Posted on Friday, 3rd April 2009 by admin
April 1, 2009 (Nashville, Tennessee) — A structured chronic kidney disease (CKD) program prior to beginning dialysis leads to better patient outcomes while on dialysis, according to a study presented here at the National Kidney Foundation 2009 Spring Clinical Meetings.
The retrospective study identified 172 patients from a CKD clinic run by St. John Hospital and Medical Center, in Detroit, Michigan, who subsequently developed end-stage renal disease and enrolled in a dialysis program, said lead author Joel M. Topf, MD. Entry criteria were no previous or intervening dialysis.
He said previous studies had looked at unstructured predialysis care. The St. John program differs from the structured approach in that it takes into account education, treatment of complications, and preparation for entry into dialysis.
One-year mortality after starting dialysis was 12.8% among the clinic group, compared with 22.6% typically seen in the Midwestern Network?11. Analysis was structured according to how long patients had participated in the clinic program before beginning dialysis, but there was no difference in outcomes, regardless of whether the patient had participated for less than 6 months, more than 24 months, or for durations between 6 and 24 months.
Dr. Topf told Medscape Nephrology that he was surprised there were no differences in “dose response” to the clinic intervention. The hospital has “deep electronic medical records on the patients” and, in ongoing analysis, they hope to identify which parts of the delivered care had the greatest effect on mortality.
Only 16% of the patients had fistulas in place. “Clearly, that did not explain the improved mortality,” he said. Perhaps it reflects a selection bias in the patient population the clinic serves.
Another study, presented by Brennan Spiegel, MD, from the University of California, in Los Angeles, looked at dialysis practices that distinguished top- from bottom-performing facilities, as measured by standardized mortality ratios during a 6-month period. The study included 90 units across 3 dialysis organizations.
Units with lower mortality rates reported that patients were more motivated, self-efficacious, and compliant with their diets. They also seemed to better integrate care across disciplines, and were more likely to use chairside computers and to have more knowledgeable dieticians.
A structured approach has worked well in treating diabetes and should work well with chronic kidney disease, said Jerry Yee, MD, a nephrologist at the Henry Ford Hospital, in Detroit. “There are multiple domains of CKD; affecting or treating all of them may be the answer. It may not be a magic bullet, but there are a lot of small magical bullets that you have to treat, and this study shows that.”
Studies have shown that when a patient has CKD, “a couple of things are done and the rest are forgotten or not done optimally. Follow-up is extremely important,” he told Medscape Nephrology. “The Northwest group stabilized almost of one quarter of their patients in late stage?4 chronic kidney disease by using a multimodal approach.”
Dr. Yee said the nephrologist should identify and treat all aspects of CKD that need to be treated — hypertension, anemia, obesity, control of hemoglobin, mineral bone disorders, and lipids. “If they do that, they will be able to walk away and say, we’ve done everything we can and the disease was more than we could contain.”
The studies did not receive commercial support. The authors have disclosed no relevant financial relationships.
National Kidney Foundation 2009 Spring Clinical Meetings: Abstracts 56 and 164.
By Bob Roehr
Medscape Medical News
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