Screening for depression: only one piece of the puzzle.

In this issue of NDT, van den Beukel et al. from the Netherlands suggest that a 5-item survey questionnaire might be used to replace the Beck Depression Index to screen patients with chronic kidney disease (CKD) for depression. The nephrology community is at a tipping point in terms of the assessment of outcomes, especially among patients on dialysis. Indeed, the entire healthcare community has begun to shift its focus to patient-reported outcomes (PROs), including quality of life, patient satisfaction and the psychosocial determinants of health. Beyond depression, there are a myriad of aspects of psychological distress that include anxiety, worrying, fear of progression of kidney disease and the fear of the future in general, death and dying, hopelessness, questions around the meaning of life and the experience of recurrent psychological and physical trauma through the CKD trajectory. We encourage the community and its researchers to embrace and research PROs, with the aim to create a holistic, patient-centered model of care for patients at all stages of CKD, including those on chronic dialysis and after transplantation, keeping the whole person-and their families-in mind.

Mineral metabolism management in Canadian peritoneal dialysis patients.

BACKGROUND: Abnormal mineral metabolism is associated with increased morbidity and mortality in dialysis patients. Therefore, the goal of this study was to compare a) mineral metabolism control among a cohort of Canadian peritoneal dialysis (PD) patients to K/DOQI-defined targets and b) the effect of different treatment strategies on mineral metabolism parameters. METHODS: We looked at a cohort of 317 Canadian PD patients from 9 clinics that used the PhotoGraph™ software program which tracks mineral metabolism management. Serum phosphorus (P), calcium (Ca) and intact parathyroid hormone (iPTH) values were collected for the patients. Data were categorized and analyzed by the type of phosphate binder prescribed, vitamin D use, and dosing and reimbursement criteria for the phosphate binder, sevelamer. RESULTS: The majority of patients achieved K/DOQI-set targets for serum P. Patients who resided in Quebec (QC), which had greater access to sevelamer, had lower mean concentrations of P and Ca, were less likely to take Ca-based phosphate binders (CBBs) exclusively and were exposed to less exogenous Ca than in Ontario (ON). CONCLUSION: Availability of the phosphate binder sevelamer and reduced doses of elemental Ca were associated with more mineral metabolism parameters within suggested target ranges. Further studies that focus on patient outcomes are warranted.

Access to new drugs for dialysis patients: challenges for indigenous and non-indigenous populations.

Most dialysis patients are on 5 - 10 medications. The costs of these medications vary widely, ranging from pennies per day for water soluble multivitamins, to several thousand dollars per year for erythropoietin-stimulating agents. In Canada, public funding for drug therapies is undertaken by each province, with wide variability in coverage and on restriction criteria for expensive new drugs. For native Canadians and Inuit, access to drugs is superior to that of other Canadians through a federal program. The Canadian system for drug evaluation, where strict evidence-based medicine (EBM) and comparative effectiveness research (CER) is applied, is instructive and may provide clues to the future from an international perspective. Given the unique challenges in nephrology, it is predicted that access to new drugs and other therapies will be restricted by these evaluation methods. Indeed, it seems desirable for nephrology organizations to respond to this new threat in a pragmatic and balanced way. Part of that response might be a call for exceptional status for dialysis, with adjusted criteria of EBM and CER that would be more suitable, and stimulate innovation and research in nephrology.

Referral for dialysis in Ontario.

BACKGROUND: Because the incidence rates of treated end-stage renal disease are much lower in Canada than in the United States, we hypothesized that decisions, made by family physicians and community internists, not to refer certain patients to nephrologists might explain this difference. OBJECTIVE: To elicit patterns of practice and attitudes from nonnephrologist physicians who care for, and possibly refer, patients with renal disease. METHODS: A mailed survey was sent to a random sample of 1924 members of the Ontario Medical Association, Sections on General and Family Practice and Internal Medicine. Of 1778 eligible respondents, responses were received from 728 physicians (40.9%). RESULTS: Patients with microscopic hematuria (79.2%), proteinuria (69.5%), and serum creatinine levels in the 120 to 150 mumol/L (1.4 to 1.7 mg/dL) range (84.3%) were generally not referred by family physicians. A hypothetical question about patient age and comorbid features revealed that physicians were less likely to refer patients as their age and comorbidity increased. In response to the question, "In the past 3 years, did you care for a patient who, after due consideration, died of renal failure without referral for dialysis," 14.2% of family physicians and 44.6% of internists said yes. Overall, 67.4% of respondents strongly or somewhat agree that rationing of dialysis is occurring now. Opinions about possible criteria for rationing of dialysis were that the majority strongly or somewhat agreed to basing a decision on the wishes of a competent patient (94.1%), short life expectancy (87.9), poor quality of life (87.0%), and age (63.6%). CONCLUSIONS: These results suggest that nonreferral for dialysis occurs in Ontario and that the act of referral, or nonreferral as the case may be, is influenced by both age and coexisting disease. The patterns of nonreferral reported raise a concern that patients who might benefit are not being referred to dialysis centers.

