High incidence of low interstitial fluid glucose among type 2 diabetes patients with chronic kidney disease (CKD) despite adhering to appropriate glycated haemoglobin targets-has time come for robust integration of interstitial fluid glucose targets into glycaemic guidelines?

AIM: We aim to compare the burden of Level 1 (<4 mmol/L) and Level 2 (<3 mmol/L) hypoglycaemia between type 2 diabetes (T2D) patients with and without chronic kidney disease (CKD). METHODS: T2D subjects with and without CKD (eGFR<60 mL/min/1.73 m2) were recruited from a tertiary-care hospital. Subjects wore the Freestyle Libre-Pro sensor for 2 weeks. The number of hypoglycaemic events and intra-day difference in Level 1 and 2 hypoglycaemias were compared between the cohorts. RESULTS: We recruited 134 subjects: 74 with CKD (44 M:30F) and 60 without CKD (36 M:24F), with no difference in HbA1c between the two cohorts (66 ± 20 vs 64 ± 16 mmol/mol, p = 0.529). The CKD cohort had increased level 1 (OR 1.73, p = 0.011), level 2 hypoglycaemias (OR 2.16, p = 0.002), and glycaemic variability than the non-CKD cohort (35.3 ± 9.5 vs 32.3 ± 6.8%). The CKD cohort had more level 2 hypoglycaemia events nocturnally compared to day at 1.9 ± 3.1 vs. 1.4 ± 2.5 events/person within the two week sensor wearing period (p = 0.022), whereas there was no significant intra-day difference in the number of such events within the non-CKD cohort. CONCLUSIONS: The CKD cohort has a greater burden of hypoglycaemia despite being treated to similar HbA1c targets. The greater number of nocturnal events warrants safety concern. Interstitial fluid glucose targets should be incorporated into the glycaemic guidelines for T2D patients with CKD.

Rapid point-of-care test for diagnosis of peritonitis in peritoneal dialysis patients.

BACKGROUND: Periplex® is a rapid point-of-care test based on the detection of interleukin-6 (IL-6) or matrix metalloproteinase-8 (MMP-8) to diagnose peritonitis in peritoneal dialysis (PD) patients. METHODS: This single-centre study was conducted in Singapore General Hospital from 2019 to 2022. The study recruited PD patients suspected of having peritonitis. Periplex was performed at the presentation and recovery of peritonitis. Primary outcomes were sensitivity and specificity of Periplex at presentation. The positive and negative predictive values of tests were also performed. RESULTS: A total of 120 patients were included in the study. The mean age was 60.9 ± 14.9 years, 53% were male, 79% were Chinese and 47.5% had diabetes mellitus. Periplex was positive in all patients with peritonitis (n = 114); sensitivity of 100%; 95% confidence interval (CI): 100-100%. Periplex was falsely positive in three patients with non-infective eosinophilic peritonitis, resulting in a low specificity of 50%; 95% CI: 41.1-59.0%. Periplex had a positive predictive value of 97.4% and a negative predictive value of 100%. During recovery from peritonitis, Periplex had high specificity (93.6%) and negative predictive value (98.7%) to indicate the resolution of infection. MMP-8 was more sensitive than IL-6 in detecting peritonitis. Periplex was positive in all patients with peritonitis regardless of the types of PD solutions used. CONCLUSIONS: Periplex had high sensitivity, and positive and negative predictive values in the diagnosis of peritonitis can be considered as a screening tool for peritonitis. Given its high specificity and negative predictive value, it may also be used to document the resolution of peritonitis.

Development and validation of a novel nomogram to predict diabetic kidney disease in patients with type 2 diabetic mellitus and proteinuric kidney disease.

