Optimising health care for people living with chronic kidney disease: Health-professional perspectives.

BACKGROUND: People with chronic kidney disease are often multimorbid and have complex psychosocial needs. For health professionals to deliver holistic, person-centred care to individuals and their carers living with this multifaceted disease, they are required to communicate complex information and problem solve in a multifactorial health and disease context. OBJECTIVES: To explore the perspectives and experiences of tertiary care multidisciplinary team members and primary care providers of health care to people with chronic kidney disease; identify opportunities to innovate and improve the coordinated delivery of health services. DESIGN: The qualitative study design used purposive sampling to recruit 39 health professionals, working in the primary and tertiary sector in a regional Australian health district. Participants included general practitioners, renal and general practice nurses, dietitians, nephrologists and social workers. APPROACH: The data were collected through semistructured interviews and analysed using a relativist ontological position and directed content analysis approach. Analysis of interviews was undertaken by three independent researchers and key themes were derived via consensus. FINDINGS AND CONCLUSIONS: A common goal to deliver person-centred individualised care was evident among health care professionals. However a deficit in shared understanding of the disease within and between disciplines was identified. The complex nature of chronic kidney disease requires up-skilling of health professionals to ensure patient education is targeted to individual health contexts and motivates self-management. Improved communication and comprehension might best be achieved across disciplines with an integrated approach to delivery of primary health care to individuals living with early-stage kidney disease.

A comprehensive renal vascular access clinic results in improved patient outcomes and reduced costs.

BACKGROUND: Management of vascular access for haemodialysis is a leading cause of morbidity and hospitalization in patients with end-stage renal disease. We sought to evaluate the change in admission and procedural outcomes before and after the establishment of a vascular surgeon-led comprehensive renal vascular access clinic (RVAC). METHOD: A retrospective clinical study was conducted after an RVAC was established in January 2013, with retrospective database created for the 24-month period prior to and after. RESULTS: The number of inpatient encounters for haemodialysis vascular access care fell over identical time periods before (n = 193) and after (n = 164) the RVAC was established. This reduction was associated with a significant decrease in length of stay (from 10.71 to 3.14 days; P = 0.0056) and thrombosed access procedures (from 32 to 16; P = 0.048). The proportion of emergency procedures fell (from 54.5 to 25.4%; P = 0.002) with a trend towards less arteriovenous fistula formations in the latter group (from 75 to 49; P = 0.099). There was also a trend towards fewer procedures in the latter group (from 195 to 151; P = 0.22). A case-mix costing analysis showed an estimated reduction in mean admission cost from $25 883.15 to $9332.81 for those 2-year periods, equating to a saving of $3.46 million associated with the introduction of the clinic. CONCLUSION: The establishment of an RVAC has led to a variety of objective performance outcome improvements, including a decrease in hospital admission, length of stay, revision and emergency surgeries, with associated cost saving. It reflects positive outcomes observed in other surgical specialties' clinics.

Pulsatility Produced by the Hemodialysis Roller Pump as Measured by Doppler Ultrasound.

Microbubbles have previously been detected in the hemodialysis extracorporeal circuit and can enter the blood vessel leading to potential complications. A potential source of these microbubbles is highly pulsatile flow resulting in cavitation. This study quantified the pulsatility produced by the roller pump throughout the extracorporeal circuit. A Sonosite S-series ultrasound probe (FUJIFILM Sonosite Inc., Tokyo, Japan) was used on a single patient during normal hemodialysis treatment. The Doppler waveform showed highly pulsatile flow throughout the circuit with the greatest pulse occurring after the pump itself. The velocity pulse after the pump ranged from 57.6 ± 1.74 cm/s to -72 ± 4.13 cm/s. Flow reversal occurred when contact between the forward roller and tubing ended. The amplitude of the pulse was reduced from 129.6 cm/s to 16.25 cm/s and 6.87 cm/s following the dialyzer and venous air trap. This resulted in almost nonpulsatile, continuous flow returning to the patient through the venous needle. These results indicate that the roller pump may be a source of microbubble formation from cavitation due to the highly pulsatile blood flow. The venous air trap was identified as the most effective mechanism in reducing the pulsatility. The inclusion of multiple rollers is also recommended to offer an effective solution in dampening the pulse produced by the pump.

'My kidneys, my choice, decision aid': supporting shared decision making.

BACKGROUND: For patients with chronic kidney disease (CKD) who are progressing to end-stage kidney disease (ESKD) a decision of whether to undertake dialysis or conservative care is a critical component of the patient journey. Shared decision making for complex decisions such as this could be enhanced by a decision aid, a practice which is well utilised in other disciplines but limited for nephrology. METHODS: A multidisciplinary team in Australia and New Zealand (ANZ) utilised current decision-making theory and best practice to develop the 'My Kidneys, My Choice', a decision aid for the treatment of kidney disease. RESULTS: A patient-centred, five-sectioned tool is now complete and freely available to all ANZ units to support the ESKD education and shared decision-making process. Distribution and education have occurred across ANZ and evaluation of the decision aid in practice is in the first phase. CONCLUSIONS: Development of a new tool such as an ESKD decision aid requires vision, multidisciplinary input and ongoing implementation resources. This tool is being integrated into ANZ, ESKD education practice and is promoting the philosophy of shared decision making.

A comparison of the ability of levels of urinary biomarker proteins and exosomal mRNA to predict outcomes after renal transplantation.

BACKGROUND: mRNA for biomarkers of kidney injury extracted from urinary exosomes may reflect or predict levels of the corresponding protein after transplantation and clinical outcomes. METHODS: Urinary exosomes were isolated from patients following renal transplantation, from healthy controls, and patients with CKD. Expression of exosomal mRNA for the injury biomarkers neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18), kidney injury molecule-1 (KIM-1), and cystatin C was compared with the concentrations of corresponding urinary proteins, 18S RNA and serum creatinine. RESULTS: All biomarker protein concentrations increased after transplantation, and urinary NGAL and IL-18 at 24 and 168 h correlated with the day 7 creatinine reduction ratio (CRR). Exosomal18S RNA increased after transplantation, but exosomal mRNA for NGAL, IL-18 and cystatin C did not correlate with the day 7 CRR, or urinary biomarker concentrations at any time after transplantation. Exosomal NGAL mRNA was lower 4 h after transplantation than in control exosomes. In contrast, exosomal mRNA for cystatin C was unchanged after transplantation and in CKD, although urinary cystatin C temporarily increased following transplantation. Urinary KIM-1 increased after transplantation, but exosomal mRNA for KIM-1 remained undetectable. In CKD 18S RNA was raised, and exosomal mRNA for NGAL, IL-18 and cystatin C was detected in all patients. While urinary NGAL was greater in CKD than control subjects, exosomal NGAL mRNA was unchanged. Exosomal IL-18 mRNA was increased in CKD, but not IL-18 protein. CONCLUSIONS: After renal transplantation, urinary NGAL and IL-18 levels reflect the day 7 CRR. However, while mRNA for these biomarkers is present in exosomes, their levels do not reflect or predict urinary biomarker levels or the CRR. This likely reflects the fact that packaging of mRNA in exosomes is selective, and is not necessarily representative of mRNA in the parent cells responsible for biomarker production.