword(s):

Atrial Fibrillation ◽

Logistic Regression ◽

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Prognostic Markers ◽

Univariate Analysis ◽

Laboratory Data ◽

Significant Difference ◽

New Onset

Abstract Background Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection can lead to many different cardiovascular complications, we were interested in studying prognostic markers in patients with atrial fibrillation/flutter (A. Fib/Flutter). Methods A retrospective cohort study of patients with confirmed COVID-19 and either with existing or new onset A. Fib/Flutter who were admitted to our hospital between March 15 and May 20, 2020. Demographic, outcome and laboratory data were extracted from the electronic medical record and compared between survivors and non-survivors. Univariate and multivariate logistic regression were employed to identify the prognostic markers associated with mortality in patients with A. Fib/Flutter Results The total number of confirmed COVID-19 patients during the study period was 350; 37 of them had existing or new onset A. Fib/Flutter. Twenty one (57%) expired, and 16 (43%) were discharged alive. The median age was 72 years old, ranged from 19 to 100 years old. Comorbidities were present in 33 (89%) patients, with hypertension (82%) being the most common, followed by diabetes (46%) and coronary artery disease (30%). New onset of atrial fibrillation was identified in 23 patients (70%), of whom 13 (57%) expired; 29 patients (78%) presented with atrial fibrillation with rapid ventricular response, and 2 patients (5%) with atrial flutter. Mechanical ventilation was required for 8 patients, of whom 6 expired. In univariate analysis, we found a significant difference in baseline ferritin (p=0.04), LDH (p=0.02), neutrophil-lymphocyte ratio (NLR) (p=0.05), neutrophil-monocyte ratio (NMR) (p=0.03) and platelet (p=0.015) between survivors and non-survivors. With multivariable logistic regression analysis, the only value that had an odds of survival was a low NLR (odds ratio 0.74; 95% confidence interval 0.53–0.93). Conclusion This retrospective cohort study of hospitalized patients with COVID-19 demonstrated an association of increase NLR as risk factors for death in COVID-19 patients with A. Fib/Flutter. A high NLR has been associated with increased incidence, severity and risk for stroke in atrial fibrillation patients but to our knowledge, we are first to demonstrate the utilization in mortality predictions in COVID-19 patients with A. Fib/Flutter. Disclosures Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)

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Cardiac echocardiogram findings of severe acute respiratory syndrome coronavirus-2-associated multi-system inflammatory syndrome in children

Cardiology in the Young ◽

10.1017/s1047951121003024 ◽

2021 ◽

pp. 1-9

Author(s):

Ashraf S. Harahsheh ◽

Anita Krishnan ◽

Roberta L. DeBiasi ◽

Laura J. Olivieri ◽

Christopher Spurney ◽

...

Keyword(s):

Coronary Artery ◽

Pericardial Effusion ◽

Acute Phase ◽

Systolic Dysfunction ◽

Interquartile Range ◽

High Rate ◽

Cardiac Complications ◽

Valvular Regurgitation ◽

Coronary Artery Abnormalities ◽

Inflammatory Syndrome

Abstract Background: A novel paediatric disease, multi-system inflammatory syndrome in children, has emerged during the 2019 coronavirus disease pandemic. Objectives: To describe the short-term evolution of cardiac complications and associated risk factors in patients with multi-system inflammatory syndrome in children. Methods: Retrospective single-centre study of confirmed multi-system inflammatory syndrome in children treated from 29 March, 2020 to 1 September, 2020. Cardiac complications during the acute phase were defined as decreased systolic function, coronary artery abnormalities, pericardial effusion, or mitral and/or tricuspid valve regurgitation. Patients with or without cardiac complications were compared with chi-square, Fisher’s exact, and Wilcoxon rank sum. Results: Thirty-nine children with median (interquartile range) age 7.8 (3.6–12.7) years were included. Nineteen (49%) patients developed cardiac complications including systolic dysfunction (33%), valvular regurgitation (31%), coronary artery abnormalities (18%), and pericardial effusion (5%). At the time of the most recent follow-up, at a median (interquartile range) of 49 (26–61) days, cardiac complications resolved in 16/19 (84%) patients. Two patients had persistent mild systolic dysfunction and one patient had persistent coronary artery abnormality. Children with cardiac complications were more likely to have higher N-terminal B-type natriuretic peptide (p = 0.01), higher white blood cell count (p = 0.01), higher neutrophil count (p = 0.02), severe lymphopenia (p = 0.05), use of milrinone (p = 0.03), and intensive care requirement (p = 0.04). Conclusion: Patients with multi-system inflammatory syndrome in children had a high rate of cardiac complications in the acute phase, with associated inflammatory markers. Although cardiac complications resolved in 84% of patients, further long-term studies are needed to assess if the cardiac abnormalities (transient or persistent) are associated with major cardiac events.

