Kidney Transplant Clinicians' Perceptions of Palliative Care for Patients With Failing Allografts in the US: A Mixed Methods Study.

RATIONALE & OBJECTIVE: Kidney transplant patients with failing allografts have a physical and psychological symptom burden as well as high morbidity and mortality. Palliative care is underutilized in this vulnerable population. We described kidney transplant clinicians' perceptions of palliative care to delineate their perceived barriers to and facilitators of providing palliative care to this population. STUDY DESIGN: National explanatory sequential mixed methods study including an online survey and semistructured interviews. SETTING & PARTICIPANTS: Kidney transplant clinicians in the United States surveyed and interviewed from October 2021 to March 2022. ANALYTICAL APPROACH: Descriptive summary of survey responses, thematic analysis of qualitative interviews, and mixed methods integration of data. RESULTS: A total of 149 clinicians completed the survey, and 19 completed the subsequent interviews. Over 90% of respondents agreed that palliative care can be helpful for patients with a failing kidney allograft. However, 46% of respondents disagreed that all patients with failing allografts benefit from palliative care, and two-thirds thought that patients would not want serious illness conversations. More than 90% of clinicians expressed concern that transplant patients and caregivers would feel scared or anxious if offered palliative care. The interviews identified three main themes: (1) transplant clinicians' unique sense of personal and professional responsibility was a barrier to palliative care engagement, (2) clinicians' uncertainty regarding the timing of palliative care collaboration would lead to delayed referral, and (3) clinicians felt challenged by factors related to patients' cultural backgrounds and identities, such as language differences. Many comments reflected an unfamiliarity with the broad scope of palliative care beyond end-of-life care. LIMITATIONS: Potential selection bias. CONCLUSIONS: Our study suggests that multiple barriers related to patients, clinicians, health systems, and health policies may pose challenges to the delivery of palliative care for patients with failing kidney transplants. This study illustrates the urgent need for ongoing efforts to optimize palliative care delivery models dedicated to kidney transplant patients, their families, and the clinicians who serve them. PLAIN-LANGUAGE SUMMARY: Kidney transplant patients experience physical and psychological suffering in the context of their illnesses that may be amenable to palliative care. However, palliative care is often underutilized in this population. In this mixed-methods study, we surveyed 149 clinicians across the United States, and 19 of them completed semistructured interviews. Our study results demonstrate that several patient, clinician, system, and policy factors need to be addressed to improve palliative care delivery to this vulnerable population.

Permission to prescribe: do cardiologists need permission to prescribe diabetes medications that afford cardiovascular benefit?

PURPOSE OF REVIEW: Antihyperglycemic therapies including sodium glucose contransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) have been demonstrated to confer significant cardiovascular benefit and reduce future events in patients with type 2 diabetes mellitus (T2DM). However, despite positive data from cardiovascular outcome trials, these therapies remain underutilized in a large proportion of patients who have clinical indications and meet coverage guidelines for their initiation. One of the causes of the observed gap between scientific evidence and clinical cardiology practice is therapeutic hesitancy (otherwise known as therapeutic inertia). The purpose of this review is to discuss the contributors to therapeutic hesitancy in the implementation of these evidence-based therapies and, more importantly, provide pragmatic solutions to address these barriers. RECENT FINDINGS: Recent studies have demonstrated that clinicians may not initiate cardiovascular protective therapies due to a reluctance to overstep perceived interdisciplinary boundaries, concerns about causing harm due to medication side effects, and a sense of unfamiliarity with the optimal choice of therapy amidst a rapidly evolving landscape of T2DM therapies. SUMMARY: Herein, we describe a multifaceted approach aimed at creating a 'permission to prescribe' culture, developing integrated multidisciplinary models of care, enhancing trainees' experiences in cardiovascular disease prevention, and utilizing technology to motivate change. Taken together, these interventions should increase the implementation of evidence-based therapies and improve the quality of life and cardiovascular outcomes of individuals with T2DM.

Nephrology Provider Surprise Question Response and Hospitalizations in Older Adults with Advanced CKD.

