Strategies to Improve Long-Term Outcomes for Patients with Chronic Kidney Disease in China.

Background: Chronic kidney disease (CKD) is an incurable disease requiring lifelong management. China has a high prevalence of CKD, which disproportionately affects older adults and those with chronic risk factors for CKD development. The rising prevalence of CKD in China places a substantial burden on the general population and the healthcare system. Summary: In China, there are currently many unmet needs for patients with CKD and high-risk individuals, resulting from a lack of education and support to reduce risk factors, delayed diagnoses, limited knowledge of CKD among primary-care physicians, and poor access to treatments among some patient populations. An integrated, nationwide approach is required to improve the current situation of CKD management in China. There are currently several national healthcare frameworks in place that focus on new major health policies to prevent disease and encourage people to adopt healthier lifestyles, and while they do not directly target CKD, they may have a positive indirect impact. We explore the unmet needs for patients with CKD in China and discuss the potential strategies that may be required to overcome them. Such strategies include improving physician and patient education, establishing a targeted screening programme, supporting patients to improve self-management behaviours, accelerating the creation of medical consortia and medical satellite centres, and migrating from hospital- to community-based management. In addition to policy-driven strategies, development of novel therapies will be key to providing new solutions for the long-term management of CKD. Key Messages: An integrated, nationwide approach is required, incorporating policy-driven changes to the clinical management of CKD, as well as the development of novel CKD treatments.

Status and factors related to post-traumatic growth in continuous ambulatory peritoneal dialysis: A multi-centre study.

AIM: To investigate the extent of post-traumatic growth, and the correlation between post-traumatic growth and self-perceived stress, post-traumatic growth and self-perceived burden among CAPD patients. DESIGN: A cross-sectional study. METHODS: This was a multi-centre study including 752 patients from 44 hospitals. Self-perceived stress, self-perceived burden and post-traumatic growth were measured using the post-traumatic growth inventory (PTGI), the Chinese version of the perceived stress questionnaire (CPSQ) and the self-perceived burden scale (SPBS). A multiple stepwise regression analysis was fit with the total PTGI score as the outcome of interest. RESULTS: Patients concurrently experienced post-traumatic growth and stress following peritoneal dialysis. The initiation of patients' education level, employment status and self-perceived stress were all found to relate to growth among Chinese CAPD patients. There was not sufficient evidence to suggest that self-perceived burden was related to experiencing growth.

Reproductive concerns and associated factors among female chronic kidney diseases patients: a Multi-Center Cross-Sectional Study.

AIM: The study aimed to investigate the current status of reproductive concerns and explore the associated factors among young female chronic kidney disease (CKD) patients. DESIGN: A multi-center cross-sectional study was designed. METHODS: The study was conducted in six representative tertiary hospitals across southwest China. A total of 295 female Chronic kidney disease patients between 18-45 years of age completed a 20 min, web-based survey, which included demographics and disease-related information questionnaire, Reproductive Concerns Scale, Generalized Anxiety Disorder 7 (GAD-7) instrument and Patient Health Questionnaire 9 (PHQ-9) instrument. RESULT: The survey total collected 270 valid questionnaires. The mean reproductive concern score was 54.39 ± 10.90 (out of a maximum of 90), with the mean scores for sub-scales ranging from 7.80 ± 1.69 to 10.44 ± 1.85. Multiple regression analysis showed that those with higher reproductive concerns were more likely to have pregnancy intentions, to be in Chronic kidney disease stages 1-3, and to have a higher GAD-7 score. This study offered further evidence of the need for improved education and emotional support surrounding reproductive concerns among young Chinese women with Chronic kidney disease.

Effects of Exercise Training on Restless Legs Syndrome, Depression, Sleep Quality, and Fatigue Among Hemodialysis Patients: A Systematic Review and Meta-analysis.

CONTEXT: Hemodialysis (HD) patients experience a heavy symptom burden that leads to a decreased quality of life. Pharmacological treatment is effective but costly and has adverse effects. Exercise is a promising approach for symptom management, but the effect of exercise on restless legs syndrome (RLS), depression, sleep quality, and fatigue in HD patients is still uncertain. OBJECTIVES: This meta-analysis was conducted to identify whether exercise training is beneficial in the treatment of the symptoms of RLS, depression, poor sleep quality, and fatigue in patients receiving HD. METHODS: A systematic search of PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Cochrane Central Register of Controlled Trials, and Web of Science was conducted to identify randomized controlled trials (RCTs) comparing exercise training with routine care on RLS, depression, sleep quality, and fatigue among HD patients. Quality assessment was conducted using the Cochrane risk of bias tool, and RevMan 5.3 was used to analyze the data. RESULTS: Fifteen RCTs that met our inclusion criteria were included. The pooled effect size showed that exercise training was effective on RLS (P < 0.001), depression (P < 0.001), and fatigue (P < 0.001). However, effect size combinations for sleep quality were not performed owing to the sensitivity analysis results. CONCLUSION: Exercise training may help HD patients to reduce the severity of RLS, depression, and fatigue. More high-quality RCTs with larger samples and comparative RCTs focused on different exercise regimens are needed.

