Management of immunosuppressive therapy after functional renal graft failure: results of a practice survey of French-speaking nephrologists / Gestion du traitement immunosuppresseur après arrêt fonctionnel du greffon rénal : résultats d'une enquête de pratique parmi les néphrologues francophones.

The management of patients with kidney transplant failure (KTF) remains a complex process involving multiple stakeholders. A working group of the Transplantation Commission of the French-speaking Society of Nephrology, Dialysis and Transplantation (SFNDT) conducted a survey on the management of immunosuppressants (IS) after KTF among nephrologists at transplant centres and general nephrologists in France, Switzerland and Belgium between March and June 2023. We analysed 232 replies from 58 nephrologists at transplant centres and 174 general nephrologists, aged 43.6 (+10.6) years. In the first three months following KTF, nephrologists reported discontinuing antimetabolite, calcineurin inhibitor (CNI) and corticosteroid treatment in 83%, 39.9% and 25.8% of cases respectively. Conversely, some nephrologists reported that they were continuing to use CNI (14%) and corticosteroids (19.1%) on a long-term basis. The patient's comorbidities associated with the discontinuation of IS treatment are cancer and opportunistic infections as KT's complications and presence of diabetes mellitus at KTF, whereas humoral rejection encourages the IS to be maintained. Transplantectomy is proposed by nephrologists most often for graft intolerance syndrome (86.5%), more rarely to discontinue IS (17.6%) or in the absence of plans of new transplantation (9.3%). In multivariate analyses, the presence of a protocol in the centre facilitated the management of IS by the general nephrologists. The management of IS after AFG by French-speaking nephrologists is heterogeneous. Specific prospective studies are needed to establish new best practice recommendations, based on more robust evidence, which could encourage better adherence by nephrologists.

La prise en charge des patients avec un arrêt fonctionnel du greffon rénal (AFG) reste un processus complexe avec de multiples intervenants. Un groupe de travail de la Société francophone de néphrologie, dialyse et transplantation (SFNDT) a conduit une enquête sur la gestion des traitements immunosuppresseurs (IS) après AFG parmi les néphrologues de centres de transplantation et néphrologues généraux en France, Suisse et Belgique francophone entre mars et juin 2023. Nous avons pu analyser 232 réponses de néphrologues (centres de transplantation N = 58 et généraux N = 174) âgés de 43,6 (± 10,6) ans. Dans les 3 premiers mois suivant l'AFG, les néphrologues déclarent interrompre le traitement par antimétabolites (83 %), inhibiteurs de la calcineurine (ICN) (39,9 %) et corticoïdes (25,8 %). À l'inverse, certains déclarent maintenir les ICN (14 %) et les corticoïdes (19,1 %) au long cours en cas de projet de nouvelle transplantation rénale (TR). La survenue de cancer pendant la TR, d'infections opportunistes dans la dernière année de TR ou à l'initiation de la dialyse, et la présence d'un diabète lors de l'AFG sont associées avec l'arrêt du traitement IS alors que la perte du greffon par rejet humoral incite à le maintenir. En analyse multivariée, la présence d'un protocole dans le centre facilite la gestion des IS par les néphrologues généraux. Enfin, la transplantectomie est proposée par les néphrologues le plus souvent pour un syndrome d'intolérance du greffon (86,5 %), plus rarement pour interrompre les IS (17,6 %) ou en l'absence de projet de nouvelle TR (9,3 %). La gestion des IS après l'AFG par les néphrologues francophones est hétérogène. Des études prospectives spécifiques sont nécessaires afin de formuler de nouvelles recommandations de bonnes pratiques, reposant sur des données probantes plus robustes, qui pourraient encourager une meilleure adhésion par les néphrologues.

Management of immunosuppressive therapy after functional renal graft failure: Results of a practice survey of French-speaking nephrologists / Gestion du traitement immunosuppresseur après arrêt fonctionnel du greffon rénal : résultats d'une enquête de pratique parmi les néphrologues francophones.

