Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center.
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Despite improvements in dialysis care, mortality of patients with end-stage renal disease (ESRD) remains high. One factor that has thus far received little attention, but might contribute to morbidity and mortality, is the timing of referral to the nephrologist. This study examines the hypothesis that late referral of patients to the nephrologist might lead to suboptimal pre-ESRD care. Clinical and laboratory data were obtained from the patient records and electronic databases of New England Medical Center, its affiliated dialysis unit (Dialysis Clinics, Inc., Boston), and the office records of the outpatient nephrology clinic. Early (ER) and late (LR) referral were defined by the time of first nephrology encounter greater than or less than 4 mo, respectively, before initiation of dialysis. Multivariate models were built to explore factors associated with LR, and whether LR is associated with hypoalbuminemia or late initiation of dialysis. Of the 135 patients, 30 (22%) were referred late. There were no differences in age, gender, race, and cause of ESRD between ER and LR patients. However, there were significant differences in insurance coverage between these two groups. In the multivariate analysis, patients covered by health maintenance organizations were more likely to be referred late (odds ratio = 4.5) than patients covered by Medicare. Compared to ER, LR patients were more likely to have hypoalbuminemia (56% versus 80%), hematocrit <28% (33% versus 55%), and predicted GFR <5 ml/min per 1.73 m2 (17% versus 40%) at the start of dialysis, and less likely to have received erythropoietin (40% versus 17%) or have a functioning permanent vascular access for the first hemodialysis (40% versus 4%). It is concluded that late referral to the nephrologist is common in the United States and is associated with poor pre-ESRD care. Pre-ESRD care of patients treated by nephrologists was also less than ideal. The patient-, physician-, and system-related factors behind this observation are unclear. Meanwhile, pre-ESRD educational efforts need to target patients, generalists, and nephrologists. (+info)
Evidence-based nephrology.
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Systematic reviews and meta-analyses are the best approaches available for summarizing the available evidence concerning the efficacy of therapies. Although the renal field has been slow to use these techniques, they are being used increasingly. In March 1997, the Cochrane Renal Group was formed, and this group aims to produce and maintain up to date systematic reviews of the evidence on the effectiveness of therapies used to treat patients with renal diseases. This group is part of the Cochrane Collaboration which is an international structure grouping collaborators together, with the aim of preparing, maintaining and disseminating systematic reviews of the effects of health care in all areas of medicine. (+info)
Evidence-based medicine and its horizons: a useful tool for nephrologists?
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Though the concept of 'evidence-based medicine' (EBM) nowadays has become very popular and even fashionable, its practice is far from being an established reality. There are many reasons why, despite its potential, EBM finds obstacles in expressing its full potential as a tool to better inform health care decisions. Broadly speaking, these obstacles fall into three categories: (i) inadequacy of available information with respect the complexities of health care delivery; (ii) poor quality of clinical research; and (iii) insufficient and inappropriate efforts to promote the uptake of effective interventions in clinical practice. In the first part of the paper, we will discuss: (i) what evidence-based medicine is; (ii) why systematic reviews are the fundamental tool of EBM and what is really special about them; (iii) what are the tools for the practice of EBM; (iv) what its limitations are; and (v) what are the hindrances to its implementation. In the second part, a brief assessment of the state of the art of systematic reviews in nephrology will be presented, with special reference to the activities of the recently launched Cochrane Collaborative Review Group in Renal Diseases. (+info)
Attitudes of Canadian nephrologists toward dialysis modality selection.
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OBJECTIVE: To determine the opinions and attitudes of Canadian nephrologists about dialysis modality decisions and optimal dialysis system design. PARTICIPANTS: Members of the Canadian Society of Nephrology. INTERVENTION: A mailed survey questionnaire. RESULTS: A 66% response rate was obtained. Decisions about modality are reported to be based most strongly on patient preference (4.4 on a scale from 1 to 5), followed by quality of life (4.06), morbidity (3.97), mortality (3.85), and rehabilitation (3.69), while neither facility (1.78) nor physician (1.62) reimbursement are important. When asked about the current relative utilization of each modality, nephrologists felt that hospital-based hemodialysis (HD) is slightly overutilized (2.53), continuous ambulatory peritoneal dialysis (CAPD) is about right (3.00), while cycler peritoneal dialysis (PD) (3.53), community-based full (3.83) and self-care HD (3.91), and home HD (4.02) are underutilized. A hypothetical question about optimal distribution to maximize survival revealed that a type of HD should constitute 62.8% of the mix, with more emphasis on cycler PD (14.9%), community-based full care HD (13.8%), self-care HD (14.5%), and home HD (9.0%) than is current practice. However, when the goal was to maximize cost effectiveness, HD fell slightly to 57.8%. CONCLUSIONS: These survey results suggest that the current national average 66%/34% HD/PD ratio is reasonable. However, there appears to be a consensus that Canada could evolve to a more cost-effective, community-based dialysis system without compromising patient outcomes. (+info)
Community nephrology: audit of screening for renal insufficiency in a high risk population.