PURPOSE: Differentiating between diabetic kidney disease (DKD) and non-diabetic kidney disease (NDKD) in patients with Type 2 diabetes mellitus (T2DM) is important due to implications on treatment and prognosis. Clinical methods to accurately distinguish DKD from NDKD are lacking. We aimed to develop and validate a novel nomogram to predict DKD in patients with T2DM and proteinuric kidney disease to guide decision for kidney biopsy. METHODS: A hundred and two patients with Type 2 Diabetes Mellitus (T2DM) who underwent kidney biopsy from 1st January 2007 to 31st December 2016 were analysed. Univariate and multivariate analyses were performed to identify predictive variables and construct a nomogram. The discriminative ability of the nomogram was assessed by calculating the area under the receiver operating characteristic curve (AUROC), while calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test and calibration plot. Internal validation of the nomogram was assessed using bootstrap resampling. RESULTS: Duration of T2DM, HbA1c, absence of hematuria, presence of diabetic retinopathy and absence of positive systemic biomarkers were found to be independent predictors of DKD in multivariate analysis and were represented as a nomogram. The nomogram showed excellent discrimination, with a bootstrap-corrected C statistic of 0.886 (95% CI 0.815-0.956). Both the calibration curve and the Hosmer-Lemeshow goodness-of-fit test (p = 0.242) showed high degree of agreement between the prediction and actual outcome, with the bootstrap bias-corrected curve similarly indicating excellent calibration. CONCLUSIONS: A novel nomogram incorporating 5 clinical parameters is useful in predicting DKD in type 2 diabetes mellitus patients with proteinuric kidney disease.

Non-steroidal anti-inflammatory drugs in chronic kidney disease and risk of acute adverse kidney events according to route of administration.

BACKGROUND: Topical non-steroidal anti-inflammatory drugs (NSAIDs) have lower risks for cardiovascular disease and gastrointestinal adverse effects compared to oral NSAIDs, but there are little data regarding their kidney risks in chronic kidney disease (CKD). We evaluated the risk of adverse acute kidney outcomes in CKD according to route of NSAID administration. METHODS: Retrospective cohort study of adults with CKD (eGFR less than 60 ml/min/1.73 m2) who received prescriptions between 2015 and 2017 from a major healthcare cluster in Singapore. The adverse acute kidney outcomes were acute kidney injury (AKI) and need for nephrology specialist consult within 30 days. RESULTS: Among 6298 adults with CKD (mean age 72.1 ± 13.3 years and eGFR 41.9 ± 12.2 ml/min/1.73 m2), systemic and topical NSAIDs were prescribed in 16.7% and 32.0%, respectively. Incident AKI (any severity), KDIGO Stage 2 or 3 AKI, and need for nephrology specialist consult occurred in 16.7%, 2.6%, and 10.6% of the study cohort, respectively. After adjusting for age, diabetes, recent cardiovascular hospitalization, baseline eGFR, RAAS blocker and diuretic, systemic NSAIDs, and topical NSAIDs, compared with the no-NSAID group, were independently associated with incident AKI [adjusted OR 1.77 (95% CI 1.46-2.15) and 1.38 (1.18-1.63), respectively]. Moderate and severe AKI (adjusted OR 1.68, 95% CI 1.09-2.58, p = 0.02) and need for nephrology consults (adjusted OR 1.41, 95% CI 1.09-1.82, p = 0.008) were also increased in systemic NSAIDs. CONCLUSION: Among adults with CKD, both systemic and topical NSAIDs were independently associated with acute adverse kidney outcomes.

Patient education interventions for haemodialysis and peritoneal dialysis catheter care: An integrative review.

Background: Inadequate training on how to care for haemodialysis and peritoneal dialysis catheters can lead to mechanical issues with the catheters and infectious complications (such as peritonitis) that could endanger patient safety, reduce the effectiveness of the dialysis treatment, and have a negative impact on patient morbidity and mortality. Such incidents can be prevented as they are mostly dependant on controllable factors - proper dialysis catheter care, which can be addressed through effective patient education. Effective patient education is crucial in ensuring that patients are equipped with the knowledge and skills necessary for both peritoneal and haemodialysis catheter care. Aims: To synthesise evidence on the: (1) patient educational interventions on haemodialysis and peritoneal dialysis catheter care; and (2) reported learning and clinical outcomes of the educational interventions provided for patients with haemodialysis and peritoneal dialysis catheter. Design: Integrative review. Methods: This review followed the framework by Whittemore and Knafl. The literature search was performed using four electronic databases: PubMed, CINAHL, Cochrane Library and ProQuest Nursing and Allied Health. The Joanna Briggs Institute Critical Appraisal Tool was used to appraise the articles that fit the inclusion and exclusion criteria. Studies published in the English language were retrieved. Results: A total of 14 studies were included. All the studies focused on educating patients who were on either tunnelled (permanent) haemodialysis catheters or peritoneal dialysis catheters. The findings identified: (1) teaching strategies used for educating patients on haemodialysis catheter care (2) teaching strategies for educating peritoneal dialysis patients on peritoneal dialysis catheter care and (3) outcomes of patient education on both haemodialysis and peritoneal dialysis catheters. Written materials and educational videos were used to instruct patients on haemodialysis catheters care. Different educational strategies for educating patients on peritoneal dialysis catheter care were also reported. They varied in terms of the composition and experience of the implementation care team members, educational approach, training duration, training location, timing relative to catheter placement, assessment method and follow-up support. The various teaching strategies were assessed and compared based on the patients' knowledge levels, catheter-related mechanical issues, and catheter-related infectious consequences (such as peritonitis). Conclusion: This review highlighted various education materials and compared different educational practices on tunnelled (permanent) haemodialysis catheter and peritoneal dialysis catheter care that healthcare providers used to increase knowledge and reduce catheter-related blood stream infections and peritonitis rates.

