Early Referral to Nephrological Care and the Uptake of Peritoneal Dialysis. An Analysis of German Claims Data

Background: Hemodialysis (HD) and peritoneal dialysis (PD) are medically equivalent alternatives for symptomatic therapy of end-stage renal disease (ESRD). An early referral (ER) of patients with chronic kidney disease (CKD) to a nephrological specialist is associated with a higher proportion of patients choosing PD. Germany historically shows a low PD uptake. This article is the first investigation into the impact of ER on the uptake of PD, using a large German claims database. Methods: Claims data of 4727 incident dialysis patients in 2015 and 2016 were analyzed. Accounting codes for nephrological care and dialysis modalities were identified. Their first documentation was defined as their first encounter with a nephrologist and their first dialysis treatment (HD or PD). ER was determined as receiving nephrological care at least six months before the first dialysis. A multivariate logistic regression model with adjusted odds ratios (AOR) investigates the impact of ER, outpatient dialysis start, age, comorbidities, and sex on the chance for PD. Results: Forty-three percent were referred to the nephrologist six months before their first dialysis (ER). Single tests, as well as the adjusted multivariate logistic regression, highlighted that ER significantly increases the chance for PD. In the multivariate model, the uptake of PD was associated with ER (AOR = 3.05; p < 0.001; 95% CI = 2.16–4.32), outpatient dialysis start (AOR = 0.71; p = 0.044; 95% CI = 0.51–0.99), younger age (AOR = 0.96; p < 0.001; 95% CI = 0.95–0.97), and fewer comorbidities (AOR = 0.85; p < 0.001; 95% CI = 0.44–1.58). Conclusions: ER of patients with CKD to a nephrologist increases PD uptake. It gives both nephrologists and patients enough time for patient education about different treatment options and can contribute to informed decisions about the dialysis treatment.

Clinical perspectives to improve pregnancy outcome in women undergoing chronic hemodialysis

Severe Chronic Kidney Disease is considered a powerful method of contraception per se, and pregnancy among women undergoing chronic hemodialysis is a rare event. Women on dialysis usually have amenorrhea or irregular menstrual cycles and sexual dysfunction. They are often unaware of their pregnancy, which delays the diagnosis and the beginning of adequate obstetric-nephrological care, increasing the risk of maternal and fetal complications including pre-eclampsia, fetal growth restriction, preterm delivery, and perinatal death. However, pregnancy among women on dialysis is increasing exponentially around the world. The authors present the two last pregnancies of patients on dialysis followed in their hospital, review clinical procedures, and the improvements of medical care during gestation used to contribute to a successful gestation outcome. Pregnancy is possible in women on chronic hemodialysis.

Analysis of medical care in Ukraine for nephrological patients in 2019

The work aimed to conduct a rating of nephrological services in the regions of Ukraine by using the method of complex statistical coefficients. Methods. Evaluation of nephrological services in the regions of Ukraine was made by using indicators of the structure, health care resources, quality and efficiency of renal medical care of patients with chronic kidney disease and patients with acute kidney injury. Results. The place of each province in the national rating of the state of renal medical care was identified. Conclusions. The organization, availability and quality of medical care for nephrological patients in Ukraine do not meet existing needs. The significant differences in the specialized nephrological care between the regions of Ukraine can be solved out through the implementation of appropriate management and financial decisions.

Onkonephrologie am Beispiel des Plasmazellmyeloms – Was Nephrologen und Hämatoonkologen voneinander lernen können

Plasma cell diseases, in particular multiple myeloma, represent an interdisciplinary challenge for oncologists and nephrologists. Patients often present initially with kidney problems to a nephrologist, requiring timely diagnosis and referral to an oncologist for treatment. On the other hand, a relevant part of patients will experience a – mostly temporary – decline in kidney function during the treatment course, which may require nephrological care. In any case, renal insufficiency can affect the therapeutic options. This article provides a short overview about common nephrological factors and complications which impact on the manifestation and course of treatment in patients with plasma cell diseases.