The management of patients with kidney transplant failure (KTF) remains a complex process involving multiple stakeholders. A working group of the Transplantation Commission of the French-speaking Society of Nephrology, Dialysis and Transplantation (SFNDT) conducted a survey on the management of immunosuppressants (IS) after KTF among nephrologists at transplant centres and general nephrologists in France, Switzerland and Belgium between March and June 2023. We analysed 232 replies from 58 nephrologists at transplant centres and 174 general nephrologists, aged 43.6 (+10.6) years. In the first three months following KTF, nephrologists reported discontinuing antimetabolite, calcineurin inhibitor (CNI) and corticosteroid treatment in 83%, 39.9% and 25.8% of cases respectively. Conversely, some nephrologists reported that they were continuing to use CNI (14%) and corticosteroids (19.1%) on a long-term basis. The patient's comorbidities associated with the discontinuation of IS treatment are cancer and opportunistic infections as KT's complications and presence of diabetes mellitus at KTF, whereas humoral rejection encourages the IS to be maintained. Transplantectomy is proposed by nephrologists most often for graft intolerance syndrome (86.5%), more rarely to discontinue IS (17.6%) or in the absence of plans of new transplantation (9.3%). In multivariate analyses, the presence of a protocol in the centre facilitated the management of IS by the general nephrologists. The management of IS after AFG by French-speaking nephrologists is heterogeneous. Specific prospective studies are needed to establish new best practice recommendations, based on more robust evidence, which could encourage better adherence by nephrologists.

La prise en charge des patients avec un arrêt fonctionnel du greffon rénal (AFG) reste un processus complexe avec de multiples intervenants. Un groupe de travail de la Société francophone de néphrologie, dialyse et transplantation (SFNDT) a conduit une enquête sur la gestion des traitements immunosuppresseurs (IS) après AFG parmi les néphrologues de centres de transplantation et néphrologues généraux en France, Suisse et Belgique francophone entre mars et juin 2023. Nous avons pu analyser 232 réponses de néphrologues (centres de transplantation N = 58 et généraux N = 174) âgés de 43,6 (± 10,6) ans. Dans les 3 premiers mois suivant l'AFG, les néphrologues déclarent interrompre le traitement par antimétabolites (83 %), inhibiteurs de la calcineurine (ICN) (39,9 %) et corticoïdes (25,8 %). À l'inverse, certains déclarent maintenir les ICN (14 %) et les corticoïdes (19,1 %) au long cours en cas de projet de nouvelle transplantation rénale (TR). La survenue de cancer pendant la TR, d'infections opportunistes dans la dernière année de TR ou à l'initiation de la dialyse, et la présence d'un diabète lors de l'AFG sont associées avec l'arrêt du traitement IS alors que la perte du greffon par rejet humoral incite à le maintenir. En analyse multivariée, la présence d'un protocole dans le centre facilite la gestion des IS par les néphrologues généraux. Enfin, la transplantectomie est proposée par les néphrologues le plus souvent pour un syndrome d'intolérance du greffon (86,5 %), plus rarement pour interrompre les IS (17,6 %) ou en l'absence de projet de nouvelle TR (9,3 %). La gestion des IS après l'AFG par les néphrologues francophones est hétérogène. Des études prospectives spécifiques sont nécessaires afin de formuler de nouvelles recommandations de bonnes pratiques, reposant sur des données probantes plus robustes, qui pourraient encourager une meilleure adhésion par les néphrologues.

Frailty and depressive symptoms in older kidney transplant recipients: opportunities for collaboration between transplant nephrologists and geriatricians.

BACKGROUND: Frailty is one of the key syndromes in geriatric medicine and an important factor for post-transplant outcomes. We aimed to describe the prevalence of frailty and examine the correlates of frailty and depressive symptoms in older kidney transplant recipients (KTRs). METHODS: This cross-sectional study involved 112 kidney transplant recipients (KTRs) aged 70 and above. Frailty syndrome was assessed using the Fried frailty criteria, and patients were categorized as frail, pre-frail, or non-frail based on five frailty components: muscle weakness, slow walking speed, low physical activity, self-reported exhaustion, and unintentional weight loss. Depressive symptoms were measured using the 15-item Geriatric Depression Scale (GDS). The relationship between frailty and depressive symptoms was evaluated using multinomial logistic regression, with the three frailty categories as the dependent variable and the severity of depressive symptoms as the independent variable, while controlling for age, gender, renal graft function, and time since transplant surgery. RESULTS: The participants had a mean age of 73.3 ± 3.3 years, and 49% were female. The prevalence of frailty syndrome was 25% (n = 28), pre-frailty was 46% (n = 52), and 29% (n = 32) of the KTRs were non-frail. The mean score for depressive symptoms was 3.1 ± 2.4 points, with 18% scoring above the clinical depression cutoff. Depressive symptoms were positively correlated with frailty (r = .46, p < .001). Among the frailty components, self-reported exhaustion (r = .43, p < .001), slow walking speed (r = .26, p < .01), and low physical activity (r = .44, p < .001) were significantly positively correlated with depressive symptoms, while muscle strength (p = .068) and unintentional weight loss (p = .050) were not. A multinomial logistic regression adjusted for covariates indicated that, compared to being non-frail, each additional point on the GDS increased the odds of being pre-frail by 39% (odds ratio [OR] = 1.39, 95% confidence interval [CI] 1.01-1.96) and roughly doubled the odds of being frail (OR = 2.01, 95% CI 1.39-2.89). CONCLUSION: There is a strong association between frailty and depression in KTRs aged 70 years and older. Targeted detection has opened up a new avenue for collaboration between geriatricians and transplant nephrologists.

