Prevalence and feasibility of assessing the frailty phenotype among hemodialysis patients in a dialysis unit.

BACKGROUND: Frailty increases risk of morbidity and mortality in hemodialysis patients. Frailty assessments could trigger risk reduction interventions if broadly adopted in clinical practice. We aimed to assess the clinical feasibility of frailty assessment among Veteran hemodialysis patients. METHODS: Hemodialysis patients' ≥50 years were recruited from a single dialysis unit between 9/1/2021 and 3/31/2022.Patients who consented underwent a frailty phenotype assessment by clinical staff. Five criteria were assessed: unintentional weight loss, low grip strength, self-reported exhaustion, slow gait speed, and low physical activity. Participants were classified as frail (3-5 points), pre-frail (1-2 points) or non-frail (0 points). Feasibility was determined by the number of eligible participants completing the assessment. RESULTS: Among 82 unique dialysis patients, 45 (52%) completed the assessment, 13 (16%) refused, 18 (23%) were not offered the assessment due to death, transfers, or switch to transplant or peritoneal dialysis, and 6 patients were excluded because they did not meet mobility criteria. Among assessed patients, 40(88%) patients were identified as pre-frail (46.6%) or frail (42.2%). Low grip strength was most common (90%). Those who refused were more likely to have peripheral vascular disease (p = 0.001), low albumin (p = 0.0187), low sodium (p = 0.0422), and ineligible for kidney transplant (p = 0.005). CONCLUSIONS: Just over half of eligible hemodialysis patients completed the frailty assessment suggesting difficulty with broad clinical adoption expectations. Among those assessed, frailty and pre-frailty prevalence was high. Given patients who were not tested were clinically high risk, our reported prevalence likely underestimates true frailty prevalence. Providing frailty reduction interventions to all hemodialysis patients could have high impact for this group.

Sjögren's Syndrome Overlap With Lupus Nephritis: A Case Report and Literature Review of a Rare Entity.

Overlap syndrome is a connective tissue disorder that satisfies the diagnostic criteria for at least two well-known autoimmune diseases. In this report, we describe a rare case of lupus overlap in an elderly woman with primary Sjögren's syndrome who presented with features of nephritic-nephrotic syndrome and renal biopsy results typical of lupus nephritis combined with multiple positive autoantibodies. The kidney biopsy results were assigned the highest weightage based on the revised 2019 systemic lupus erythematosus (SLE) classification criteria developed by the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR). The patient's condition significantly improved after appropriate immunosuppressive therapy was initiated. With the revised ACR/EULAR-2019 criteria, we anticipate that more SLE patients with typical lupus nephritis biopsy findings will be diagnosed accurately.

Subarachnoid Hemorrhage in Autoimmune Vasculitis: A Rare Presentation of Systemic Lupus Erythematosus-Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis Overlap Syndrome.

Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) and systemic lupus erythematosus (SLE), though they share similar clinical characteristics, are distinguishable based on specific characteristics. The concomitant presentation of SLE and AAV as overlap syndrome is rare and makes the diagnosis challenging. Here, we describe a rare case of SLE and AAV overlaps presenting with hemorrhagic stroke as initial presentation, which has been reported only once before. The presence of several positive autoantibodies made the diagnosis challenging, but a kidney biopsy provided the definitive diagnosis and aided in initiating immunosuppressive therapy. The patient did not respond to standard initial surgical measures to lower elevated intracranial pressure and showed significant improvement to immunosuppressive therapy proving the temporal relationship. The authors of this case study aim to highlight the importance of considering SLE-AAV overlap in patients presenting with features similar to those described in the case report and intervening early, as delays in diagnosis can be fatal.

Needs and Considerations for Standardization of Kidney Disease Education in Patients with Advanced CKD.

Kidney health advocacy organizations and leaders in the nephrology community have repeatedly emphasized the need to increase home dialysis utilization in the United States. Limited awareness and understanding of options for the management of kidney failure among patients living with advanced CKD is a significant barrier to increasing the selection and use of home dialysis. Studies have shown that providing targeted comprehensive patient education before the onset of kidney failure can improve patients' awareness of kidney disease and substantially increase the informed utilization of home dialysis. Unfortunately, in the absence of validated evidence-based education protocols, outcomes associated with home dialysis use vary widely among published studies, potentially affecting the routine implementation and reporting of these services among patients with advanced CKD. This review provides pragmatic guidance on establishing effective patient-centered education programs to empower patients to make informed decisions about their KRT and, in turn, increase home dialysis use.

VA-Based Peritoneal Dialysis Program Feasibility Considerations and Process Outline.