BACKGROUND: Older adults with advanced non-dialysis-dependent chronic kidney disease (NDD-CKD) face a high risk of hospitalization and related adverse events. METHODS: This prospective cohort study followed nephrology clinic patients ≥60 years old with NDD-CKD stages 4-5. After an eligible patient's office visit, study staff asked the patient's provider to rate the patient's risk of death within the next year using the surprise question ("Would you be surprised if this patient died in the next 12 months?") with a 5-point Likert scale response (1, "definitely not surprised" to 5, "very surprised"). We used a statewide database to ascertain hospitalization during follow-up. RESULTS: There were 488 patients (median age 72 years, 51% female, 17% black) with median estimated glomerular filtration rate 22 mL/min/1.73 m2. Over a median follow-up of 2.1 years, the rates of hospitalization per 100 person-years in the respective response groups were 41 (95% confidence interval [CI]: 34-50), "very surprised"; 65 (95% CI: 55-76), "surprised"; 98 (95% CI: 85-113), "neutral"; 125 (95% CI: 107-144), "not surprised"; and 120 (95% CI: 94-151), "definitely not surprised." In a fully adjusted cumulative probability ordinal regression model for proportion of follow-up time spent hospitalized, patients whose providers indicated that they would be "definitely not surprised" if they died spent a greater proportion of follow-up time hospitalized compared with those whose providers indicated that they would be "very surprised" (odds ratio 2.4, 95% CI: 1.0-5.7). There was a similar association for time to first hospitalization. CONCLUSION: Nephrology providers' responses to the surprise question for older patients with advanced NDD-CKD were independently associated with proportion of future time spent hospitalized and time to first hospitalization. Additional studies should examine how to use this information to provide patients with anticipatory guidance on their possible clinical trajectory and to target potentially preventable hospitalizations.

Migrated fractured sternal wire in proximity to the main pulmonary artery: Case report and review.

BACKGROUND: We present a case of a 83-year-old man with a prior history of coronary artery bypass who presented to his family physician with progressive symptoms that raised concern for heart failure exacerbation. A chest X-ray was performed, which showed a fractured topmost sternal wire in the lateral projection and indicated that the sternal wire had migrated into the anterior mediastinum. An emergent electrocardiogram-gated flash computed tomography angiography confirmed the location of the fractured wire to be in close proximity to the main pulmonary artery. A discussion of migrated sternal wires with a literature review of cases is provided as well. AIMS: To present a case of a migrated sternal wire and a literature review. METHODS: An extensive literature review using pubmed and medline with relevant keywords was preformed. RESULTS: 11 known cases of migrated sternal wires with various complications, as detailed in the review table. The mortality rate is low but can be associated with significant morbidity. DISCUSSION: Fractured wires are quite common and are usually a benign radiographic finding. However, migration of sternal wires is an extremely rare phenomenon. Only a few reported cases in the literature were sternal wires have migrated beyond the sternum, leading to catastrophic clinical consequences, as detailed in the review table. CONCLUSION: Sternal wire complications secondary to migration beyond the sternum are rare but potentially fatal. Precise wire location and risk assessment with CT are more appropriate when wire location cannot be clearly delineated by plain film radiography.

Health Outcome Priorities of Older Adults with Advanced CKD and Concordance with Their Nephrology Providers' Perceptions.

BACKGROUND: Older adults with advanced CKD have significant pain, other symptoms, and disability. To help ensure that care is consistent with patients' values, nephrology providers should understand their patients' priorities when they make clinical recommendations. METHODS: Patients aged ≥60 years with advanced (stage 4 or 5) non-dialysis-dependent CKD receiving care at a CKD clinic completed a validated health outcome prioritization tool to ascertain their health outcome priorities. For each patient, the nephrology provider completed the same health outcome prioritization tool. Patients also answered questions to self-rate their health and completed an end-of-life scenarios instrument. We examined the associations between priorities and self-reported health status and between priorities and acceptance of common end-of-life scenarios, and also measured concordance between patients' priorities and providers' perceptions of priorities. RESULTS: Among 271 patients (median age 71 years), the top health outcome priority was maintaining independence (49%), followed by staying alive (35%), reducing pain (9%), and reducing other symptoms (6%). Nearly half of patients ranked staying alive as their third or fourth priority. There was no relationship between patients' self-rated health status and top priority, but acceptance of some end-of-life scenarios differed significantly between groups with different top priorities. Providers' perceptions about patients' top health outcome priorities were correct only 35% of the time. Patient-provider concordance for any individual health outcome ranking was similarly poor. CONCLUSIONS: Nearly half of older adults with advanced CKD ranked maintaining independence as their top heath outcome priority. Almost as many ranked being alive as their last or second-to-last priority. Nephrology providers demonstrated limited knowledge of their patients' priorities.

Event-related distress in kidney disease patients.