Nephrologists' perspectives and experiences with hospice among older adults with end-stage kidney disease.

BACKGROUND: Hospice care leads to improved patient and family outcomes. Hospice use among older adults with end-stage kidney disease (ESKD) is markedly lower than among older adults with other serious illnesses, and the majority of those with ESKD who use hospice enroll in the last days of life. Here, our aim was to explore barriers to timely receipt of high-quality hospice care for older adults with ESKD. METHODS: Utilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi-structured interviews with 20 nephrologists in the United States focused on treatment decision-making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high-quality hospice. RESULTS: With a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists' interviews revealed two interrelated contributors to the lack of timely access to high-quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD. CONCLUSIONS: Our findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients.

Kidney adolescent and young adult clinic: A transition model in Africa.

Adolescents and Young Adults (AYAs) with chronic kidney disease (CKD) have challenges unique to this developmental period, with increased rates of high-risk behavior and non-adherence to therapy which may impact the progression of kidney disease and their requirement for kidney replacement therapy (KRT). Successful transition of AYA patients are particularly important in low- and middle-income countries (LMICs) where KRT is limited, rationed or not available. Kidney AYA transition clinics have the potential to improve clinical outcomes but there is a paucity of data on the clinical translational impact of these clinics in Africa. This review is a reflection of the 20-year growth and development of the first South African kidney AYA transition clinic. We describe a model of care for patients with CKD, irrespective of etiology, aged 10-25 years, transitioning from pediatric to adult nephrology services. This unique service was established in 2002 and re-designed in 2015. This multidisciplinary integrated transition model has improved patient outcomes, created peer support groups and formed a training platform for future pediatric and adult nephrologists. In addition, an Adolescent Centre of Excellence has been created to compliment the kidney AYA transition model of care. The development of this transition pathway challenges and solutions are explored in this article. This is the first kidney AYA transition clinic in Africa. The scope of this service has expanded over the last two decades. With limited resources in LMICs, such as KRT, the structured transition of AYAs with kidney disease is not only possible but essential. It is imperative to preserve residual kidney function, maximize the kidney allograft lifespan and improve adherence, to enable young individuals an opportunity to lead productive lives.

Residents' satisfaction and suggestions to improve nephrology residency in Italy, and comparison with the organization in other European countries.

BACKGROUND: In Italy, nephrology residency is available in twenty-one nephrology schools, each with its own strengths and weaknesses. The present study is aimed at exploring the residents' satisfaction with their training programs. METHODS: Between April 20th and May 19th, 2021, a questionnaire on residency satisfaction consisting of 49 items was sent to 586 residents and 175 recently certified specialists (qualified to practice as nephrologists in 2019 and 2020), with a response rate of 81% and 51%, respectively. The teaching organization was contextualized with a survey involving 13 European nephrology schools. RESULTS: Most residency fellowship programs received a good rating with regard to "satisfaction", in particular for the following items: number of hospitalizations followed-up, chronic hemodialysis training, follow-up of transplanted patients, diagnosis and treatment of glomerulonephritis. The teachings that were identified as being of lower quality or insufficient intensity included vascular access management, ultrasound diagnostics and renal nutrition. The need for improvement in formal teaching programs was underlined. Young nephrologists were rather satisfied with their salary and with the quality of the work they were doing, but only few were interested in an academic career since it was generally held that it is "too difficult" to obtain a university position. Many young nephrologists who filled in the questionnaire felt that lack of experience in peritoneal dialysis and vascular access management was a barrier to finding an ideal job. Compared to other European training programs, the Italian program differs with regard to longer exposure to nephrology (as compared to internal medicine), and greater flexibility for internships in different settings, including abroad. CONCLUSIONS: This first nationwide survey on the satisfaction of residents in nephrology indicates that, despite rather good overall satisfaction, there is room for improvement to make nephrology a more appealing choice and to fulfill the needs of a growing number of renal disease patients.