Validation of the kidney failure risk equation in predicting the risk of progression to kidney failure in a multi-ethnic Singapore chronic kidney disease cohort.

INTRODUCTION: The Kidney Failure Risk Equation (KFRE) was developed to predict the risk of progression to end-stage kidney disease (ESKD). Although the KFRE has been validated in multinational cohorts, the Southeast Asian population was under-represented. This study aimed to validate the KFRE in a multi-ethnic Singapore chronic kidney disease (CKD) cohort. METHODS: Stage 3-5 CKD patients referred to the renal medicine department at Singapore General Hospital in 2009 were included. The primary outcome (time to ESKD) was traced until 30 June 2017. The eight- and four-variable KFRE (non-North America) models using age, gender, estimated glomerular filtration rate, urine albumin-creatinine ratio, serum albumin, phosphate, bicarbonate and calcium were validated in our cohort. Cox regression, likelihood ratio (Χ2), adequacy index, Harrell's C-index and calibration curves were calculated to assess the predictive performance, discrimination and calibration of these models on the cohort. RESULTS: A total of 1,128 patients were included. During the study period, 252 (22.3%) patients reached ESKD at a median time to ESKD of 84.8 (range 0.1-104.7) months. Both the eight- and four-variable KFRE models showed excellent predictive performance and discrimination (eight-variable: C-index 0.872, 95% confidence interval [CI] 0.850-0.894, adequacy index 97.3%; four-variable: C-index 0.874, 95% CI 0.852-0.896, adequacy index 97.9%). There was no incremental improvement in the prediction ability of the eight-variable model over the four-variable model in this cohort. CONCLUSION: The KFRE was validated in a multi-ethnic Singapore CKD cohort. This risk score may help to identify patients requiring early renal care.

Native kidney biopsies in older adults: disease spectrum, long-term kidney and patient survival and safety.

PURPOSE: Patients undergoing kidney biopsy are increasingly older. We aimed to evaluate the clinical utility of kidney biopsy, long-term clinical outcomes, and safety of high-risk biopsies in older adults undergoing kidney biopsy in a multi-ethnic Southeast Asian cohort. METHODS: We performed a single-center retrospective study of older patients (age ≥ 60 years) who underwent native kidney biopsies between June 2011 and March 2015. The primary long-term outcome of interest was a composite of ESKD or death. The safety outcome of interest was post-biopsy bleeding in the high-risk subgroup, defined by serum creatinine > 150 µmol/l. RESULTS: Older adults accounted for 153 of 545 (28.1%) native renal biopsies performed. The median age of these older adults was 66.6 (IQR 63.0, 70.6) years. Kidney dysfunction was frequent and severe in this cohort, with 41.2% having eGFR < 30 ml/min/m2 and 71.2% having nephrotic-range proteinuria at presentation. A significant proportion (124 patients; 81.0%) had treatable diagnoses. Of these, 90 (72.6%) received immunosuppressive therapy. On Kaplan-Meier analysis, patients with pauci-immune glomerulonephritis (p = 0.004) and diabetic nephropathy (p = 0.005) were at a significantly increased risk of the composite outcome of ESKD or death. On multivariate analysis, older age and lower eGFR were independently associated with ESKD or death and ESKD alone. Lupus nephritis and diabetic nephropathy were independently associated with ESKD or death, while immunosuppressant therapy was associated with reduced ESKD alone. In the high-risk subgroup, post-biopsy bleeding occurred in 19 (22.8%) patients. Desmopressin use was not associated with reduced bleeding complications. CONCLUSION: Our study confirmed the utility of kidney biopsy in older adult patients for diagnosis and management, although risk counselling and close monitoring for bleeding complications is necessary.