BACKGROUND: Non-dialysis-dependent chronic kidney disease (CKD) and dialysis-dependent Stage 5 CKD (CKD5) are associated with a significant physical and psychosocial burden. Little is known, however, about the impact of stressful life events on CKD and CKD5 patients. This study aimed to determine the prevalence of stressful life events in CKD and CKD5 patients and identify the factors correlated with high levels of event-related distress. METHODS: This cross-sectional study's sample consisted of 181 patients (91 with non-dialysis-dependent CKD Stages 4 and 5, 90 with CKD5) who filled out the Impact of Event Scale (IES), which measures subjective distress related to stressful life events. Other measures included scores from the Medical Outcomes Study Short Form-36, Patient Health Questionnaire-9 (PHQ-9) and Dialysis Symptom Index (DSI). RESULTS: One hundred and three subjects reported stressors on the IES. Almost half the stressors (49.5%) related to personal health; the rest fell into other categories. There were significant differences between the no stressor, low event-related distress and high event-related distress groups in age (P < 0.001), PHQ-9 score (P < 0.001) and DSI score (P = 0.002). After adjustment, PHQ-9 score was associated with high event-related distress [odds ratio (OR) 1.20, 95% confidence interval (CI) 1.10-1.32], as was DSI score (OR 1.04, 95% CI 1.02-1.07) in a separate model. CONCLUSIONS: Event-related distress is common in CKD and CKD5 patients. High event-related distress is associated with worse depressive symptoms and greater somatic and emotional symptom burden, even with adjustments for age and gender. The renal practitioner may need to address patients' event-related distress in order to provide optimal care.

Impact of fatigue on outcomes in the hemodialysis (HEMO) study.

BACKGROUND: Fatigue is a common debilitating symptom in chronic kidney disease patients on maintenance hemodialysis. However, little is known about its pathogenesis and association with survival. METHODS: This study examines the correlates and outcomes of fatigue among 1,798 hemodialysis patients enrolled in the HEMO study. Fatigue was assessed using the SF-36 vitality scale. Multivariable analysis was used to assess independent associations of demographic and clinical characteristics with baseline fatigue and longitudinal changes in fatigue. The association of fatigue with all-cause and cause-specific mortality and cardiac hospitalizations was also assessed. RESULTS: Higher index of coexistent diseases (ICED) score, diabetes, non-African-American race, lower serum albumin, use of medications for sleep and poor sleep quality were found to be significantly associated with more fatigue at baseline. In longitudinal analyses, patients who were older, had been on dialysis longer, had higher ICED score, and reported using medications for sleep were more likely to experience worsening fatigue, whereas higher serum albumin was strongly associated with an improvement in level of fatigue. A 10-point increase in vitality score was associated with 10% increase in mean survival (p < 0.0001). CONCLUSIONS: Demographic and clinical factors have significant associations with fatigue, which itself predicts mortality. Improving fatigue in the end-stage renal disease population may positively impact patient well-being and survival.

Blown Wide Open: An Unusual Case of Torrential Mitral Regurgitation Resolving With a Cough.

Mitral regurgitation can have varying hemodynamic parameters dependent on factors such as pressure gradients, exercise, and/or provocative maneuvers. We present a case of unusual dynamic mitral regurgitation resolved by coughing in a patient with hypertrophic cardiomyopathy. (Level of Difficulty: Intermediate.).

Patient reactions to witnessed medical events in the dialysis center or to the sudden absence of other patients from the center: A qualitative study.

INTRODUCTION: Patients receiving in-center maintenance hemodialysis (HD) spend a significant amount of time together. To date, little or no research has examined how these patients perceive and process other patients' medical events in and absences from their centers. We therefore undertook this qualitative study using semi-structured interviews to explore these phenomena from the patient perspective. METHODS: Patients at a suburban Pittsburgh HD center participated in semi-structured interviews in April to May 2011, reporting on their impressions of their relationships with other patients in the center; their experiences of witnessing clinical decompensations in the center; and their reactions to absences of fellow patients from the center. Trained coders developed a codebook and applied it to interview transcripts. FINDINGS: There were 17 participants, 47% women, 29% black, with median age 63 years. Almost every participant had witnessed other patients' medical events during HD. Three main themes emerged in analysis of interviews: (1) incomplete knowledge of many aspects of witnessed events and patient absences in the HD center; (2) a process of "filling in the blanks": Participants used their own past events and absences to help process other patients' events and absences and used other patients' events and absences to help process their own future events and absences; and (3) participants' broad support for HD center staff being able to share with other patients basic information about their whereabouts if they themselves are absent from the center. DISCUSSION: Witnessed medical events in and patients' absences from the HD center are not only common but are also important to patients, who struggle to process these events and absences due to limited information about what actually happened. Interventions, such as providing patients with more information, could improve patients' experience of witnessed events and fellow patients' absences and potentially impact other patient-centered outcomes.