Factors influencing renal replacement therapy modality choice from the nephrologist's perspective.

BACKGROUND: Peritoneal dialysis (PD) offers quality of life and empowerment for persons with end-stage kidney disease (ESKD). Nevertheless, the prevalence of PD is low in Belgium and Europe in general. Reimbursement, patient mix and late referral have been quoted as underlying reasons. However, to date no one-size-fits-all solution increasing uptake of PD has been successfully implemented. We aimed to understand the nephrologist's perspective, beliefs, and experiences on dialysis modality selection and to clarify underlying process-level and intrinsic motivations steering final decisions. METHODS: Using purposeful sampling, Belgian nephrologists (non-/academic, geographical spread, age, gender) were selected. We conducted semi-structured interviews, and audiotapes were transcribed verbatim. Meaningful units were grouped into (sub-)themes, and a conceptual framework was developed using grounded theory according to Charmaz as guidance. RESULTS: Twenty-nine nephrologists were interviewed. We identified four themes: Trust and belief (in PD as a technique; own expertise, knowledge and team; in behavior of patient, family practitioner), feeling of control (paternalism; insecurity; prejudice), vision of care and approach (shared decision making; troubleshooting attitude; flexibility and creativity; complacency), and organizational issues (predialysis; access; financial; and assisted PD). CONCLUSIONS: Based on these interviews, it is apparent that next to already identified singular issues such as late referral, predialysis education, patient mix and financial incentives, more intrinsic factors also impact uptake of home-based therapies. These factors intertwine and relate both to process-level topics and to attitudes and culture of the nephrologists within the team.

Results from a cross-specialty consensus on optimal management of patients with chronic kidney disease (CKD): from screening to complications.

BACKGROUND: Chronic kidney disease (CKD) affects around 10% of the global population and has been estimated to affect around 50% of individuals with type 2 diabetes and 50% of those with heart failure. The guideline-recommended approach is to manage with disease-modifying therapies, but real-world data suggest that prescribing rates do not reflect this in practice. OBJECTIVE: To develop a cross-specialty consensus on optimal management of the patient with CKD using a modified Delphi method. DESIGN: An international steering group of experts specialising in internal medicine, endocrinology/diabetology, nephrology and primary care medicine developed 42 statements on aspects of CKD management including identification and screening, risk factors, holistic management, guidelines, cross-specialty alignment and education. Consensus was determined by agreement using an online survey. PARTICIPANTS: The survey was distributed to cardiologists, nephrologists, endocrinologists and primary care physicians across 11 countries. MAIN OUTCOMES AND MEASURES: The threshold for consensus agreement was established a priori by the steering group at 75%. Stopping criteria were defined as a target of 25 responses from each country (N=275), and a 4-week survey period. RESULTS: 274 responses were received in December 2022, 25 responses from Argentina, Australia, Brazil, Guatemala, Mexico, Singapore, South Korea, Taiwan, Thailand, Turkey and 24 responses from Egypt. 53 responses were received from cardiologists, 52 from nephrologists, 55 from endocrinologists and 114 from primary care physicians. 37 statements attained very high agreement (≥90%) and 5 attained high agreement (≥75% and <90%). Strong alignment between roles was seen across the statements, and different levels of experience (2-5 years or 5+ years), some variation was observed between countries. CONCLUSIONS: There is a high degree of consensus regarding aspects of CKD management among healthcare professionals from 11 countries. Based on these strong levels of agreement, the steering group derived 12 key recommendations focused on diagnosis and management of CKD.

Genomics in nephrology: identifying informatics opportunities to improve diagnosis of genetic kidney disorders using a human-centered design approach.