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Sustaining Research-Based Practices in Reading

Remedial and Special Education ◽

10.1177/074193259902000502 ◽

1999 ◽

Vol 20 (5) ◽

pp. 263-287 ◽

Cited By ~ 58

Author(s):

Janette K. Klingner ◽

Sharon Vaughn ◽

Marie Tejero Hughes ◽

Maria Elena Arguelles

Keyword(s):

Instructional Practices ◽

High Rate ◽

Strategic Reading ◽

School Year ◽

Wide Range ◽

Sustained Use ◽

Development Experience ◽

Collaborative Strategic Reading ◽

Research Based Practices ◽

Over Time

This study examined the extent to which the reading instructional practices learned by a cohort of teachers who participated in an intensive, yearlong professional development experience during the 1994-1995 school year have been sustained and modified over time. Teachers learned three multileveled practices—partner reading, collaborative strategic reading, and making words—that promote gains in reading for students from a wide range of achievement levels. Teachers were observed and interviewed 3 years later to determine the extent to which they continued to implement the practices, the ways in which they modified them, and factors that influenced their sustained use of the practices. With the exception of one teacher, all the teachers sustained one or more of the three practices at a high rate.

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60. New Prognostic Markers for COVID-19 Disease

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.370 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S161-S162

Author(s):

Amr Ramahi ◽

Kok Hoe Chan ◽

Laxminarayan Prabhakar ◽

Iyad Farouji ◽

Divya Thimmareddygari ◽

...

Keyword(s):

Logistic Regression ◽

Cohort Study ◽

Prognostic Markers ◽

Univariate Analysis ◽

Laboratory Data ◽

Hospitalized Patients ◽

Prognostic Indicators ◽

Blood Profile ◽

New Model ◽

D Dimer

Abstract Background A few COVID-19 related retrospective studies have established that older age, elevated neutrophil-lymphocyte ratio (NLR), and decreased lymphocyte-CRP ratio (LCR) were associated with worse outcome. Herein, we aim to identify new prognostic markers associated with mortality. Methods We conducted a retrospective hospital cohort study on patients ≥ 18 years old with confirmed COVID-19, who were admitted to our hospital between 03/15/2020 and 05/25/2020. Study individuals were recruited if they had a complete CBC profile and inflammatory markers such as CRP, ferritin, D-dimer and LDH, as well as a well-defined clinical outcomes (discharged alive or expired). Demographic, clinical and laboratory data were reviewed and retrieved. Univariate and multivariate logistic regression methods were employed to identify prognostic markers associated with mortality. Results Out of the 344 confirmed COVID-19 hospitalized patients during the study period, 31 who did not have a complete blood profile were excluded; 303 patients were included in the study, 89 (29%) expired, and 214 (71%) were discharged alive. Demographic analysis was tabulated in Table 1. The univariate analysis showed a significant association of death with absolute neutrophil count (ANC, p=0.022), NLR (p=002), neutrophil-monocyte ratio (NMR, p=< 0.0001), LCR (p=0.007), lymphocyte-LDH ratio (LLR, p=< 0.0001), lymphocyte-D-dimer ratio (LDR, p=< 0.0001), lymphocyte-ferritin ratio (LFR, p=< 0.0001), and platelets (p=0.037) with mortality. With multivariable logistic regression analysis, the only values that had an odds of survival were high LDR (odds ratio [OR] 1.763; 95% confidence interval [CI], 1.20–2.69), and a high LFR (OR 1.136, CI 1.01–1.34). We further build up a model which can predict >85% mortality in our cohorts with the utilization of D-dimer (>500 ng/ml), Ferritin (>200 ng/ml), LDR (< 1.6), LFR (< 4) and ANC (>2.5). This new model has a ROC of 0.68 (p< 0.0001). Conclusion This retrospective cohort study of hospitalized patients with COVID-19 suggests LDR and LFR as potential independent prognostic indicators. A new model with combination of D-dimer, Ferritin, LDR, LFR and ANC, was able to predict >85% mortality in our cohort with ROC of 0.68, it will need to be validated in a prospective cohort study. Disclosures Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)