Reconceptualizing advance care planning from the patient's perspective.

BACKGROUND: Traditional academic assumptions about advance care planning (ACP) include the following: (1) the purpose of ACP is preparing for incapacity; (2) ACP is based on the ethical principle of autonomy and the exercise of control; (3) the focus of ACP is completing written advance directive forms; and (4) ACP occurs within the context of the physician-patient relationship. These assumptions about ACP have never been empirically validated. OBJECTIVE: To examine the traditional academic assumptions by exploring ACP from the perspective of patients actively participating in the planning process. METHODS: Forty-eight patients (30 men and 18 women with a mean age of 48.3 years) who were undergoing hemodialysis were interviewed 6 months after receiving an advance directive form. Their experience of ACP was noted in interviews that were audiotaped, transcribed, and analyzed. RESULTS: The participants said that their purpose in ACP was to prepare for death and dying, and their underlying goals included the exercise of control and an attempt to relieve burdens placed on loved ones. Advance care planning was viewed as a social process, and completing a written advance directive form was often regarded as unnecessary. Participants often involved close loved ones, but physicians infrequently. CONCLUSIONS: The traditional academic assumptions are not fully supported from the perspective of patients involved in ACP. The patients we interviewed stated that (1) the purpose of ACP is not only preparing for incapacity but also preparing for death; (2) ACP is not based solely on autonomy and the exercise of control, but also on personal relationships and relieving burdens placed on others; (3) the focus of ACP is not only on completing written advance directive forms but also on the social process; and (4) ACP does not occur solely within the context of the physician-patient relationship but also within relationships with close loved ones.

Nonreferral and nonacceptance to dialysis by primary care physicians and nephrologists in Canada and the United States.

Research from Canada and the United States suggests that not offering dialysis to patients who might benefit still occurs. This study was conducted to investigate nonreferral and nonacceptance to dialysis by primary care physicians (PCPs) and nephrologists in these countries. We surveyed a random sample of Canadian and US PCPs and nephrologists concerning their attitudes toward and experience with withholding dialysis in patients with advanced chronic renal failure. In response to a question about whether the physician believes there should be an age beyond which dialysis should not be offered, 12% of Canadian PCPs, 20% of US PCPs, 4% of Canadian nephrologists, and 9% of US nephrologists answered yes. When asked about their recommendations concerning dialysis initiation in 10 vignettes of patients with impending end-stage renal disease (ESRD), the responses of Canadian and US physicians were similar. PCPs compared with nephrologists were less likely to recommend dialysis in cases with physical illnesses and more likely to recommend it in cases with neuropsychiatric impairments. Over a 3-year period, 13% of Canadian PCPs and 19% of US PCPs reported nonreferral to dialysis at least once. Withholding rates were 25% for Canadian PCPs, 16% for US PCPs, 13% for Canadian nephrologists, and 17% for US nephrologists. We conclude that although nonreferral of patients who might benefit from dialysis still occurs, it does not seem to be common, and the attitudes of Canadian and US physicians toward this issue are similar and could not entirely account for the much greater incidence of treated ESRD in the United States. PCPs and nephrologists should continue to be educated about the modern criteria for patient selection for dialysis.

What do American nephologists think about dialysis modality selection? .

In the United States, 87.3% of the patients with end-stage renal disease (ESRD) requiring dialysis are treated with hemodialysis (HD) and 12.7% with peritoneal dialysis (PD). This represents a greater use of HD than in many other nations. We mailed a survey questionnaire to members of the National Kidney Foundation Council on Dialysis to better understand the attitudes of American nephrologists toward dialysis modality decisions. We received responses from 240 of 507 nephrologists (47.3%). The respondents were heavily involved in clinical dialysis work. Results showed that decisions regarding modality selection were strongly based on patient preference (4.54 on a scale of 1 to 5), quality of life (4.18), morbidity (4.02), and mortality (3.90), whereas the least important factors reported were facility reimbursement (2.09) and physician reimbursement (1.98). When asked about the current use of modalities, hospital-based HD and full-care HD were believed to be overused (2.63 for each on a scale of 1 [vastly overused] to 5 [vastly underused]), whereas home HD (4.29), continuous ambulatory PD (3.71), and cycler PD (3.59) were underused. A hypothetical question about optimal modality distribution to maximize survival or cost-effectiveness showed that HD should constitute 71% or 66% of dialysis (with 11% or 14% in the form of home HD, respectively). PD use would increase between two- and threefold over current practices. Our results suggest that American nephrologists believe home therapies are underused. Because modality distribution is an important determinant of costs and possibly outcomes in patients with ESRD, there is an urgent need for further research in this area.