P1471FUNNEL PLOTS OF PATIENT-REPORTED OUTCOMES (PROS) TO EVALUATE NEPHROLOGICAL CARE: BASIC PRINCIPLES AND CONSIDERATIONS

Background and Aims Funnel plots are used to evaluate healthcare quality by comparing hospital performances on certain outcomes. So far, in nephrology, only clinical outcomes like mortality and complications are used for this purpose. However, with the increasing importance of patient-reported outcomes (PROs; e.g. health related quality of life [HRQOL]), PROs should also be taken into account in this quality assessment. Understanding the underlying methods and challenges is needed for optimal use of PROs in this context. Therefore, we aim to provide insight into the use and interpretation of funnel plots by presenting an overview of the basic principles and considerations when applied to PROs, using examples from Dutch routine dialysis care. Method Data on PROs (HRQOL and symptom burden), sociodemographic and clinical characteristics of patients receiving dialysis were obtained from the Dutch renal registry and were used to illustrate and explain the different components of a funnel plot, the underlying concepts (e.g. case mix and indirect standardization) and the interpretation of funnel plots. Additionally, some methodological issues are highlighted that should be considered when these methods are applied to PROs. Results A funnel plot is a graphical aid that consists of four components: an indicator, reference standard, measure of precision (usually the sample size) and control limits (see Figure). Funnel plots provide insight into hospitals’ performances by comparing the observed outcome to the expected outcome. A hospital’s expected outcome is calculated using the scores in the reference population (given the hospital’s patient population, i.e. case mix) and represents the outcome that would have been observed if the hospital had performed equal to the reference standard. Hospitals may be considered as under- or overperforming when exceeding the upper or lower 95% control limit. Advantages of funnel plots include: clearly visualized precision, detection of volume-effects, discouragement of ranking hospitals and easy interpretation of results. However, without basic knowledge of underlying methods, it is easy to fall into pitfalls, including: overinterpretation of standardized scores, incorrect direct comparisons of hospitals and to assume a hospital to be in-control based on under-powered comparisons. Furthermore, application to PROs is accompanied with additional challenges such as the multidimensional nature of PROs (e.g. HRQOL) which makes adequate case mix correction more difficult, and difficulties with measuring PROs, for instance to achieve high response rates or the dependence on good psychometric properties of the PRO-measures. Conclusion PROs partly determine the value of nephrological care and should therefore be considered in healthcare quality assessment. Understanding of the underlying methods using funnel plots is necessary for optimal use and correct interpretation of hospital comparisons on PROs. Some challenges need to be addressed before these methods can be applied to PROs, namely: high and consistent response rates, adequate case mix correction and high-quality PRO measures.

Modifying Phosphate Toxicity in Chronic Kidney Disease

Phosphate toxicity is a well-established phenomenon, especially in chronic kidney disease (CKD), where hyperphosphatemia is a frequent occurrence when CKD is advanced. Many therapeutic efforts are targeted at phosphate, and comprise dietary intervention, modifying dialysis schemes, treating uncontrolled hyperparathyroidism and importantly, phosphate binder therapy. Despite all these interventions, hyperphosphatemia persists in many, and its pathological influence is ongoing. In nephrological care, a somewhat neglected aspect of treatment—when attempts fail to lower exposure to a toxin like phosphate—is to explore the possibility of “anti-dotes”. Indeed, quite a long list of factors modify, or are mediators of phosphate toxicity. Addressing these, especially when phosphate itself cannot be sufficiently controlled, may provide additional protection. In this narrative overview, several factors are discussed that may qualify as either such a modifier or mediator, that can be influenced by other means than simply lowering phosphate exposure. A wider scope when targeting phosphate-induced comorbidity in CKD, in particular cardiovascular disease, may alleviate the burden of disease that is the consequence of this potentially toxic mineral in CKD.