Background: Home dialysis utilization is lower among veterans than in the general US population. Several sociodemographic factors and comorbidities contribute to peritoneal dialysis (PD) underutilization. In 2019, the Veterans Health Administration (VHA) Kidney Disease Program Office convened a PD workgroup to address this concern. Observations: The PD workgroup was explicitly concerned by the limited availability of PD within the VHA, which frequently requires veterans to transition kidney disease care from US Department of Veterans Affairs medical centers (VAMCs) to non-VHA facilities when they progress from chronic kidney disease to end-stage kidney disease, causing fragmentation of care. Since the administrative requirements and infrastructure of VAMCs vary, the workgroup focused its deliberations on synthesizing a standard process for evaluating the feasibility and establishing a new PD program within any individual VAMC. A 3-phased approach was envisioned, beginning with ascertainment of prerequisites, leading to an examination of the clinical and financial feasibility through the process of data gathering and synthesis, culminating in a business plan that translates the previous 2 steps into an administrative document necessary for obtaining VHA approvals. Conclusions: VAMCs can use the guide presented here to improve therapeutic options for veterans with kidney failure by establishing a new or restructured PD program.

First Case Report of Sphingobium lactosutens as a Human Pathogen Causing Peritoneal Dialysis-Related Peritonitis.

Novel pathogens keep evolving from time to time. In this article, we describe a rare case of the bacterium Sphingobium lactosutens causing peritoneal dialysis-related peritonitis in a patient who presented to our dialysis clinic with typical features of abdominal pain and diffuse abdominal tenderness and was successfully treated with the intraperitoneal antibiotic therapy. There were only very few cases of infections caused by Sphingobium species before. Here, we discuss the infections caused by other Sphingobium species, probable sources of infection, clinical findings, and susceptibility patterns. We also aim to create awareness about this rare bacterial pathogen and emphasize the need for more research to successfully treat and prevent future infections.

The First Case of Ceftazidime-Induced Antibiomania: A Case Report and Literature Review.

Antibiomania is a rare type of secondary mania caused by antibiotics. Here, we describe the first case report of antibiomania in a peritoneal dialysis patient caused by ceftazidime, a cephalosporin antibiotic. Manic symptoms were noted in the patient described here a few days after starting the antibiotic and worsened over the course of a few weeks of antibiotic treatment. There is a close temporal relationship between the start of antibiotics and the onset of manic symptoms in this case. Antibiotics from various groups have been implicated as the causative agents in a few case reports of antibiomania. Several hypotheses have been postulated regarding the underlying mechanism of antibiomania. The authors of this article highlight the importance of recognizing the psychiatric side effects of antibiotics early and formulating effective management options to prevent detrimental effects on a patient's clinical condition.

Diversity of the midstream urine microbiome in adults with chronic kidney disease.

PURPOSE: To examine the characteristics of the midstream urine microbiome in adults with stage 3-5 non-dialysis-dependent chronic kidney disease (CKD). METHODS: Patients with non-dialysis-dependent CKD (estimated glomerular filtration rate [eGFR] < 60 ml/min/1.73 m2) and diuretic use were recruited from outpatient nephrology clinics. Midstream voided urine specimens were collected using the clean-catch method. The bacterial composition was determined by sequencing the hypervariable (V4) region of the bacterial 16S ribosomal RNA gene. Extraction negative controls (no urine) were included to assess the contribution of extraneous DNA from possible sources of contamination. Midstream urine microbiome diversity was assessed with the inverse Simpson, Chao and Shannon indices. The diversity measures were further examined by demographic characteristics and by comorbidities. RESULTS: The cohort of 41 women and 36 men with detectable bacterial DNA in their urine samples had a mean age of 71.5 years (standard deviation [SD] 7.9) years (range 60-91 years). The majority were white (68.0%) and a substantial minority were African-American (29.3%) The mean eGFR was 27.2 (SD 13.6) ml/min/1.73 m2. Most men (72.2%) were circumcised and 16.6% reported a remote history of prostate cancer. Many midstream voided urine specimens were dominated (> 50% reads) by the genera Corynebacterium (n = 11), Staphylococcus (n = 9), Streptococcus (n = 7), Lactobacillus (n = 7), Gardnerella (n = 7), Prevotella (n = 4), Escherichia_Shigella (n = 3), and Enterobacteriaceae (n = 2); the rest lacked a dominant genus. The samples had high levels of diversity, as measured by the inverse Simpson [7.24 (95% CI 6.76, 7.81)], Chao [558.24 (95% CI 381.70, 879.35)], and Shannon indices [2.60 (95% CI 2.51, 2.69)]. Diversity measures were generally higher in participants with urgency urinary incontinence and higher estimated glomerular filtration rate (eGFR). After controlling for demographics and diabetes status, microbiome diversity was significantly associated with estimated eGFR (P < 0.05). CONCLUSIONS: The midstream voided urine microbiome of older adults with stage 3-5 non-dialysis-dependent CKD is diverse. Greater microbiome diversity is associated with higher eGFR.

A question prompt sheet for adult patients with chronic kidney disease.