Treatment-related decisional conflict in pre-dialysis chronic kidney disease patients in Singapore: Prevalence and determinants.

BACKGROUND: In advanced chronic kidney disease (CKD), patients face complex decisions related to renal replacement modality that can cause decisional conflict and delay. This study aimed to evaluate the prevalence of severe decisional conflict across decision types and to identify the psychosocial and clinical factors associated with decisional conflict in this population. DESIGN: Observational cross-sectional study. METHODS: Patients with CKD in renal care were recruited. The Decisional Conflict Scale (DCS), Functional, Communicative, and Critical Health Literacy (FCCHL), Health Literacy Questionnaire (HLQ), Hospital Anxiety and Depression Scale (HADS), Brief Illness Perception Questionnaire (BIPQ), and the Kidney-disease Quality of Life (KDQOL) questionnaires were used. Clinical data were obtained from medical records. Bivariate and multivariable logistic regression models were used to identify predictors of severe decisional conflict (DCS score ≥ 37.5). RESULTS: Participants (N = 190; response rate = 56.7%; mean age = 62.8 ± 10.8) reported moderate levels of decisional conflict (29.7 ± 14.5). The overall prevalence of severe decisional conflict was 27.5% (n = 46) with no significant differences across decision types (dialysis, modality, access). Ethnicity (Chinese), marital status (married), BIPQ treatment control, coherence, KDQOL staff encouragement, and all health literacy domains, except functional health literacy, were significant predictors of decisional conflict in the unadjusted models. In the multivariable model, only the health literacy domains of FCCHL Communicative, and HLQ Active Engagement remained significant. CONCLUSION: Even after pre-dialysis education, many CKD patients in this study still report severe decisional conflict, with rates remaining substantial across decision junctures. The associations of decisional conflict and health literacy skills related to communication and engagement with healthcare providers indicate that more collaborative and patient-centric pre-dialysis programs may support patient activation and resolve decisional conflict.

Non-Steroidal Anti-Inflammatory Drugs and Risk of Acute Kidney Injury and Hyperkalemia in Older Adults: A Retrospective Cohort Study and External Validation of a Clinical Risk Model.

AIM: Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used analgesics among older adults. Adverse effects may be avoided by careful patient selection. We aimed to evaluate the incidence of acute kidney injury (AKI) and/or hyperkalemia, risk factors, and the accuracy of an NSAID risk prediction model in a cohort of Asian older adults. METHODS: We conducted a retrospective cohort study of older adults, age 65 years and above, who received prescriptions between March 2015 and December 2017 from Singapore's largest cluster of public healthcare institutions. Factors associated with 30-day incident acute kidney injury and/or hyperkalemia were evaluated with multivariable regression analysis. Calibration and discrimination of the Nash prediction model were assessed using the Hosmer-Lemeshow goodness-of-fit test and C-statistic, respectively. RESULTS: The primary outcome occurred in 16.7% of 12,798 older adults. Topical NSAIDs (adjusted OR 1.29, 95% CI 1.15-1.45), systemic NSAIDs of 1-14 days' duration (adjusted OR 1.43, 95% CI 1.27-1.62), and systemic NSAIDs > 14 days (adjusted OR 1.84, 95% CI 1.37-2.49) were independently associated with the primary outcome, compared with no NSAID. Diabetes mellitus, cardiovascular disease, lower estimated glomerular filtration rate (eGFR), and diuretics were also independently associated with increased incident AKI and/or hyperkalemia. When applied to older adults with systemic NSAIDs > 14 days (n = 305), the Nash risk model had poor calibration (p < 0.001) and poor discrimination with C-statistic 0.527 (0.438, 0.616). CONCLUSIONS: Longer NSAID duration and systemic compared with topical route were associated with incremental odds for acute renal events. Further studies are required to improve the available risk model to guide NSAID prescriptions in older adults.

Effectiveness and acceptability of a multidisciplinary approach in improving the care of patients with advanced chronic kidney disease: a pilot study.