Left ventricular mass index increase in early renal disease: impact of decline in hemoglobin.

Cardiovascular disease occurs in patients with progressive renal disease both before and after the initiation of dialysis. Left ventricular hypertrophy (LVH) is an independent predictor of morbidity and mortality in dialysis populations and is common in the renal insufficiency population. LVH is associated with numerous modifiable risk factors, but little is known about LV growth (LVG) in mild-to-moderate renal insufficiency. This prospective multicenter Canadian cohort study identifies factors associated with LVG, measured using two-dimensional-targeted M-mode echocardiography. Eight centers enrolled 446 patients, 318 of whom had protocol-mandated clinical, laboratory, and echocardiographic measurements recorded. We report 246 patients with assessable echocardiograms at both baseline and 12 months with an overall prevalence of LVH of 36%. LV mass index (LVMI) increased significantly (>20% of baseline or >20 g/m2) from baseline to 12 months in 25% of the population. Other than baseline LVMI, no differences in baseline variables were noted between patients with and without LVG. However, there were significant differences in decline of Hgb level (-0.854 v -0.108 g/dL; P = 0.0001) and change in systolic blood pressure (+6.50 v -1.09 mm Hg; P = 0.03) between the groups with and without LVG. Multivariate analysis showed the independent contribution of decrease in Hgb level (odds ratio [OR], 1.32 for each 0.5-g/dL decrease; P = 0.004), increase in systolic blood pressure (OR, 1.11 for each 5-mm Hg increase; P = 0.01), and lower baseline LVMI (OR, 0.85 for each 10-g/m2; P = 0.011) in predicting LVG. Thus, after adjusting for baseline LVMI, Hgb level and systolic blood pressure remain independently important predictors of LVG. We defined the important modifiable risk factors. There remains a critical need to establish optimal therapeutic strategies and targets to improve clinical outcomes.

Cardiovascular disease in patients with chronic kidney disease: getting to the heart of the matter.

The high prevalence of cardiovascular disease (CVD) in patients with kidney disease is well described. This Canadian, multicenter, observational cohort study reports the prevalence and risk factors of CVD associated with kidney disease, in a cohort of patients with established chronic kidney disease (CKD), who are followed-up by nephrologists. This analysis sought to answer 2 questions: (1) in patients with established CKD, are the prevalence and progression of CVD accounted for by conventional or uremia-related risk factors, and (2) to what extent can progression to renal replacement therapy (RRT) be explained by CVD versus traditional risk factors for kidney disease? This study population consists of 313 patients (predominantly men) who had a mean age of 56 years and a mean creatinine clearance of 36 mL/min. Thirty percent were diabetic. The overall prevalence of CVD was 46%, and was independent of severity of kidney dysfunction (P = 0.700). The median follow-up time was 23 months, for a total of 462 patient years. We note the overall incidence of CVD events (new CVD or worsening of CVD) was 47/244 (20%). The best predictors of new CVD events among those without preexisting CVD were diabetes (odds ratio [OR] = 5.35, P = 0.018) and age (OR = 1.26, P = 0.08). In those with preexisting CVD, low diastolic pressure (DP) (OR =.72, P = 0.004) and high triglycerides (OR = 1.48, P = 0.019) at baseline were independent predictors of progression of CVD. We could not determine an independent impact of kidney function on CVD in the overall cohort. Furthermore, we determined that the presence of CVD itself confers an increased risk for progression to RRT (relative risk [RR] = 1.58, P = 0.047), adjusted for kidney function. This is the first in-depth analysis of CVD in a cohort of patients with established chronic kidney disease who are not on dialysis. The question regarding the impact of the altered biology of uremia in contributing to CVD progression remains unanswered, and clearly needs further study. However, the findings do raise the issue of whether aggressive treatment of CVD and risk factors might, in fact, reduce progression to RRT. Further large-scale, observational studies as well as interventional studies are needed to more clearly understand the complex biology of cardiovascular and kidney disease progression.

