Practical Use of Patient-Reported Outcome Measures in Chronic Kidney Disease-Associated Pruritus.

Regulatory and clinical stakeholders are increasingly advocating for the use of patient-reported outcome (PRO) measures; however, the use of PROs is still not widespread. Patient reports are often the best ways to diagnose and monitor the effect of treatment on symptoms when the symptoms are subjective, as with pruritus. While many PRO tools are available to assess the severity of pruritus and its impact on quality of life (e.g., sleep), these are not used in a consistent manner and their results may not translate into clinical action. In this article, we present an introduction to PROs and their use in the assessment of chronic kidney disease-associated pruritus, as well as a practical guide to some of the PRO tools currently available, to empower all members of the nephrology patient care team to use these tools appropriately for the benefit of the patient.

Nutritional Considerations for Patients With Renal Failure Undergoing Sleeve Gastrectomy.

Obesity is highly prevalent in patients with renal disease, as it contributes to or accelerates the progression of kidney disease and is frequently a barrier to kidney transplantation. Patients with renal disease have unique dietary needs due to various metabolic disturbances resulting from altered processing and clearance of nutrients. They also frequently present with physical disability, resulting in difficulty achieving adequate weight loss through lifestyle modifications. Therefore, kidney transplant candidates may benefit from bariatric surgery, particularly sleeve gastrectomy (SG), as the safest, most effective, and long-lasting weight loss option to improve comorbidities and access to transplantation. However, concerns regarding nutritional risks prevent broader dissemination of SG in this population. No specific guidelines tailored to the nutritional needs of patients with renal disease undergoing SG have been developed. Moreover, appropriate monitoring strategies and interventions for muscle loss and functional status preservation, a major concern in this at-risk population, are unknown. We aimed to summarize the available literature on the nutritional requirements of patients with renal disease seeking SG as a bridge to transplantation. We also provide insight and guidance into the nutritional management pre and post-SG.

Management of Patients With Kidney Disease Undergoing Bariatric Surgery: A Multidisciplinary Approach.

Bariatric surgery is increasingly recognized as a safe and effective treatment for obesity in patients with chronic kidney disease (CKD), including stages 4, 5, and 5D (on dialysis). Among the available surgical methods, sleeve gastrectomy (SG) is the most commonly performed weight loss procedure and is mainly done to facilitate kidney transplantation (KT). However, many KT candidates treated with SG remain on the transplant waiting list for months to years, with some never receiving a transplant. Therefore, appropriate candidates for SG must be selected, and post-SG management should address the unique needs of this population, with a focus on sustaining the metabolic benefits of surgery while minimizing potential side effects related to rapid weight loss which may inadvertently lead to muscle and bone catabolism. Multidisciplinary post-SG care in this population may lead to overall better health on the transplant waiting list, resulting in a higher percentage of post-SG patients ultimately receiving KT. To tailor the effective treatment for these patients, clinicians should acknowledge that patients with CKD stage 4-5D have different nutritional needs and are metabolically and psychosocially distinct from the general bariatric surgery population. Sarcopenia is highly prevalent and may be exacerbated by muscle catabolism following SG if not adequately addressed. Blood pressure, glucose, and bone metabolism are all affected by the CKD stage 4-5D, and therefore require distinct diagnostic and management approaches. Long-standing chronic disease, associated comorbidities, and low adherence to medical therapies require ongoing comprehensive psychosocial assessment and support. This paper aims to review and consolidate the existing literature concerning the intersection of CKD stage 4-5D and the consequences of SG. We also suggest future clinical outcome studies examining novel treatment approaches for this medically complex population.

Nutrition management of gastric bypass in patients with chronic kidney disease.

Frequent monitoring by a dietitian can ensure desirable progression of the post-surgery diet, adequate nutritional composition, management of food intolerances, and ongoing education/reinforcement of the post-surgical nutritional needs. Additionally, it is critical for dietitians to assess the type of GBP because increased nutritional risks result with longer limb lengths and will require closer monitoring. With close follow up and adherence to recommendations, patients with CKD who undergo GBP can reduce the risk of post-surgical, nutrition complications.

Time in Therapeutic Range for Dialysis Patients on Warfarin: Determination and the Effect of Dietary Intervention.

This study aimed to identify the time in therapeutic range (TTR) for dialysis patients on warfarin, and improve TTR with dietary review and intervention of interacting foods. We identified 151 patients undergoing hemodialysis in two units who were being treated with warfarin from January 1, 2010, through February 1, 2018, who were included in the overall TTR study. Of these, 15 patients were available to undergo the dietary intervention. International normalized ratio values were collected retrospectively for all eligible hemodialysis patients, and TTR was calculated for each period in which the patient was on hemodialysis. Patients who were available and agreed to the intervention underwent targeted dietician review of interacting foods, and their TTR post-treatment was calculated. The median (interquartile range [IQR]) TTR was 44 (IQR, 29 to 53) % among the 151 patients. Among the 15 patients who underwent the intervention, median (IQR) TTR was 52 (IQR, 32 to 56) pre-intervention and 51 (IQR, 38 to 69) post-intervention (P=0.53). TTR for dialysis patients is low in this overall cohort despite patients being seen at an integrated health care system. Focused improvement projects such as dietary review of interacting foods may help increase a patient's TTR.