OBJECTIVE: This study aimed at determining the feasibility of conducting a large-scale pragmatic effectiveness study on the implementation of multidisciplinary care (MDC) program for patients with advanced chronic kidney disease (CKD). METHODS: This is a single-arm pre-post intervention design pilot study over 12 months. Participants with an estimated glomerular filtration rate (eGFR) between 11 and 20 ml/min/1.73m2 were screened and recruited at the initial MDC clinic visit and followed for 12 months. Clinical parameters, KDQOL™-36, questionnaires, and interviews were collected, administered, and analysed for enrolment and completion rates, baseline characteristics, implementation fidelity, adherence to CKD interventions, eGFR decline, CKD complications, health-related quality of life, and participants' acceptability of the program. RESULTS: The study enrolment and completion rates were 43.1% (50/116 screened) and 66.0% (33/50 recruited) respectively. The participants had a mean age of 68.5 years (SD9.0) and a mean eGFR of 15.4 ml/min/1.73m2(3.2). After 12 months of MDC program, there was increased adherence to CKD interventions (difference  - 0.6(1.0), 95%CI  - 1.1,  - 0.1, p = 0.02). There was good participants' acceptability of the program with participants being more satisfied with the waiting time and having a better understanding of kidney failure after attending the program. No difference in the eGFR decline noted (difference 0.0 ml/min/1.73m2(5.3), 95%CI  - 1.9, 1.9, p = 1.00). CONCLUSION: Our pilot data suggest increased adherence to CKD interventions and good acceptability to MDC program, albeit no difference in eGFR decline probably because of the small sample size. However, reasons for overall low enrolment and completion rates need to be explored and addressed while designing a future large-scale randomised controlled trial.

Non-steroidal anti-inflammatory drugs and risk of acute adverse renal outcomes in diabetes and diabetic kidney disease.

BACKGROUND: Individuals with diabetes mellitus (DM) may be susceptible to non-steroidal anti-inflammatory drug (NSAID)-induced acute kidney injury (AKI) but data on NSAID-related adverse renal events is sparse. OBJECTIVE: We aimed to evaluate the risk of acute kidney injury and/or hyperkalemia after systemic NSAID among individuals with DM and diabetic chronic kidney disease (CKD). METHODS: Retrospective cohort study of 3896 adults with DM with incident prescriptions between July 2015 and December 2017 from Singapore General Hospital and SingHealth Polyclinics. Laboratory, hospitalization and medication data were retrieved from electronic medical records. The primary outcome was the incidence of AKI and/ or hyperkalemia within 30 days after prescription. RESULTS: AKI and/or hyperkalemia occurred in 13.5% of all DM and 15.8% of diabetic CKD. The association between systemic NSAID >14 days and 30-day risk of AKI and/or hyperkalemia failed to reach statistical significance in unselected DM (adjusted OR 1.62, 95% CI 0.99-2.65, p = 0.05) and diabetic CKD (adjusted OR 0.64, 95% CI 0.15-2.82, p = 0.64), but the odds of AKI and/or hyperkalemia were markedly and significantly increased when NSAID was prescribed with renin-angiotensin-aldosterone system (RAAS) blocker (adjusted OR 4.17, 95% CI 1.74-9.98, p = 0.001) or diuretic (adjusted OR 3.31, 95% CI 1.09-10.08, p = 0.04) and in the absence of diabetic CKD (adjusted OR 1.98, 95% CI 1.16-3.36, p = 0.01). CONCLUSION: NSAID prescription >14 days in individuals with DM with concurrent RAAS blockers or diuretics was associated with higher 30-day risk of AKI and/or hyperkalemia.

Chlorhexidine-impregnated sponge dressing for prevention of catheter exit-site infection in peritoneal dialysis patients: a pilot study.

PURPOSE: The study aimed to examine effect of chlorhexidine dressing in the prevention of peritoneal dialysis (PD)-related infection in PD patients. METHODS: This single-center pilot study recruited 50 incident PD patients to use weekly chlorhexidine dressing. The primary outcome was exit-site/tunnel infection rate. Secondary outcomes were peritonitis rate, time to first PD-related infection, infection-related hospitalization, technique and patient survival, adverse events, and chlorhexidine dressing acceptability. These clinical outcomes were compared with those of a historical cohort (2016-2017) using daily gentamicin cream. RESULTS: A total of 50 patients were recruited to use chlorhexidine and followed up for one year. The exit-site/tunnel infection rate was 0.09 (95% confidence interval [CI] 0.02-0.22) and peritonitis rate was 0.07 (95% CI 0.01-0.19) episodes per patient-year with chlorhexidine dressing. The 1-year infection-free survival rates for exit-site/tunnel infection and peritonitis were 92% and 94%, respectively. The 1-year technique and patient survival rates were 86% and 96%, respectively. Overall, 12% of participants developed localized contact dermatitis with chlorhexidine. Most participants (73%) reported that chlorhexidine dressings were very acceptable. Compared to a historical cohort using gentamicin cream (n = 238), the chlorhexidine group had similar exit-site/tunnel infection rates (incidence rate ratio [IRR] 0.65, 95% CI 0.22-1.92) but had lower peritonitis rates (IRR 0.24, 95% CI 0.07-0.77), and lower PD infection-related hospitalization rates (IRR 0.21, 95% CI 0.06-0.69) after adjusting for age, sex, race, primary kidney disease, and diabetes mellitus. CONCLUSION: Weekly chlorhexidine dressing was associated with acceptable PD-related infection outcomes and was well-accepted by patients, although had a 12% rate of delayed localized contact dermatitis. TRIAL REGISTRATION NUMBER AND DATE: The study was registered under www.clinicaltrials.gov with the reference number of NCT03406520 on 23 January 2018.