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Identification of the Clinical Features Distinguishing Psoriatic Arthritis and Fibromyalgia

The Journal of Rheumatology ◽

10.3899/jrheum.110893 ◽

2012 ◽

Vol 39 (4) ◽

pp. 849-855 ◽

Cited By ~ 68

Author(s):

ANTONIO MARCHESONI ◽

FABIOLA ATZENI ◽

ANTONIO SPADARO ◽

ENNIO LUBRANO ◽

GIUSEPPE PROVENZANO ◽

...

Keyword(s):

Psoriatic Arthritis ◽

Clinical Features ◽

Disease Duration ◽

Univariate Analysis ◽

Laboratory Data ◽

Fibromyalgia Impact Questionnaire ◽

Somatic Symptoms ◽

Tender Point ◽

Antiinflammatory Drugs ◽

Associated Symptoms

Objective.To identify the clinical features that can help to distinguish between psoriatic arthritis (PsA) and fibromyalgia (FM).Methods.Our cross-sectional study was carried out in 10 Italian rheumatology centers between January and September 2009, and enrolled all consecutive patients with PsA and FM who agreed to participate. Standard clinical and laboratory data for PsA and FM were collected from all patients. Records were made of somatic symptoms, response to nonsteroidal antiinflammatory drugs (NSAID), self-evaluated pain, general health, disability, and responses to the Fibromyalgia Impact Questionnaire. Data were statistically analyzed by univariate and multivariate analyses, and receiver-operating characteristic curves. The analysis concentrated on the clinical features shared by the 2 conditions.Results.Two hundred sixty-six patients with PsA (mean age 51.7 yrs; disease duration 10.2 yrs) and 120 patients with FM (mean age 50.2 yrs; disease duration 5.6 yrs) were evaluated. Univariate analysis showed that patients with FM had higher mean tender point and enthesitis scores, more somatic symptoms, and responded less to NSAID. Multivariate analysis showed that the presence of ≥ 6 FM-associated symptoms and ≥ 8 tender points was the best predictor of FM.Conclusion.The shared clinical features of PsA and FM that had the greatest discriminating power for FM were the number of FM-associated symptoms and tender point count.

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Abstract 16884: Evaluating the Effectiveness of Atrial Fibrillation Ablation Guided by Spatiotemporal Electrogram Dispersion

Circulation ◽

10.1161/circ.142.suppl_3.16884 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Brian Liu ◽

Arismendy Nunez-Garcia ◽

Cao Tran ◽

Michael Wu

Keyword(s):