Suffering and Symptoms At the End of Life in ICU Patients Undergoing Renal Replacement Therapy.

BACKGROUND: We know little about the end-of-life suffering and symptoms of intensive care unit (ICU) decedents in general and those who undergo renal replacement therapy (RRT) in particular. OBJECTIVES: To examine differences in end-of-life suffering and various symptoms' contribution to suffering between ICU decedents who did not undergo RRT, those who underwent RRT for end-stage kidney disease (ESKD), and those who underwent RRT for acute kidney injury (AKI). METHODS: This is a cross-sectional study conducted at a quaternary-level referral hospital September 2015-March 2017. Nurses completed interviews about ICU patients' suffering and symptoms in their final week. We dichotomized overall suffering into elevated and non-elevated and each symptom as contributing or not to a patient's suffering. RESULTS: Sixty-four nurses completed interviews on 165 patients. Median patient age was 67 years (interquartile range 57, 78); 41% were female. In a multivariable model, undergoing RRT for AKI (odds ratio [OR] 2.95, 95% confidence interval [CI] 1.34-6.49) was significantly associated with elevated suffering compared to no RRT; undergoing RRT for ESKD was not. Adjusting for length of stay, AKI-RRT patients were more likely than non-RRT patients to have fecal incontinence (OR 2.21, 95% CI 1.00-4.93), painful broken skin (OR 2.41, 95% CI 1.14-5.12), and rashes (OR 3.61, 95% CI 1.35-9.67) contributing to their suffering. CONCLUSIONS: Undergoing RRT for AKI was associated with elevated suffering in the last week of life in ICU decedents. Painful broken skin, rashes, and fecal incontinence were more likely to contribute to suffering in AKI-RRT patients than in non-RRT patients. How to reduce suffering associated with AKI-RRT in ICU patients merits further study.

Inexpensive, High-Fidelity Model to Simulate Ultrasound-Guided Pericardiocentesis for Cardiology Resident Training.

Adult cardiology residency training programs require residents to become proficient at many procedural skills, including pericardiocentesis. However, in many programs, opportunities to perform this procedure are limited. Expensive mannequins have been developed to assist with teaching this skill, however, the associated cost make them impractical for many programs. We hypothesized that a low-cost, high-fidelity pericardiocentesis model could be constructed using items easily accessible to any consumer. We describe a pericardiocentesis model made from pork skin, pork ribs, gelatin, a plastic bag, and an avocado. Total cost was less than CAD$40.00 and preparation time was approximately 60 minutes. The model was evaluated with a survey by 14 senior cardiology and critical care residents as well as 3 experienced senior cardiologists. Imaging results from the ultrasound revealed that the target fluid was easily visualized and all trainees were successful in aspirating fluid. The model was durable and withstood more than a dozen punctures, demonstrating its ability to train multiple residents. Respondents to the survey reported the model as highly realistic. All cardiology residents agreed or strongly agreed that the model should be incorporated into their formal curriculum. This study shows that a low-cost, high-fidelity model can be constructed and easily implemented into the formal curriculum of adult cardiology residency programs. It allows residents the opportunity to practice pericardiocentesis in a low-risk setting on a high-yield device.

Pharmacological treatment of congestive heart failure in Canada: a description of care in five provinces.

INTRODUCTION: Congestive heart failure (CHF) is responsible for significant morbidity, mortality and health resource consumption. There have been major advances in the treatment of this condition over the past two decades, yet little information is currently available regarding the current status of CHF management in Canada. OBJECTIVE: To describe the pharmacological management of patients hospitalized with CHF in five provinces: Alberta, British Columbia, Nova Scotia, Ontario and Quebec. DESIGN AND METHODS: Administrative data sources were used to identify all consecutive patients hospitalized with a principal diagnosis of CHF and discharged alive in the provinces of Alberta, British Columbia, Quebec and Ontario. Rates of use of prespecified medications at 30 days after hospital discharge were obtained for patients 65 years of age and older by linkage of their hospital records with drug benefit plans in these provinces. For Nova Scotia, the disease-specific registry of the Improving Cardiovascular Outcomes in Nova Scotia (ICONS) study was used to obtain discharge medications of individuals consecutively hospitalized with a diagnosis of CHF. Where available, data were acquired from 1997 to 2002. RESULTS: Data were obtained for a total of 115,037 patients in the five provinces over the five-year period. Overall, 54.9% of patients received an angiotensin-converting enzyme inhibitor at or 30 days after hospital discharge, with minimal change in prescription rates over the five-year period. Beta-blocker prescription rates increased steadily during the study, more than doubling from 15.0% in 1997/1998 to 32.0% in 2001/2002. Spironolactone use increased dramatically, with only 2.2% of patients receiving this medication in 1997/1998 compared with 18.7% in 2001/2002. The rates of digoxin prescription decreased each year, while the use of angiotensin receptor blockers increased slightly throughout the observation period. CONCLUSIONS: While the use of evidence-based treatment for CHF in Canada is increasing and is currently at levels similar to those reported in other developed countries, there is still the potential in every province for further improvement.

