Association of Polypharmacy with Kidney Disease Progression in Adults with CKD

Background and objectivePolypharmacy is common in patients with CKD and reportedly associated with adverse outcomes. However, its effect on kidney outcomes among patients with CKD has not been adequately elucidated. Hence, this investigation was aimed at exploring the association between polypharmacy and kidney failure requiring KRT.Design, setting, participants, and measurementsWe retrospectively examined 1117 participants (median age, 66 years; 56% male; median eGFR, 48 ml/min per 1.73 m2) enrolled in the Fukushima CKD Cohort Study to investigate the association between the number of prescribed medications and adverse outcomes such as kidney failure, all-cause mortality, and cardiovascular events in Japanese patients with nondialysis-dependent CKD. Polypharmacy and hyperpolypharmacy were defined as the regular use of 5–9 and ≥10 medications per day, respectively.ResultsThe median number of medications was eight; the prevalence of polypharmacy and hyperpolypharmacy was each 38%. During the observation period (median, 4.8 years), 120 developed kidney failure, 153 developed cardiovascular events, and 109 died. Compared with the use of fewer than five medications, adjusted hazard ratios (95% confidence intervals) associated with polypharmacy and hyperpolypharmacy were 2.28 (1.00 to 5.21) and 2.83 (1.21 to 6.66) for kidney failure, 1.60 (0.85 to 3.04) and 3.02 (1.59 to 5.74) for cardiovascular events, and 1.25 (0.62 to 2.53) and 2.80 (1.41 to 5.54) for all-cause mortality.ConclusionsThe use of a high number of medications was associated with a high risk of kidney failure, cardiovascular events, and all-cause mortality in Japanese patients with nondialysis-dependent CKD under nephrology care.

Effect of Nephrology Care on Mortality in Incident Dialysis Patients: A Population-Based Cohort Study

Long-term and continuous nephrology care effects on post-dialysis mortality remain unclear. This study aims to systematically explore the causal effect of nephrology care on mortality for patients with dialysis initiation. We conducted a retrospective cohort study to include incident patients with dialysis for ≥ 3 months in Taiwan from 2004 through 2011. The continuous nephrology care of incident patients in the three years before their dialysis was measured every six months. Continuous nephrology care was determined by 0–6, 0–12, …, 0–36 months and their counterparts; and none, intermittent, 0–6 months, …, and 0–36 months. Simple and weighted hazards ratio (HR) and 95% confidence interval (CI) for one-year mortality were estimated after propensity score (PS) matching. We included a total of 44,698 patients (mean age 63.3 ± 14.2, male 51.9%). Receiving ≥ 1 year predialysis nephrology care was associated with a 22% lower post-dialysis mortality hazard. No different effects were found (ranges of PS matching HR: 0.77–0.80) when comparing the defined duration of nephrology care with their counterparts. Stepped survival benefits were newly identified in the intermittent care, which had slightly lower HRs (weighted HR: 0.88, 95% CI: 0.79–0.97), followed by reviving care over six months to two years (ranges of weighted HR: 0.60–0.65), and reviving care over two years (ranges of weighted HR: 0.48–0.52). There was no existing critical period of nephrology care effect on post-dialysis, but there were extra survival benefits when extending nephrology care to >2 years, which suggests that continuous and long-term care during pre-dialysis/chronic kidney disease phase is required.

Provision of Kidney Disease Education Service is Associated with Improved Vascular Access Outcomes among the US Incident Hemodialysis Patients

Background: Pre-end stage renal disease (ESRD) Kidney Disease Education (KDE) has been shown to improve multiple chronic kidney disease (CKD) outcomes but, its impact on vascular access outcomes is not well-studied. In 2010, Medicare launched KDE reimbursements policy for patients with advanced CKD. Methods: In this retrospective USRDS analysis, we identified all adult incident hemodialysis patients with a minimum of 6-months of pre-ESRD Medicare coverage during the first five-years of CMS-KDE policy and divided them into CMS-KDE services recipients (KDE-cohort) and non-recipients (non-KDE cohort). The primary outcome was incident arteriovenous fistula (AVF) and the composite of incident AVF or arteriovenous graft (AVG) utilization. Secondary outcomes were central venous catheter (CVC) with maturing AVF/AVG and pure CVC utilizations. Step-wise multivariate analyses were performed in four progressive models (model 1: KDE alone, model 2: multivariate model encompassing model 1 with socio-demographics, model 3: model 2 with comorbidity and functional status, and model 4: model 3 with pre-ESRD nephrology care). Results: Of the 211,990 qualifying incident hemodialysis patients during the study period, 2,887(1.4%) received KDE services before dialysis initiation. The rates of incident AVF and composite AVF/AVG were more than double (29.7% and 34.9% respectively, compared to 14.2% and 17.2%) and pure catheter use about a third lower (40.4% compared to 64.5%) in the KDE cohort compared to the non-KDE cohort. Maximally adjusted odds ratio(99% confidence interval) in model 4 for study outcomes were: incident AVF use: 1.78 (1.55-2.05), incident AVF/AVG use: 1.78 (1.56-2.03), incident CVC with maturing AVF/AVG: 1.69 (1.44-1.97)and pure CVC without any AVF/AVG: 0.51 (0.45-0.58). The benefits of KDE service were maintained even after accounting for the presence, duration and facility of ESRD care. Conclusion: Occurrence of pre-ESRD KDE service is associated with significantly improved incident vascular access outcomes. Targeted studies are needed to examine the impact of KDE on patient engagement and self-efficacy as a cause for improvement in vascular access outcomes.