BACKGROUND: Patients with chronic kidney disease (CKD) commonly have unmet information needs. Greater patient participation in healthcare discussions can address these needs and improve health outcomes. We developed a patient-centered question prompt sheet (QPS) to engage CKD patients in healthcare conversations. METHODS: We conducted a two phase, mixed-methods, cross-sectional study involving semi-structured telephone interviews. Patients with an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2, on dialysis, or with a kidney transplant were recruited from one Veterans Affairs (VA) nephrology clinic. Phase 1 interviews included open-ended questions assessing patients' CKD-related information needs and generated a preliminary 67-item QPS. Phase 2 interview participants rated the importance of asking each question on a 5-point Likert scale and provided open-ended feedback. All participants rated their willingness to use a CKD-QPS. Input from patient ratings, a multidisciplinary team, and from members of the National Kidney Disease Education Program (NKDEP) Coordinating Panel helped to shorten and refine the QPS. A qualitative thematic approach was used to analyze open-ended responses. Quantitative data were analyzed for means and proportions. RESULTS: Eighty-five patients participated. Most were male (97 %), non-Hispanic white (71 %), and mean age was 67 years. Patients desired more information about CKD, particularly dialysis/transplant, and the relationship between CKD and comorbid medical conditions. The final QPS included 31-questions divided into 7 CKD subtopics. Most patients (88 %) reported being 'completely' or 'very' willing to use a CKD-QPS in future doctor visits. CONCLUSIONS: CKD patients have unmet information needs. We developed a QPS to engage CKD patients in healthcare discussions and to facilitate patient-centered care. Future research should assess whether the CKD-QPS addresses patients' information needs, enhances doctor-patient communication, and improves health outcomes.

Urinary incontinence and diuretic avoidance among adults with chronic kidney disease.

PURPOSE: Diuretics remain an important medication for hypertension management among adults with chronic kidney disease (CKD), but diuretics may also worsen urinary symptoms, especially urinary incontinence (UI). This single-center pilot study examined the prevalence of UI among adults age ≥60 years with CKD using diuretics and assessed diuretic avoidance due to urinary symptoms. METHODS: Patients with non-dialysis-dependent CKD (estimated glomerular filtration rate <60 ml/min/1.73 m(2)) and diuretic use were recruited from outpatient nephrology clinics. Urinary symptoms and diuretic avoidance were assessed using standardized questionnaires. RESULTS: The cohort of 44 women and 54 men had a mean age of 71.8 (8.4) years, and urgency-UI, stress-UI and mixed-UI (the presence of both urgency-UI and stress-UI) were reported by 44.9 % (n = 44), 36.7 % (n = 36) and 26.5 % (n = 26), respectively. Nocturia was noted in 68 % (n = 67). Overall, 15.3 % (6 men and 9 women) reported diuretic avoidance. Avoidance of diuretics was 27.3 % (n = 12), 25.5 % (n = 9) and 34.6 % (n = 9) among participants with urgency-UI, stress-UI and mixed-UI, respectively, while only 6.8 % (n = 3) of participants without any UI reported diuretic avoidance. After adjusting for age, sex and diuretic type (loop vs. others), both urgency-UI (odds ratio 5.9 95 % CI 1.5-22.8) and mixed-UI (odds ratio 5.7; 95 % CI 1.6-19.9) were significantly associated with diuretic avoidance compared to participants without urgency-UI, or mixed-UI, respectively. Stress-UI and nocturia were not significantly associated with diuretic avoidance. CONCLUSIONS: UI is common among older adults with CKD receiving diuretics. Patients with urgency-UI are more likely to avoid diuretics.

Barriers to effective communication between veterans with chronic kidney disease and their healthcare providers.

BACKGROUND: Many patients with chronic kidney disease (CKD) have insufficient knowledge about CKD, which is associated with poorer health outcomes. Effective patient-provider communication can improve CKD patients' knowledge, thereby augmenting their participation in self-care practices. However, barriers to addressing CKD patients' information needs have not been previously characterized. METHODS: Adults with an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m(2) or on chronic dialysis or with a kidney transplant were recruited from a Department of Veterans Affairs (VA) nephrology clinic. Semi-structured telephone interviews were conducted to assess patients' CKD information needs and demographic characteristics. A qualitative approach was used to analyze interview transcripts and identify themes pertaining to communication dynamics. RESULTS: Thirty-two patients participated. The mean age of participants was 63 years; most were male (94%) and non-Hispanic white (53%). CKD severity groups represented included CKD-3 (eGFR 30-59 mL/min/1.73 m(2); 34%), CKD-4 (eGFR 15-29 mL/min/1.73 m(2); 25%), CKD-5 (eGFR <15 mL/min/1.73 m(2); 16%), end-stage kidney disease on dialysis (13%) and kidney transplant recipients (12%). Several key themes emerged about barriers to patient-provider communication based on patients' reported care at both VA and non-VA facilities, including patients perceived their role as a 'listener', reported limited CKD knowledge, did not understand physicians' explanations and were dissatisfied with the patient-provider relationship. CONCLUSIONS: Several barriers to patient-provider communication prevent patients from meeting their information needs and perpetuate patient passivity. Future research should evaluate whether interventions that empower CKD patients to actively participate in their care increase knowledge and improve health outcomes.