Survival after acute hemodialysis in Pennsylvania, 2005-2007: a retrospective cohort study.

BACKGROUND: Little is known about acute hemodialysis in the US. Here we describe predictors of receipt of acute hemodialysis in one state and estimate the marginal impact of acute hemodialysis on survival after accounting for confounding due to illness severity. MATERIALS AND METHODS: This is a retrospective cohort study of acute-care hospitalizations in Pennsylvania from October 2005 to December 2007 using data from the Pennsylvania Health Care Cost Containment Council. Exposure variable is acute hemodialysis; dependent variable is survival following acute hemodialysis. We used multivariable logistic regression to determine propensity to receive acute hemodialysis and then, for a Cox proportional hazards model, matched acute hemodialysis and non-acute hemodialysis patients 1∶5 on this propensity. RESULTS: In 2,131,248 admissions of adults without end-stage renal disease, there were 6,657 instances of acute hemodialysis. In analyses adjusted for predicted probability of death upon admission plus other covariates and stratified on age, being male, black, and insured were independent predictors of receipt of acute hemodialysis. One-year post-admission mortality was 43% for those receiving acute hemodialysis, compared to 13% among those not receiving acute hemodialysis. After matching on propensity to receive acute hemodialysis and adjusting for predicted probability of death upon admission, patients who received acute hemodialysis had a higher risk of death than patients who did not over at least 1 year of follow-up (hazard ratio 1·82, 95% confidence interval 1·68-1·97). CONCLUSIONS: In a populous US state, receipt of acute hemodialysis varied by age, sex, race, and insurance status even after adjustment for illness severity. In a comparison of patients with similar propensity to receive acute hemodialysis, those who did receive it were less likely to survive than those who did not. These findings raise questions about reasons for lack of benefit.

Percutaneous intrapericardial injection of triamcinolone in a patient with incessant pericarditis: a novel technique.

Incessant pericarditis is an uncommonly encountered clinical problem that can be extremely difficult to manage. We present a case of incessant pericarditis with multiple recurrences during tapering of systemic corticosteroids. We injected intrapericardial triamcinolone, using a technique originally developed to access the epicardium for catheter ablation. This approach resulted in immediate success, followed by long-term resolution of the patient's pericarditis. This novel technique may be of benefit in this small group of patients and may represent a safer alternative to pericardiectomy for those resistant to oral corticosteroid tapering.

The association of mental health over time with cardiac outcomes in HEMO study patients.

BACKGROUND AND OBJECTIVES: Poor mental health over time is significantly associated with cardiovascular morbidity and mortality in the general population, which is the leading cause of death in dialysis patients. Most studies of dialysis patients, however, have investigated the relationship between baseline mental health measurements and all-cause mortality and not mental health measured longitudinally throughout a study and cause-specific mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This study examined the association of changes in mental health over time with all-cause and cause-specific deaths and cardiac hospitalizations in the Hemodialysis study patients. Mental health was assessed at baseline and annually during the study with short form 36 mental health index scores. Poorer mental health was defined by a mental health index score≤60. RESULTS: Patients with poorer mental health at baseline were more likely to have less than a high school education and be unmarried, have significantly higher index of coexistent disease scores, and report taking ß-blockers and sleep medications. Low mental health scores over time were independently associated with a decrease in survival time from all-cause mortality by -0.06 (-0.10, -0.03; P<0.001), and they also significantly hastened time to first cardiac hospitalization by -0.08 (-0.13, -0.02; P=0.01) and composite of first cardiac hospitalization or cardiac death by -0.04 (-0.07, -0.02; P<0.001). CONCLUSIONS: This study found an independent association between poor mental health over time and all-cause mortality, cardiac hospitalization, and the composite of cardiac death or cardiac hospitalization in hemodialysis patients. The results underscore the importance of attention to mental health related to cardiac complications and even death in dialysis patients.