An enzymatic method for measuring serum mannitol and its use in hemodialysis patients.

We evaluated two chemical methods for quantifying mannitol in serum, based on the oxidation of mannitol by periodate, and measurement of the formaldehyde formed with chromotropic acid (colorimetry) or acetylacetone (fluorometry). We found interference in these methods by serum glycerol. Additionally, a high-performance liquid chromatography (HPLC) method was evaluated and found to be specific but impractical for routine use. We therefore, developed an enzymatic fluorometric procedure, based on the oxidation of mannitol by beta-NAD to fructose and NADH, in the presence of the enzyme mannitol dehydrogenase (MD). MD is not commercially available and was partially purified from cultures of Leuconostoc mesenteroides. This new method is specific, sensitive, simple, and accurate and is proposed as the method of choice for measuring mannitol in the serum of patients who received this sugar alcohol during routine hemodialysis treatment.

Management of end-stage autosomal dominant polycystic kidney disease with hemodialysis and transplantation.

This is an analysis of the outcome of 35 patients with end-stage autosomal dominant polycystic kidney disease (ADPKD) at Toronto Western Hospital (TWH) during a 10-year period. The primary treatment in each case was hemodialysis. In the 15 patients managed exclusively with hemodialysis the one- and five-year actuarial survival was 93% and 77% respectively. Twenty patients ultimately received a total of 26 cadaveric renal allografts. Graft survival at one year was 76%. One- and five-year patient survival was 92% and 73% respectively. Beyond 5 years a trend towards increased survival in the transplant group was seen, compared with the exclusively hemodialyzed group. Bilateral nephrectomy prior to transplantation was associated with high morbidity and mortality, and did not change either graft or patient survival. In view of the similar survival and because it is accepted that transplantation offers the highest quality of life amongst the modalities of treatment for end-stage renal failure, transplantation should be considered the treatment of choice for end-stage ADPKD. There is no justification for routine bilateral nephrectomy before renal transplantation.

Canadian survey of clinical status at dialysis initiation 1998-1999: a multicenter prospective survey.

AIMS: The current growth in end-stage kidney disease populations has led to increased efforts to understand the impact of status at dialysis initiation on long-term outcomes. Our main objective was to improve the understanding of current Canadian nephrology practice between October 1998 and December 1999. METHODS: Fifteen nephrology centers in 7 provinces participated in a prospective data collection survey. The main outcome of interest was the clinical status at dialysis initiation determined by: residual kidney function, preparedness for chronic dialysis as measured by presence or absence of permanent peritoneal or hemodialysis access, hemoglobin and serum albumin. Uremic symptoms at dialysis initiation were also recorded, however, in some cases these symptom data were obtained retrospectively. RESULTS: Data on 251 patients during 1-month periods were collected. Patients commenced dialysis at mean calculated creatinine clearance levels of approximately 10 ml/min, with an average of 3 symptoms. 35% of patients starting dialysis had been known to nephrologists for less than 3 months. These patients are more likely to commence without permanent access and with lower hemoglobin and albumin levels. Even of those known to nephrologists, only 66% had permanent access in place. CONCLUSIONS: Patients commencing dialysis in Canada appear to be doing so in relative concordance with published guidelines with respect to timing of initiation. Despite an increased awareness of kidney disease, a substantial number of patients continues to commence dialysis without previous care by a nephrologist. Of those who are seen by nephrologists, clinical and laboratory parameters are suboptimal according to current guidelines. This survey serves as an important baseline for future comparisons after the implementation of educational strategies for referring physicians and nephrologists.

A call to arms: economic barriers to optimal dialysis care.

Epidemic growth rates and the enormous cost of dialysis pressure end-stage renal disease (ESRD) delivery systems around the world. Payers of dialysis services can constrain costs through (1) limiting access to dialysis, (2) reducing the quality of dialysis, and (3) placing constraints on modality distribution. In order to secure the necessary resources for ESRD care, we propose that the nephrology community consider the following suggestions: First, future leaders in dialysis should acquire additional advanced training in innovative pathways such as health care economics, business and health care administration, and health care policy. Second, the international nephrology community must strongly engage in ongoing advocacy for accessible, high quality, cost-effective care.Third, efforts should be made to better define and then implement optimal dialysis modality distributions that maximize patient outcomes but limit unnecessary costs. Fourth, industry should be encouraged to lower the unit cost of dialysis, allowing for improved access to dialysis, especially in developing countries. Fifth, research should be encouraged that seeks to identify measures that will reduce dialysis costs but will not impair quality of care. Finally, early referral of patients with progressive renal disease to nephrology clinics, empowerment of informed patient choice of dialysis modality, and proper and timely access creation should be encouraged and can be expected to help limit overall expenditures. Ongoing efforts in these areas by the nephrology community will be essential if we are to overcome the challenges of ESRD growth in this new decade.