[Effects of Nurse-Led Team Management on Type 2 Diabetes Patients in the Community].

BACKGROUND: Managing increasing numbers of diabetic patients is placing increasing pressure on healthcare providers, especially general practitioners, who usually serve in multiple roles. This situation has caused generally poor results in terms of diabetes management. However, community nurses in some countries have successfully and effectively controlled chronic diseases among their patients. Therefore, the effects of nurse-led management is worth further exploration in order to better understand and promote this mode of care. PURPOSE: To explore the effects of community-nurse-led team management on diabetes patients. METHODS: An experimental research design was adopted. Patients with type 2 diabetes were recruited from two community health centers (the first for the intervention group, the second for the control group) in Wuhou District, Chengdu City, China. The intervention group received nurse-led team management care for 2 years, while the control group received standard care. The evaluations were conducted before the intervention and at 6, 12, and 24 months into the intervention. Outcomes included glycosylated hemoglobin (HbA1c) level, body mass index, waist circumference, visual acuity, ankle brachial index, kidney function index, urinary protein level, and electrocardiogram. RESULTS: The 179 participants included 88 in the intervention group and 91 in the control group. After the intervention, HbA1c level, ankle brachial index, and waist circumference were all significantly better in the intervention group than in the control group (F = 28.894, p < .01; F = 4.065, p < .01; F = 5.540, p < .01). The other outcome variables remained statistically similar between both groups throughout the study period. CONCLUSIONS: Community nurse-led team management is an effective mode of care in terms of controlling blood glucose control and preventing diabetes-related complications.

Do psychological interventions reduce depression in hemodialysis patients?: A meta-analysis of randomized controlled trials following PRISMA.

BACKGROUND: Depression is highly prevalent in hemodialysis patients and results in poor patient outcomes. Although psychological interventions are being developed and used for these patients, there is uncertainty regarding the effectiveness of these interventions. The purpose of this meta-analysis is to evaluate the effects of psychological interventions on depression treatment in hemodialysis patients. METHODS: All randomized controlled trials (RCTs) relevant to the depression treatment of hemodialysis patients through psychological interventions were retrieved from the following databases: Embase, Pubmed, PsycINFO, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials. The reference lists of identified RCTs were also screened. The Cochrane risk of bias tool was used to evaluate the quality of the studies, RevMan (5.3) was used to analyze the data, and the evidence quality of the combined results was evaluated using GRADE (3.6.1). RESULTS: Eight RCTs were included. The combined results showed that psychological interventions significantly reduced the scores of the Beck Depression Inventory (P<0.001) and interdialysis weight gain (P<0.001). However, due to the high heterogeneity, effect size combinations of sleep quality and quality of life were not performed. CONCLUSION: Psychological interventions may reduce the degree of depression and improve fluid intake restriction adherence. More rigorously designed research is needed.

The Efficacy of a Nurse-Led Disease Management Program in Improving the Quality of Life for Patients with Chronic Kidney Disease: A Meta-Analysis.

BACKGROUND: The impacts of nurse-led disease management programs on the quality of life for patients with chronic kidney disease have not been extensively studied. Furthermore, results of the existing related studies are inconsistent. The focus of the proposed meta-analysis is to evaluate the efficacy of nurse-led disease management programs in improving the quality of life for patients with chronic kidney disease. METHODS: Literature survey was performed to identify the eligible studies from PubMed, Current Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials with predefined terms. The outcome measured was quality of life. This meta-analysis was conducted in line with recommendations from the preferred reporting items for systematic reviews and meta-analyses. RESULTS: Eight studies comprising a total of 1520 patients were included in this meta-analysis, with 766 patients assigned to the nurse-led disease management program. Nurse-led disease management improved the quality of life in terms of symptoms, sleep, staff encouragement, pain, general health perception, energy/fatigue, overall health and mental component summary when evaluated 6 weeks after the beginning of intervention. When evaluated 12 weeks later, the quality of life in terms of symptoms, sleep, staff encouragement, energy/fatigue, and physical component summary was improved. Stratified by the modalities of dialysis, similar results of pooled analyses were observed for patients with peritoneal dialysis or hemodialysis, compared with the overall analyses. The results of sensitivity analyses were the same as the primary analyses. The symmetric funnel plot suggested that the possibility of potential publication bias was relatively low. CONCLUSION: Nurse-led disease management program seems effective to improve some parameters of quality of life for patients with chronic kidney disease. However, the seemingly promising results should be cautiously interpreted and generalized and still need to be confirmed through well-designed large-scale prospective randomized controlled trials.