Short-Course Systemic and Topical Non-Steroidal Anti-Inflammatory Drugs: Impact on Adverse Renal Events in Older Adults with Co-Morbid Disease.

BACKGROUND: Prolonged systemic non-steroidal anti-inflammatory drugs (NSAIDs) have been associated with adverse renal outcomes among older adults. However, there is scant data regarding the renal safety of topical and short-course systemic NSAIDs. We aimed to evaluate the risk of acute adverse renal outcomes among older adults prescribed topical and short-term systemic NSAIDs. METHODS: We conducted a retrospective cohort study of all older adults, age 60 years and above, who received prescriptions between July 2015 and December 2017 from the largest tertiary hospital and a major public primary care institution in Singapore. Data from 6 months before until 30 days after the first prescription were retrieved from electronic medical records. The primary outcome was the incidence of acute kidney injury (serum creatinine increased >26.5 µmol/L or >50% from baseline) and/or hyperkalemia within 30 days. A multi-variate analysis taking into account age, sex, co-morbidities, baseline-estimated glomerular filtration rate and serum potassium, NSAID route of administration, and concurrent renin-angiotensin-aldosterone system blocker and diuretic prescription was performed to evaluate factors associated with the primary outcome. RESULTS: We identified 12,773 older adults with incident prescriptions: 3982 (31.2%) received short-course systemic NSAIDs, 3784 (29.6%) received topical NSAIDs, and 5007 (39.2%) did not receive any NSAID. Both short-course systemic NSAIDs (adjusted odds ratio [OR] 1.59, 95% confidence interval [CI] 1.41-1.80, p < 0.001) and topical NSAIDs (adjusted OR 1.48, 95% CI 1.31-1.67, p < 0.001), compared with the no-NSAID group, were independently associated with the primary outcome. Among older adults with co-morbid conditions and prescribed NSAIDs, topical NSAIDs had a reduced odds of 30-day incident acute kidney injury and/or hyperkalemia in diabetes mellitus (adjusted OR 0.78, 95% CI 0.65-1.06, p = 0.007), chronic kidney disease (adjusted OR 0.74, 95% CI 0.60-0.90, p = 0.003), and cardiovascular disease (adjusted OR 0.54, 95% CI 0.37-0.79, p < 0.001), compared with short-course systemic NSAIDs. CONCLUSIONS: NSAIDs increased the risk of acute adverse renal events. Topical NSAIDs, compared with short-course systemic NSAIDs, were associated with a reduced incidence of acute kidney injury and/or hyperkalemia among older adults with additional risk factors.

Psychosocial Factors, Intentions to Pursue Arteriovenous Dialysis Access, and Access Outcomes: A Cohort Study.

