Iron-Deficiency Anemia in CKD: A Narrative Review for the Kidney Care Team.

Anemia is a common complication of chronic kidney disease (CKD) and is associated with increased mortality and reduced health-related quality of life. Anemia is characterized by a decrease in hemoglobin, the iron-rich protein that the body uses for oxygen transport. Iron is required to produce hemoglobin, and disruptions in the iron homeostasis can lead to iron-deficiency anemia. Management of anemia in individuals with CKD is typically performed by a team of physicians, nurse practitioners, physician assistants, or registered nurses. Throughout the care continuum, the management can be enhanced by multidisciplinary care, and individuals with CKD can benefit from the involvement of other specialties, with dietitians/nutritionists playing an important role. However, a key area of unmet clinical need is how to assess and address iron-deficiency anemia. This review aims to provide an overview of iron-deficiency anemia in CKD and how this may be diagnosed and managed by the entire kidney care team, such as describing the mechanisms underlying iron homeostasis, the complications of iron-deficiency anemia, and the current challenges associated with its diagnosis and treatment in CKD. Opportunities for each multidisciplinary team member to add value to the care of individuals with CKD and iron-deficiency anemia are also described.

Patency of the Viabahn stent graft for the treatment of outflow stenosis in hemodialysis grafts.

BACKGROUND: To evaluate arteriovenous graft patency when failing grafts are treated with Viabahn covered stents vs percutaneous angioplasty (PTA) alone. METHODS: A retrospective review of all patients that underwent endovascular interventions for failing grafts at a single institution between January 2010 and July 2013 was performed. Forty-four patients were identified who were treated with PTA alone (11) and with Viabahn stent grafts (33) for stenoses in the venous to graft anastomoses. Patient demographics, procedural success, and intraoperative complications were recorded as well as graft patency at 3, 6, and 12 months. Graft patency was reviewed and compared with PTA alone. RESULTS: There was no statistically significant difference between the 2 groups regarding gender, frequency of diabetes, hypertension, coronary artery disease, or peripheral arterial disease. Primary technical success defined as residual stenosis 10% or less was achieved in 100% of the cases. Follow-up was determined by flow velocities during dialysis and ultrasound imaging in the vascular laboratory. At 12 months 87.8% (29/33) grafts with stents were functional vs 36.4% (4/11) of those with PTA alone. Primary patency of the stent group was 61%, 52%, and 42% at 3, 6, and 12 months respectively vs the PTA group 64%, 45%, and 9%. CONCLUSIONS: Grafts treated with Viabahn covered stents for outflow stenosis have a superior patency to PTA alone, 12 months after treatment; although earlier post treatment results are comparable.

The intersection of the Medicare end-stage renal disease (ESRD) benefit and hospice: an overview for home care and hospice clinicians.

End-of-life care is underutilized in patients with kidney failure despite high mortality and multiple comorbid conditions. Recent revisions in the Medicare Benefit Policy Manual and the Conditions for Coverage for End-Stage Renal Disease provide a clearer understanding for referral to palliative and hospice care. There are recommendations to improve end-of-life care in this complicated population.

Discharge knowledge and concerns of patients going home with a wound.

PURPOSE: To examine patients' wound care knowledge and concerns prior to discharge from an acute care hospital. DESIGN: Comparative descriptive study of patients with wounds. SETTING AND SUBJECTS: Participants (N = 76) included 17 men and 59 women who were African American (n = 33, 43.4%) or Caucasian (n = 43, 56.6%) and ranged in age from 20 to 83 years (M = 48, SD = 13). There were 67 persons with acute wounds and 9 with chronic wounds. All were scheduled to be discharged home from a large urban acute care hospital. INSTRUMENTS: The questionnaire for this study included the following sections: Demographic, Admission and Discharge, Health, Wound Care, Beliefs about Wounds and their Care, Pain and Wounds, Literacy and Learning, and Discharge Concerns. RESULTS: Participants' greatest concerns about going home were: (1) how active to be at home, (2) wound pain, (3) looking for wound complications, and (4) watching for wound infection. Many participants did not know the dressing (38.2%) or solution to cleanse the wound (58.7%) at home. Most had taken care of a wound before (67.1%), could see (68.4%) and reach (69.7%) the wound, and had looked at it (64.5%) during the hospitalization. Patients with acute and chronic wounds did not differ significantly in their concerns about their wound or their fear of taking care of their wound. Participants generally had appropriate knowledge about wounds and hand washing, nutrition, going out of the home, and cigarette smoking. They had incorrect information about drying out wounds and leaving them open to breathe the air. The majority of patients with chronic wounds preferred getting answers to questions about their wound and its care from their physician followed by their clinic and family/friends. Patients with acute wounds overwhelmingly chose their physician as a source of information about their wound and its care, followed by calling a nurse at the hospital and using the Internet. CONCLUSIONS: Patients were able to verbalize their concerns about going home with a wound. Concerns about discharge may help to direct patient teaching in preparation for discharge. Teaching literature could include the most common concerns, as well as ways to avoid misinformation about wound care. Discharge teaching needs to begin early so that patients feel they have adequate time to learn and ask questions. Further research is needed about patients' wound care knowledge and discharge concerns.

Bariatric surgery: patient incision care and discharge concerns.

Because it provides greater and more durable weight reduction than behavioral and pharmacological interventions for the morbidly obese, the number of bariatric surgeries is increasing - one such procedure is the Roux-en-Y gastric bypass. A cross-sectional study was conducted to examine incision care knowledge and discharge concerns of patients who had undergone this type of gastric bypass bariatric surgery. Participants (N = 31; 28 women, three men; mean age 45 years), recruited from a bariatric surgery center in a large, urban teaching hospital, had undergone a Roux-en-Y gastric bypass by either the open (n = 29) or laparoscopic (n = 2) method. Patients scheduled to be discharged home, 21 years of age or older, and able to understand and respond in English were eligible to participate. Participants completed questionnaires that included demographic information and rating scales regarding incision care knowledge, fears, and discharge concerns. Mean time from hospital admission to study participation was 1.1 days (SD = 3 days). Knowledge of incision care and amount of information received about incision care were rated low. The five most frequently mentioned postdischarge concerns included bowel trouble at home, wound pain at home, looking for wound complications, watching for wound infection, and activity limitations. The higher the amount of information received about incision care, the higher the patient's knowledge (r = .57, P <.001). Lower incision care knowledge scores were correlated with a higher fear of incision care (r = .46, P = .008) and patients reporting greater pain had more concerns about discharge (r = .49, P <.005). Little is known about preparing the bariatric surgery patient for discharge home. To improve outcomes, research that examines issues including discharge teaching methods, patient concerns, and information for persons undergoing bariatric surgery is needed.

Discharge information needs of patients after surgery.

Patients who have undergone surgical procedures often have self-care concerns in their preparation for discharge from the hospital. This article examines the research literature about information needs of postoperative patients prior to their discharge. The most common concerns were the incision/wound care, pain management, activity level, monitoring for complications, symptom management, elimination, and quality of life. Because of their clinical knowledge of the perioperative experience, wound, ostomy, and continence nurses and other advanced practice nurses have a critical role in the development of discharge-educational programs for postoperative patients and caregivers. Because unmet discharge needs can contribute to poor patient outcomes and readmission, it is critical that wound, ostomy, and continence nurses, advanced practice nurses, and clinical staff nurses accurately identify patients' informational needs and find ways to meet these needs especially with the aging population, new/advanced surgical procedures, vulnerability/poverty, and literacy level of patients.