Medical management: a model for giving medical aid to children with infectious-inflammatory diseases of the urinary system

Increasing requirements of medical aid given to children with infectious-inflammatory diseases of the urinary system stipulate the necessity to improve its quality using evidence-based therapeutic-diagnostic and organization technologies. The aim of the work – to substantiate, develop the improved model of the specialized nephrology care for children with infectious inflammatory diseases of the urinary system at the regional level. The official statistical data have been studied (2006 to 2017); information-analytical and statistical methods have been used. A bacteriological study (2009–2016) of urine samples was carried out for 3089 children (0–17 years old) in the Chernivtsi region. They formed the foundation for substantiation and development of an improved functional-organizational model of the system. In addition to the existing and functionally changed elements contains new elements: regional/inter-regional center of specialized medical aid to children with infectious-inflammatory diseases of the urinary system. Implementation of the elements of the suggested improved model in a part of a rational approach in distribution of functions concerning medical observation of patients at the stages of giving medical aid enabled to make the period of hospitalization of nephrological patients 11,40% shorter and an average period of treatment of patients with infectious-inflammatory diseases of the urinary system 2,93% shorter.

Referring patients with chronic kidney disease back to primary care: a criteria-based analysis in outpatient renal clinics

Background The increased demand for nephrology care for patients with chronic kidney disease (CKD) necessitates a critical review of the need for secondary care facilities and the possibilities for referral back to primary care. This study aimed to evaluate the characteristics and numbers of patients who could potentially be referred back to primary care, using predefined criteria developed by nephrologists and general practitioners. Method We organised a consensus meeting with eight nephrologists and two general practitioners to define the back referral (BR) criteria, and performed a retrospective cohort study reviewing records from patients under nephrologist care in three hospitals. Results We reached a consensus about the BR criteria. Overall, 78 of the 300 patients (26%) in the outpatient clinics met the BR criteria. The characteristics of the patients who met the BR criteria were: 56.4% male, a median age of 70, an average of 3.0 outpatients visits per year, and a mean estimated glomerular filtration rate of 46 ml/min/1,73m2. Hypertension was present in 67.9% of this group, while 27.3% had diabetes and 16.9% had cancer. The patients who could be referred back represented all CKD stages except stage G5. The most common stage (16%) was G3bA2 (eGFR 30 ≤ 44 and ACR 3 ≤ 30). Conclusion A substantial proportion of patients were eligible for referral back to primary care. These patients often have a comorbidity, such as hypertension or diabetes. Future research should focus on generalisability of the BR criteria, the feasibility of actual implementation of the back referral, follow-up assessments of renal function and patient satisfaction.

MO643EFFECTS OF SELF-PRESCRIPTION OF INSULIN ON GLYCAEMIC CONTROL IN PATIENTS UNDER NEPHROLOGY CARE

Background and Aims Co-existence of diabetes mellitus (DM) and kidney disease is common. In-patient hypo- and hyperglycaemia are associated with adverse outcomes and, for hypoglycaemia, an increased length of inpatient stay (LOS). NICE and the National Patient Safety Agency recommend in-patients with DM previously established on insulin be allowed to self-prescribe to reduce hypo and hyperglycaemia. It is unclear how this occurs in clinical practice in patients under nephrology care. We sought to describe glycaemic control and diabetes management in patients admitted to our nephrology service. Method All patients admitted to the Glasgow Renal and Transplant Unit between June and August 2020 were identified. In those with a previous diagnosis of DM, demographic data were collected including reason for admission and use of insulin. Self-prescription of insulin, blood sugar levels and episodes of hypo (BM <4mmol/L) and hyperglycaemia (BM >14mmol/L) were identified. Analysis was undertaken in SPSS v 27.0.1.0. Results One hundred and sixty-seven patients with a diagnosis of DM were admitted over the three month period. The remaining results refer only to the 90(54%) patients established on insulin before the index admission. Mean age was 58±7.1 years, 56% (n=50) were male and 77% (n=69) self-prescribed insulin throughout admission. Table 1 shows type of DM and regular insulin regimen. Mean HbA1C pre-admission was 68±6.4mmol/mol. Fifty-one (57%) patients were on dialysis and 12 (13%) had a functioning transplant. Reasons for admission included infection (n=21), to undergo a procedure eg arteriovenous fistula creation (n=21), AKI (n=10) and fluid overload (n=8). These 90 patients accounted for 113 admissions with a median LOS of 5 (2-9) days. In 46 (41%) admissions, there was at least one episode of hypoglycaemia and in 95 (84%) at least one episode of hyperglycaemia. During 12 (13%) admissions, there were neither hypo nor hyperglycaemic episodes. Insulin self-prescribers were younger (56±12.7 ‘v’ 60±9.7 years, p=0.04) and more likely to experience hypoglycaemia than those who did not self-prescribe (p=0.03). There was no significant increase in hyperglycaemia nor in median LOS between the groups. Episodes of hypoglycaemia were more likely with a lower mean fasting blood sugar (fbs), regardless of self-prescription of insulin (11±3.8 ‘v’ 13±5.1mmol/L, p=0.02) Conclusion Most patients with DM admitted under the care of nephrology, self-prescribe insulin. These patients are more likely to have an episode of hypoglycaemia and hypoglycaemia is more likely to occur if the fbs is <13mmol/L. It is unclear how our experience differs from that of other specialties. However, reducing renal function, eg in the setting of dialysis or AKI, and uncertainties regarding the carbohydrate content of hospital food may play a role in predisposing to hypoglycaemia. In order to facilitate safe management of DM in the inpatient nephrology wards, whilst preserving patients’ autonomy, attention should be paid to the fbs level and self-prescription of insulin should be permitted within a narrow range of the patients’ regular dosing regimen.