RATIONALE & OBJECTIVE: Suboptimal dialysis preparation of patients with chronic kidney disease (CKD) is common, but little is known about its relationship to psychosocial factors. This study aimed to assess patients' attitudes about access creation and to identify factors associated with patients' intentions regarding dialysis access creation and outcomes. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 190 patients with stage 4/5 CKD not receiving dialysis treated at 2 hospitals in Singapore and 128 of their family members. PREDICTORS: Self-reported measures of illness perception, health-related quality of life, and attitudes toward access creation. Sociodemographic and clinical measures were also obtained. OUTCOME: Intention to create an arteriovenous fistula (AVF; ie, proceed with access vs wait and see) and time to creation of a functional AVF. ANALYTICAL APPROACH: Exploratory factor analysis (EFA) was undertaken to construct internally consistent subscales for a newly developed questionnaire about attitudes toward access creation. Logistic regression and cause-specific hazards models were conducted to identify psychosocial factors associated with patients' access creation intentions and access outcomes, respectively. RESULTS: EFA (explained 50.1% variance) revealed 4 domains: access and dialysis concerns, need for dialysis, worry about cost, and value of access. A high risk of intention to delay access creation (51.1%) was found among patients despite early referral and education. Multivariable analysis (R2=0.45) showed that the intention to proceed with access creation was associated with greater perceived value from access (odds ratio, 2.61; 95% CI, 1.46-4.65; P<0.001). LIMITATIONS: Limited generalization, as only those already receiving nephrology care were studied. CONCLUSIONS: Approximately half of the patients studied planned to delay access creation. The questionnaire developed to evaluate attitudes about access creation may help identify individuals for whom decision-support programs would be useful. These findings highlight the need to understand and address patients' concerns about access creation.

Patient-Related Barriers to Timely Dialysis Access Preparation: A Qualitative Study of the Perspectives of Patients, Family Members, and Health Care Providers.

RATIONAL & OBJECTIVE: A key aspect of smooth transition to dialysis is the timely creation of a permanent access. Despite early referral to kidney care, initiation onto dialysis is still suboptimal for many patients, which has clinical and cost implications. This study aimed to explore perspectives of various stakeholders on barriers to timely access creation. STUDY DESIGN: Qualitative study. SETTING & PARTICIPANTS: Semi-structured interviews with 96 participants (response rate, 67%), including patients with stage 4 chronic kidney disease (n = 30), new hemodialysis patients with (n = 18) and without (n = 20) permanent access (arteriovenous fistula), family members (n = 19), and kidney health care providers (n = 9). ANALYTICAL APPROACH: Thematic analysis. RESULTS: Patients reported differential levels of behavioral activation toward access creation: avoidance/denial, wait and see, or active intention. 6 core themes were identified: (1) lack of symptoms, (2) dialysis fears and practical concerns (exaggerated fear, pain, cost, lifestyle disruptions, work-related concerns, burdening their families), (3) evaluating value against costs/risks of access creation (benefits, threat of operation, viability, prompt for early initiation), (4) preference for alternatives, (5) social influences (hearsay, family involvement, experiences of others), and (6) health care provider interactions (mistrust, interpersonal tension, lack of clarity in information). Themes were common to all groups, whereas nuanced perspectives of family members and health care providers were noted in some subthemes. LIMITATIONS: Response bias. CONCLUSIONS: Individual, interpersonal, and psychosocial factors compromise dialysis preparation and contribute to suboptimal dialysis initiation. Our findings support the need for interventions to improve patient and family engagement and address emotional concerns and misperceptions about preparing for dialysis.

Healthcare professionals' perceptions of the role of a multidisciplinary approach in improving the care of patients with advanced chronic kidney disease.

OBJECTIVE: To explore and understand the experiences of healthcare professionals (HCPs) delivering care in a multidisciplinary care (MDC) clinic for advanced chronic kidney disease (CKD) patients. METHODS: This is a qualitative study based on semi-quantitative questionnaire and semi-structured interviews with thematic analysis and deductive mapping onto the Theoretical Framework of Acceptability. Sixteen HCPs caring for advanced CKD patients in a MDC clinic in a tertiary teaching hospital in Singapore were recruited based on maximum variation sampling procedures. RESULTS: The majority of the HCPs were supportive of a MDC clinic. There was a positive overall opinion of the programme [median 7.0 of 10.0 (IQR 7.0-8.0)], high satisfaction ratings for interaction with other members of team [6.9 (5.3-8.0)] and time spent with patients [7.0 (5.3-7.0)]. Thematic analysis of the interviews identified the value of MDC clinic in the provision of one-stop care, the improvement in communication and collaboration between HCPs, the facilitation of patient activation to make planned kidney care decisions, and the optimisation of medications. The main challenges were lack of continuity of care, manpower constraints, poor patient navigation between HCPs, poor patient attendance with allied HCPs, and the perception of increased cost and time spent by patients in each MDC clinic visit. The proposed interventions were notification of patients beforehand of the MDC clinic schedule and provision of navigation to patients within the MDC clinic. CONCLUSION: A multidisciplinary care clinic for advanced chronic kidney disease patients was viewed positively by the majority of the healthcare professionals, with areas for improvement.