BACKGROUND: Genomic kidney conditions often have a long lag between onset of symptoms and diagnosis. To design a real time genetic diagnosis process that meets the needs of nephrologists, we need to understand the current state, barriers, and facilitators nephrologists and other clinicians who treat kidney conditions experience, and identify areas of opportunity for improvement and innovation. METHODS: Qualitative in-depth interviews were conducted with nephrologists and internists from 7 health systems. Rapid analysis identified themes in the interviews. These were used to develop service blueprints and process maps depicting the current state of genetic diagnosis of kidney disease. RESULTS: Themes from the interviews included the importance of trustworthy resources, guidance on how to order tests, and clarity on what to do with results. Barriers included lack of knowledge, lack of access, and complexity surrounding the case and disease. Facilitators included good user experience, straightforward diagnoses, and support from colleagues. DISCUSSION: The current state of diagnosis of kidney diseases with genetic etiology is suboptimal, with information gaps, complexity of genetic testing processes, and heterogeneity of disease impeding efficiency and leading to poor outcomes. This study highlights opportunities for improvement and innovation to address these barriers and empower nephrologists and other clinicians who treat kidney conditions to access and use real time genetic information.

Role of the Opinions of the Nephrologist and Structural Factors in Dialysis Modality Selection. Results of a Peritoneal Dialysis Study Group Questionnaire.

Background. The use of PD depends on economic, structural and organizational factors. The nephrologist's opinion is that peritoneal dialysis is less used than it shold be. In Italy, PD is not carried out in private Centers, but neither is it in around one third of Public Centers. The aim of this study was to investigate the opinions of nephrologists on PD in Public Centers only, thereby nullifying the influence of the economic factors. Materials and Methods. The investigation was carried out by means of an online questionnaire (Qs) via mail, and during meetings and Congresses in 2006-07. The Qs investigated the characteristics of the Centers, the nephrologists interviewed, and opinions on the various aspects of the choice of Renal Replacement Therapy Renal Replacement Therapy (RRT) (26 questions). Responses were received from 454 nephrologists in 270 public Centers. Among these, 205 centers (370 Qs) report PD (PD-YES), 36 (42 Qs) do not (PD-NO) and 29 (42 Qs) do not use it but send patients selected for PD to other Centers (PD-TRANSF). Results. The PD-NO and PD-TRANSF Centers are significantly smaller, with greater availability of beds. In the PD-YES Centers the presence of a pre-dialysis pathway, early referral and nurses dedicated solely to PD are associated with a higher use of PD. The nephrologists in the PD-NO Centers rate PD more negatively in terms of both clinical and non-clinical factors. The belief that more than 40% of patients can do either PD or HD differs among the nephrologists in the PD-YES (74.3%), PD-TRANSF (45.2%) and PD-NO (28.6%) Centers. Likewise, the belief that PD can be used as a first treatment in more than 30% of cases differs among the nephrologists in PD-YES (49.2%), PD-TRANSF (33.3%) and PD-NO (14.3%) Centers. Conclusions. The use of PD in Public Centers is conditioned by both structural and organizational factors, and by the opinions of nephrologists on the use and effectiveness of the technique.

Japanese clinical practice patterns of rituximab treatment for minimal change disease in adults 2021: A web-based questionnaire survey of certified nephrologists.

BACKGROUND: In Japan, rituximab (RTX) for adult-onset frequently relapsing (FR)/steroid-dependent (SD) minimal change disease (MCD) is not explicitly reimbursed by insurance, and its standard regimen has not been established. METHODS: We conducted a cross-sectional web-based survey between November and December 2021. The participants were nephrologists certified by the Japanese Society of Nephrology and answered 7 items about RTX for adult MCD. Factors related to the experience of RTX administration at their facilities were estimated by generalized estimating equations. RESULTS: Of 380 respondents, 181 (47.6%) reported the experience of RTX use for adult MCD at their current facilities. Those who worked at university hospitals (vs. non-university hospitals, proportion difference 13.7%) and at facilities with frequent kidney biopsies (vs. 0 cases/year, 19.2% for 1-40 cases/year; 37.9% for 41-80 cases/year; 51.9% for ≥ 81 cases/year) used RTX more frequently. Of 181 respondents, 28 (15.5%) answered that there was no insurance coverage for RTX treatment. Of 327 respondents who had the opportunity to treat MCD, which was a possible indication for RTX, 178 (54.4%) indicated withholding of RTX administration. The most common reason was the cost due to lack of insurance coverage (141, 79.2%). Regarding RTX regimens for FR/SD MCD, introduction treatment with a single body surface area-based dose of 375 mg/m2 and maintenance treatment with a 6-month interval were the most common. CONCLUSION: This survey revealed the nephrologists' characteristics associated with RTX use, the barriers to RTX use, and the variation in the regimens for adult MCD in Japan.