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BACKGROUND: The rate of acceptance onto dialysis programmes has doubled in the past 10 years and is steadily increasing. Early detection and treatment of renal failure slows the rate of progression. Is it feasible to screen for patients who are at increased risk of developing renal failure? We have audited primary care records of patients aged 50-75 years who have either hypertension or diabetes, and are therefore considered to be at high risk of developing renal insufficiency. Our aim was to see whether patients had had their blood pressure measured and urine tested for protein within 12 months, and plasma creatinine measured within 24 months. METHODS: This was a retrospective study of case notes and computer records in 12 general practices from inner and greater London. A total of 16,855 patients were aged 50-75 years. From this age group, 2693 (15.5%) patients were identified as being either hypertensive or diabetic, or both. RESULTS: Of the 2561 records audited, 1359 (53.1%) contained a plasma creatinine measured within 24 months, and 11% of these (150) had a value > 125 micromol/l. This equates to a prevalence of renal insufficiency of > 110,000 patients per million in this group. Forty two patients (28%) had been referred to a nephrologist. Of records audited, 73% contained a blood pressure measurement and 29% contained a test for proteinuria within 12 months. CONCLUSIONS: There is a high prevalence of chronic renal insufficiency in hypertensive and diabetic patients. It is feasible to detect renal insufficiency at a primary care level, but an effective system will require computerized databases that code for age, ethnicity, measurement of blood pressure and renal function, as well as diagnoses. (+info)
Latin American nephrology: scientific production and impact of the publications.
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BACKGROUND: During the last two decades, there has been a significant change in the origin and impact of the world's biomedical scientific production, particularly in countries in which the investment in research accounts for an important portion of the gross national product (GNP). However, in less developed countries, budget restrictions and the lack of policies toward research may determine a limited growth of the scientific production. METHODS: We examined the number and impact of peer-reviewed publications from Latin America included in the Institute of Scientific Information (ISI) and MEDLINE databases. In addition, we analyzed the number of abstracts submitted to the congresses of the International Society of Nephrology (ISN), American Society of Nephrology (ASN), and Latin American Society of Nephrology and Hypertension (SLANH). RESULTS: The number of peer-reviewed publications in nephrology from authors in Latin America during the last 20 years represented less than 1% of the world's total. Only 13 out of the 22 Latin American countries accounted for these publications. The citation impact (3.52) was below the world average (7.82). However, this index showed a tendency towards growth in the five most productive countries. Likewise, the number of abstracts submitted to international meetings of nephrology by authors in Latin American countries has shown a steady growth in the recent years, but remains proportionately low compared with the rest of the world. CONCLUSIONS: This study indicates that although efforts toward improving the quantity and quality of research in Latin America have been made, the final results are less than other regions in the world. Possible factors responsible for the low performance include a failure in academic motivation and lack of pressure for publication, as well as limited research funding. Therefore, important efforts from local and international nephrological communities are needed to boost research in Latin America. (+info)
Edmund Randerath (1899-1961): experimental proof for the glomerular origin of proteinuria.
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A century ago, Edmund Randerath (1899-1961), who was one of the pioneers in nephrology that provided indirect experimental proof for the glomerular origin of proteinuria, was born. In the first decades of this century, the concept prevailed that "nephrosis" was a process of primary tubular cell degeneration. In contrast to prevailing opinion, he interpreted these changes to be the result of the uptake and storage of serum proteins after they had been filtered in the glomerulus. Edmund Randerath proved the glomerular origin of proteinuria by astute experiments in amphibia. In the salamander, an intraperitoneal injection of albumin provoked the supposedly "degenerative" changes of tubular epithelial cells in only those nephrons that drained the coelomic cavity and were devoid of glomeruli, but not in those nephrons that were closed and attached to glomeruli. This observation provided incontrovertible evidence that the presence of serum proteins in tubular fluid was a prerequisite for the development of the tubular epithelial cell changes typically seen in nephrotic patients. (+info)
Level of renal function at the initiation of dialysis in the U.S. end-stage renal disease population.
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Level of renal function at the initiation of dialysis in the U.S. end-stage renal disease population. BACKGROUND: More than 285,000 individuals in the United States suffer from end-stage renal disease (ESRD) and are treated predominantly by dialysis. Despite the high cost and poor outcomes of dialysis treatment for ESRD, there are few data about the level of renal function at the onset of ESRD and no established medical criteria for the initiation of dialysis. METHODS: We report the level of serum creatinine and glomerular filtration rate (GFR) in 90,897 patients who began dialysis in the U. S. between April 1995 through September 1997. Data were obtained from the U.S. Renal Data System. GFR was predicted by an equation developed from the Modification of Diet in Renal Disease Study. RESULTS: The mean (SD) serum creatinine was 8.5 (3.8) mg/dl. The mean (SD) predicted GFR was 7.1 (3.1) ml/min/1.73 m2, with a range from 1 to 42 ml/min/1.73 m2. The proportion of patients with predicted GFR of > 10, 5 to 10, and <5 ml/min/1.73 m2 was 14, 63, and 23%, respectively. The mean predicted GFR was significantly lower among younger patients, women, African Americans, patients with a higher body weight, patients with ESRD because of diseases other than diabetes, uninsured patients, patients who were employed, homemakers or students, and patients selecting hemodialysis. CONCLUSIONS: There is wide variation in renal function at the initiation of dialysis in the U.S. ESRD population, and a substantial fraction of patients start dialysis at very low levels of predicted GFR. Further analyses are needed to examine the factors associated with late initiation of dialysis and its impact on the cost and outcomes of ESRD. (+info)