Atrial Fibrillation ◽

Atrial Tachycardia ◽

Statistical Significance ◽

Univariate Analysis ◽

External Validation ◽

Posterior Wall ◽

High Rate ◽

Single Center Experience ◽

The Mean

Introduction: Catheter ablation of atrial fibrillation (AF) guided by spatiotemporal dispersion (SD) of electrograms has been proposed as an ablation strategy to treat patients with persistent AF. However, external validation of this technique is lacking. Here we report a single center experience using ablation by SD. Hypothesis: Targeting regions with SD is associated with a high rate of termination and favorable freedom from AF among patients with persistent AF. Methods: Patients with persistent AF who underwent SD from November 2018 to January 2020 were included in this study. All patients underwent pulmonary vein isolation (PVI) in addition to targeting areas of SD. Lesions on areas of electrogram dispersion were anchored to the PVI or to mitral or posterior wall lines where appropriate. EKG, Holter, event monitors or device interrogations were obtained at 3 and 6 months to assess for arrhythmia recurrence. Results: 44 patients met the inclusion criteria and were included in the study. The patients had a mean age of 69±8 years and were 68 % male. The prevalence of comorbidities was as follows: hypertension (89%), diabetes (21%), OSA (37%) and CAD (26%). Average CHADSVASC score was 2.9±1.4, LVEF was 53±11% and left atrium (LA) diameter was 5.2±1 cm. The recurrence rate of AF at 6 months was 14% whereas the recurrence of atrial tachycardia was 20%. Acute AF termination was observed in 73% of the patients. Termination to sinus occurred in 38% of the patients and the remaining terminated to atrial tachycardia which was subsequently ablated to sinus. The mean procedure duration was 240±90 minutes. Univariate analysis showed recurrence was associated with LA diameter (r=.52; p<.001). No recurrences were observed among patients with a LA diameter < 5 cm. Termination rates were higher among patients with LA diameter < 5 cm when compared to LA diameter ≥ 5 cm. However, it did not reach statistical significance (80% vs. 60%; p=.21). Conclusions: The target of electrograms with SD during AF ablation added to PVI was associated with a high termination rate and a good freedom from AF recurrence at 6 months. The ideal candidate for this procedure may be those with LA diameter < 5 cm among persistent AF. The long-term efficacy of this technique merits further studies in larger populations.

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MAIN FEATURES AND TRENDS OF DEVELOPMENT OF THE SERVICE MARKET

International scientific journal Internauka Series Economical Sciences ◽

10.25313/2520-2294-2021-4-7081 ◽

2017 ◽

Author(s):

Larysa Getman ◽

Keyword(s):

Customer Loyalty ◽

Consumer Choice ◽

Information Technologies ◽

Service Sector ◽

Supply And Demand ◽

High Rate ◽

Barriers To Entry ◽

Relevant Market ◽

Service Market ◽

Wide Range

The article discusses approaches to the interpretation of the concept of a service, its specific differences from a physical product and the main features as an object of purchase and sale in the relevant market. Based on the analysis and systematization of existing scientific views, the main features of the service market and the features of the interaction of supply and demand in the service sector are revealed. The practice of functioning of the service market demonstrates the high dynamics of market processes, a pronounced segmentation of demand for services, a high degree of differentiation of services, a high rate of capital turnover and the important role of non-price barriers to entry into the market. The essence and value of the customer's customer loyalty for successful commercial activities and increasing the competitiveness of the manufacturer-supplier of the service has been investigated. Loyalty becomes an indicator of business performance and its ability to innovate. A customer-oriented business philosophy, where a wide range of factors of influence on the formation of customer loyalty is taken into account and used, will allow the company to count on long-term relationships with the consumer and will attract new customers through his positive experience. The possibilities and features of the application of competitive strategies by firms in the field of service activities were analyzed. The main trends in the development of the services market in the current stage, namely the processes of its digitalization, have been investigated. The buyer today is interested not only in price and quality, but also in good service. If a company meets customer service demand through the introduction of chat bots, self- service terminals, mobile applications, etc., then this contributes to the formation of a positive customer experience, which ultimately increases sales. The features and advantages of using information technologies both in business activities and in the implementation of consumer choice have been determined.

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Nonbacterial Thrombotic Endocarditis Associated with Acute Promyelocytic Leukemia: An Autopsy Case Report

Medicina ◽

10.3390/medicina57111264 ◽

2021 ◽

Vol 57 (11) ◽

pp. 1264

Author(s):

Tadayuki Hashimoto ◽

Tatsuya Aoki ◽

Yoshitaka Kawabata ◽

Yoshihiro Owai ◽

Yoshikazu Matsuda ◽

...

Keyword(s):