Optimising care: Impact of regular nephrologist appointments on clinical outcome for chronic kidney disease patients in primary care.

INTRODUCTION: The rise in the cases of chronic kidney disease (CKD) with the increasing prevalence of non-communicable diseases such as type 2 diabetes mellitus and hypertension is a major public health concern in Malaysia. This results in the many cases of chronic kidney disease being managed in primary healthcare clinics. This study examines the pre- and post-clinical outcomes of scheduled nephrologist visits on CKD patients in a primary health care clinic in Ipoh, Perak. MATERIALS AND METHODS: This is a retrospective crosssectional study reviewing the medical records of patients seen by visiting nephrologists from January 2019 to December 2021 in Greentown Health Clinic. The study population are patients with CKD stage 3b, 4 and 5 who are followed up in Greentown Health Clinic. Universal sampling was done, a total of 87 patients reviewed at least once by the visiting nephrologist and with retrievable medical records were included in the study. Those whose medical records were irretrievable were excluded. Blood pressure, urine protein, fasting blood sugar (FBS), glycated haemoglobin (HbA1c), serum creatinine, eGFR and fasting lipid profile (FLP) pre- and post-visits were collected by reviewing patient medical records and laboratory results. The results were then analysed and compared using SPSS version 26. RESULTS: The median age of patients in this study was 66 years of age, the majority were male patients (54%) and Malay ethnicity (62.1%). Absence of urine microalbuminuria pre and post referral remain the same (n = 11). During prenephrologist visits, a higher percentage of patients exhibited moderate (30-300 mg/g) and severe (>300 mg/g) increase in urine albuminuria (15.7% and 7.2%, respectively) compared to the post-referral period. In patients with significant urine protein pre-referral, patient group with urine protein 3+ showed the highest increment of 30.1% (n = 22), in comparison to 19.3% (n = 16) observed during prereferral. Statistically significant clinical outcomes between pre- and post-referral to the nephrologist include reduction of systolic blood pressure [141±15 mmHg versus 135 ±12 mmHg, p = 0.001] and diastolic blood pressure [median = 80 mmHg (IQR: 10) versus median=71 mmHg (IQR: 17), p < 0.001]. Similarly, total cholesterol [median = 4.4 mmol/L (IQR: 1.4) versus median = 4.0 mmol/L (IQR: 1.5, p = 0.001] and LDL [median = 2.5 mmol/L (IQR: 1.2) versus median = 2.2 mmol/L (IQR: 1.2), p < 0.001)] exhibited statistically significant differences between pre- and post-referral. However, HDL remained unchanged and other outcome variables showed no significant differences. CONCLUSION: Incorporating nephrologist visits in primary care seems to have positive impact towards patient clinical outcomes. Results shown in this study can aid other primary care clinics in the decision to initiate nephrologist services in the primary care setting as a multidisciplinary approach to managing CKD patients.

Nephrologists' perspectives on communication and decision-making regarding technique survival in peritoneal dialysis: an international qualitative interview study.

OBJECTIVES: Peritoneal dialysis (PD) allows patients increased autonomy and flexibility; however, both infectious and non-infectious complications may lead to technique failure, which shortens treatment longevity. Maintaining patients on PD remains a major challenge for nephrologists. This study aims to describe nephrologists' perspectives on technique survival in PD. DESIGN: Qualitative semistructured interview study. Transcripts were thematically analysed. SETTING AND PARTICIPANTS: 30 nephrologists across 11 countries including Australia, the USA, the UK, Hong Kong, Canada, Singapore, Japan, New Zealand, Thailand, Colombia and Uruguay were interviewed from April 2017 to November 2019. RESULTS: We identified four themes: defining patient suitability (confidence in capacity for self-management, ensuring clinical stability and expected resilience), building endurance (facilitating access to practical support, improving mental well-being, optimising quality of care and training to reduce risk of complications), establishing rapport through effective communications (managing expectations to enhance trust, individualising care and harnessing a multidisciplinary approach) and confronting fear and acknowledging barriers to haemodialysis (preventing crash landing to haemodialysis, facing concerns of losing independence and positive framing of haemodialysis). CONCLUSION: Nephrologists reported that technique survival in PD is influenced by patients' medical circumstances, psychological motivation and positively influenced by the education and support provided by treating clinicians and families. Strategies to enhance patients' knowledge on PD and communication with patients about technique survival in PD are needed to build trust, set patient expectations of treatment and improve the process of transition off PD.