Are North American nephrologists biased against peritoneal dialysis?

OBJECTIVE: To examine possible bias against peritoneal dialysis (PD) by nephrologists less familiar with it. DESIGN: Secondary analysis of a previously reported survey. PARTICIPANTS: All practicing Canadian nephrologists (n = 290, response rate 66.2%) and a subgroup of American nephrologists who were members of the National Kidney Foundation Council on Dialysis (n = 507, response rate 47.3%). Responses were then subdivided by type of dialysis practice: mainly or only hemodialysis (HD, n = 117), mainly or only PD (n = 16), or both HD and PD (n = 232). INTERVENTION: Self-administered mailed questionnaire. MAIN OUTCOME MEASURES: Opinions and attitudes of nephrologists concerning patient characteristics favoring one dialysis modality over the other, as well as the relative utilization of HD and PD currently and in a hypothetical ideal situation. RESULTS: The main differences were present between physicians practicing mainly HD and physicians practicing mainly PD, with those practicing both giving answers usually intermediate to the others. The maximum weight suitable for PD was 10 kg less according to HD-oriented nephrologists compared with PD-oriented nephrologists (97.8 kg vs 108.5 kg). All nephrologists agreed that, ideally, 40% of prevalent end-stage renal disease patients should be on PD to optimize cost-effectiveness, whereas the proportion should be between 32% and 45% when one optimizes survival, wellness, and quality of life. In general, differences between groups were small. CONCLUSIONS: Most nephrologists favored a proportion of PD higher than the current prevalence seen in either Canada or the U.S.A. If physicians' biases are contributing to the distribution of dialysis modalities, they are not likely to be major factors. Unknown but important factors, external to the physician, may shape modality distribution more than the opinions and attitudes of physicians. If a more balanced and cost-effective dialysis delivery system is desired, more understanding and manipulation of these non physician-related factors will be required.

Attitudes of Canadian nephrologists toward dialysis modality selection.

OBJECTIVE: To determine the opinions and attitudes of Canadian nephrologists about dialysis modality decisions and optimal dialysis system design. PARTICIPANTS: Members of the Canadian Society of Nephrology. INTERVENTION: A mailed survey questionnaire. RESULTS: A 66% response rate was obtained. Decisions about modality are reported to be based most strongly on patient preference (4.4 on a scale from 1 to 5), followed by quality of life (4.06), morbidity (3.97), mortality (3.85), and rehabilitation (3.69), while neither facility (1.78) nor physician (1.62) reimbursement are important. When asked about the current relative utilization of each modality, nephrologists felt that hospital-based hemodialysis (HD) is slightly overutilized (2.53), continuous ambulatory peritoneal dialysis (CAPD) is about right (3.00), while cycler peritoneal dialysis (PD) (3.53), community-based full (3.83) and self-care HD (3.91), and home HD (4.02) are underutilized. A hypothetical question about optimal distribution to maximize survival revealed that a type of HD should constitute 62.8% of the mix, with more emphasis on cycler PD (14.9%), community-based full care HD (13.8%), self-care HD (14.5%), and home HD (9.0%) than is current practice. However, when the goal was to maximize cost effectiveness, HD fell slightly to 57.8%. CONCLUSIONS: These survey results suggest that the current national average 66%/34% HD/PD ratio is reasonable. However, there appears to be a consensus that Canada could evolve to a more cost-effective, community-based dialysis system without compromising patient outcomes.

Percutaneously inserted silastic jugular hemodialysis catheters seldom cause jugular vein thrombosis.

To find out whether internal jugular vein cannulation with a soft silastic hemodialysis access catheter causes jugular vein thrombosis, the authors carried out Doppler ultrasound examinations on 96 patients receiving hemodialysis who had undergone 144 separate catheter insertion episodes in 116 veins. Two internal jugular vein thromboses were found in 101 veins that had been the site of percutaneous insertions only. In addition, 5 internal jugular vein thromboses were identified in 15 veins that had been cannulated surgically with the Quinton PermCath. The authors conclude that percutaneous internal jugular vein cannulation for hemodialysis access causes an acceptably low incidence of jugular vein damage. This strengthens the case for preferential use of the internal jugular vein for vascular access in patients with end-stage renal failure, and suggests that percutaneous cannulation is less damaging than surgical insertion.