Acute Promyelocytic Leukemia ◽

Laboratory Data ◽

Anticoagulation Therapy ◽

Sudden Onset ◽

Promyelocytic Leukemia ◽

Intensity Change ◽

High Signal ◽

Left Brain ◽

Wide Range ◽

Nonbacterial Thrombotic Endocarditis

Valve vegetation is one of the most fearful findings for physicians. The first diagnosis that comes to their mind is infective endocarditis (IE), but it can also be noninfective; nonbacterial thrombotic endocarditis (NBTE). NBTE can be even more challenging than IE for physicians because of the wide range of differential diagnoses such as malignancies, autoimmune disorders and human immunodeficiency virus. A 45-year-old woman presented at the emergency room with a sudden onset of dysarthria and right-sided hemiplegia. Laboratory data showed her blood counts and coagulation test were mostly normal and the magnetic resonance imaging detected a high-signal-intensity change in her left brain. An echocardiogram found a vegetation-like structure on her atrial valve. We highly suspected IE leading to cerebral embolism. The clot was successfully removed by our neurosurgeons and anticoagulation therapy was started concurrently. Her state of consciousness improved, but then she suffered a brain hemorrhage and died. The autopsy revealed that the cause of her vegetation was acute promyelocytic leukemia (APL). Based on these findings, it is important to remember that APL can be the cause of NBTE even if the blood count and coagulation tests are almost normal.

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A national study of practice patterns in UK renal units in the use of dialysis and conservative kidney management to treat people aged 75 years and over with chronic kidney failure

Health Services and Delivery Research ◽

10.3310/hsdr03120 ◽

2015 ◽

Vol 3 (12) ◽

pp. 1-186 ◽

Cited By ~ 21

Author(s):

Paul Roderick ◽

Hugh Rayner ◽

Sarah Tonkin-Crine ◽

Ikumi Okamoto ◽

Caroline Eyles ◽

...

Keyword(s):

Kidney Failure ◽

Older Patients ◽

Practice Patterns ◽

Laboratory Data ◽

National Study ◽

Service Development ◽

Renal Unit ◽

Number Of Patients ◽

Wide Range ◽

The Way

BackgroundConservative kidney management (CKM) is recognised as an alternative to dialysis for a significant number of older adults with multimorbid stage 5 chronic kidney disease (CKD5). However, little is known about the way CKM is delivered or how it is perceived.AimTo determine the practice patterns for the CKM of older patients with CKD5, to inform service development and future research.Objectives(1) To describe the differences between renal units in the extent and nature of CKM, (2) to explore how decisions are made about treatment options for older patients with CKD5, (3) to explore clinicians’ willingness to randomise patients with CKD5 to CKM versus dialysis, (4) to describe the interface between renal units and primary care in managing CKD5 and (5) to identify the resources involved and potential costs of CKM.MethodsMixed-methods study. Interviews with 42 patients aged > 75 years with CKD5 and 60 renal unit staff in a purposive sample of nine UK renal units. Interviews informed the design of a survey to assess CKM practice, sent to all 71 UK units. Nineteen general practitioners (GPs) were interviewed concerning the referral of CKD patients to secondary care. We sought laboratory data on new CKD5 patients aged > 75 years to link with the nine renal units’ records to assess referral patterns.ResultsSixty-seven of 71 renal units completed the survey. Although terminology varied, there was general acceptance of the role of CKM. Only 52% of units were able to quantify the number of CKM patients. A wide range reflected varied interpretation of the designation ‘CKM’ by both staff and patients. It is used to characterise a future treatment option as well as non-dialysis care for end-stage kidney failure (i.e. a disease state equivalent to being on dialysis). The number of patients in the latter group on CKM was relatively small (median 8, interquartile range 4.5–22). Patients’ expectations of CKM and dialysis were strongly influenced by renal staff. In a minority of units, CKM was not discussed. When discussed, often only limited information about illness progression was provided. Staff wanted more research into the relative benefits of CKM versus dialysis. There was almost universal support for an observational methodology and a quarter would definitely be willing to participate in a randomised clinical trial, indicating that clinicians placed value on high-quality evidence to inform decision-making. Linked data indicated that most CKD5 patients were known to renal units. GPs expressed a need for guidance on when to refer older multimorbid patients with CKD5 to nephrology care. There was large variation in the scale and model of CKM delivery. In most, the CKM service was integrated within the service for all non-renal replacement therapy CKD5 patients. A few units provided dedicated CKM clinics and some had dedicated, modest funding for CKM.ConclusionsConservative kidney management is accepted across UK renal units but there is much variation in the way it is described and delivered. For best practice, and for CKM to be developed and systematised across all renal units in the UK, we recommend (1) a standard definition and terminology for CKM, (2) research to measure the relative benefits of CKM and dialysis and (3) development of evidence-based staff training and patient education interventions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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