The Importance of Early Diagnosis and Intervention in Chronic Kidney Disease: Calls-to-Action from Nephrologists Based Mainly in Central/Eastern Europe.

BACKGROUND: Chronic kidney disease (CKD) has a global prevalence of 9.1-13.4%. Comorbidities are abundant and may cause and affect CKD. Cardiovascular disease strongly correlates with CKD, increasing the burden of both diseases. SUMMARY: As a group of 15 clinical nephrologists primarily practicing in 12 Central/Eastern European countries, as well as Israel and Kazakhstan, herein we review the significant unmet needs for patients with CKD and recommend several key calls-to-action. Early diagnosis and treatment are imperative to ensure optimal outcomes for patients with CKD, with the potential to greatly reduce both morbidity and mortality. Lack of awareness of CKD, substandard indicators of kidney function, suboptimal screening rates, and geographical disparities in reimbursement often hamper access to effective care. KEY MESSAGES: Our key calls-to-action to address these unmet needs, thus improving the standard of care for patients with CKD, are the following: increase disease awareness, such as through education; encourage provision of financial support for patients; develop screening algorithms; revisit primary care physician referral practices; and create epidemiological databases that rectify the paucity of data on early-stage disease. By focusing attention on early detection, diagnosis, and treatment of high-risk and early-stage CKD populations, we aim to reduce the burdens, progression, and mortality of CKD.

Refractory IgA Nephropathy: A Challenge for Future Nephrologists.

IgA nephropathy (IgAN) represents the most prevalent form of primary glomerulonephritis, and, on a global scale, it ranks among the leading culprits behind end-stage kidney disease (ESKD). Presently, the primary strategy for managing IgAN revolves around optimizing blood pressure and mitigating proteinuria. This is achieved through the utilization of renin-angiotensin system (RAS) inhibitors, namely, angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs). As outlined by the KDIGO guidelines, individuals who continue to show a persistent high risk of progressive ESKD, even with comprehensive supportive care, are candidates for glucocorticoid therapy. Despite these therapies, some patients have a disease refractory to treatment, defined as individuals that present a 24 h urinary protein persistently >1 g after at least two rounds of regular steroids (methylprednisolone or prednisone) and/or immunosuppressant therapy (e.g., mycophenolate mofetil), or who do not tolerate regular steroids and/or immunosuppressant therapy. The aim of this Systematic Review is to revise the current literature, using the biomedical database PubMed, to investigate possible therapeutic strategies, including SGLT2 inhibitors, endothelin receptor blockers, targeted-release budesonide, B cell proliferation and differentiation inhibitors, fecal microbiota transplantation, as well as blockade of complement components.

Nephrologist follow-up care for the acute kidney injury-chronic kidney disease continuum and clinical outcomes: A systematic review and meta-analysis.

BACKGROUND: Acute kidney injury (AKI) to chronic kidney disease (CKD) continuum will increase patients' risk of mortality and long-term dialysis. The aim of the present meta-analysis is to explore the effectiveness of nephrologist care and focus on the follow-up in patients with AKI. METHODS: A systematic search of studies on nephrologist care for the AKI to CKD continuum has been conducted from PubMed and other different databases. Briefly, the primary outcome is the odds ratio of mortality as well as the secondary outcome is de novo renal replacement therapy. RESULTS: This research includes one randomized controlled trial (RCT) and four cohort studies comprised of 15 541 participants in total. The quantitative analysis displays a lower mortality rate with nephrologist care versus non-nephrologist care in patients' discharge after a hospitalization complicated by AKI (odds ratio: 0.768; 95% CI, 0.616-0.956). By means of Trial Sequential Analysis (TSA), we conclude that nephrologist care after an AKI episode declines 30% relative risks of all-cause mortality. CONCLUSION: Nephrologist care for AKI patients after a hospitalization significantly has reduced mortality compared to those followed up by non-nephrologists. There is a trend toward a potentially superior survival rate with nephrologist care has been going well in the recent years.