Remote ischemic conditioning for kidney protection: A meta-analysis.

BACKGROUND: Results from randomized controlled trials (RCTs) concerning kidney effect of remote ischemic conditioning (RIC) are inconsistent. METHODS: We searched for relevant studies in Medline, Embase, the Cochrane Library, Google Scholar and Chinese database (SinoMed), as well as relevant references from their inception to November 2015. We performed a systematic review and meta-analysis of all eligible RCTs of RIC with kidney events. RESULTS: We included 37 RCTs from 2007 to 2015 involving 8168 patients. Pooled analyses of all RCTs showed RIC significantly reduced the incidence of investigator-defined acute kidney injury (AKI) compared with control groups (RR 0.84, 95% CI 0.73-0.96, P = .009) (I(2) = 25%). However, the difference was not significant when only RIFLE (Risk, Injury, Failure, Loss, End Stage), AKIN (Acute Kidney Injury Network), or KDIGO (Kidney Disease Improving Global Outcomes) criteria were applied to the definition of AKI (RR 0.87, 95% CI 0.74-1.02, P = .08) (I(2) = 22%). In subgroup analysis, RIC showed a significant benefit on reducing investigator-defined AKI in patients following percutaneous coronary intervention (RR 0.64, 95% CI 0.46-0.87), but not after cardiac surgery (RR 0.93, 95% CI 0.82-1.06). There was no difference for changes in the incidence of renal replacement therapy, estimated glomerular filtration rate or serum creatinine. CONCLUSIONS: RIC might be beneficial for the prevention of investigator-defined AKI; however, the effect is likely small. Moreover, due to lack of an effect on use of renal replacement therapy, estimated glomerular filtration rate, RIFLE, AKIN, or KDIGO-defined AKI, and serum creatinine, the evidence for RIC is not robust. Finally, recent large-scale RCTs of RIC focusing on patient-centered outcomes do not support the wider application of RIC.

The effect of perceived organisational support on burnout among community health nurses in China: the mediating role of professional self-concept.

AIM: To examine the mediating effect of professional self-concept on the association between perceived organisational support and burnout among community health nurses in Chengdu, China. BACKGROUND: Burnout is a common phenomenon among nurses and previous studies have focused on work environmental factors contributing to burnout. Limited studies have examined the effects of perceived organisational support and professional self-concept on burnout among community health nurses. METHODS: This was a cross-sectional study with 551 community health nurses in Chengdu, China, which included a two-stage sampling method. Structural equation modelling was used to examine the relationships among perceived organisational support, professional self-concept and burnout. RESULTS: The final sample included 456 nurses (82.7%). Perceived organisational support was a significant positive direct predictor for professional self-concept and a significant negative direct predictor for burnout. Professional self-concept was a significant negative direct contributor to burnout. Professional self-concept had a mediating effect on the relationship between perceived organisational support and burnout. CONCLUSIONS: Perceived organisational support may result in reduced burnout by facilitating the development of positive professional self-concept. IMPLICATIONS FOR NURSING MANAGEMENT: Strategies such as establishing a supportive work environment and professional competence training may be effective methods for burnout prevention and management among community health nurses.

Effect of professional self-concept on burnout among community health nurses in Chengdu, China: the mediator role of organisational commitment.

AIMS AND OBJECTIVES: To examine the associations among professional self-concept, organisational commitment and burnout, and to analyse the mediating role of organisational commitment on the relationship between professional self-concept and burnout among community health nurses in Chengdu, China. BACKGROUND: Previous studies have focused on work environmental variables that contributed to burnout in nurses. However, no study has explored the mediating effect of organisational commitment on the correlation between professional self-concept and burnout in community health nurses. DESIGN: A cross-sectional descriptive study. METHODS: This study was conducted at 36 community health centres in Chengdu, China with 485 nurses sampled using a two-stage sampling method. The measures used in our study included Nurses' Self-concept Questionnaire, Organisational Commitment Scale and Maslach Burnout Inventory. RESULTS: The results of structural equation model techniques indicated that, in the direct approach, positive professional self-concept resulted in increased organisational commitment and reduced burnout. Higher organisational commitment resulted in less burnout. In the indirect approach, organisational commitment performed as a partial mediator on the correlation between professional self-concept and burnout. CONCLUSIONS: Positive perception of professional self-concept can result in reduced burnout via enhancing organisational commitment. RELEVANCE TO CLINICAL PRACTICE: It is crucial for nursing administrators to develop effective intervention strategies such as skills escalator training and assertive training, and establishing a supportive working environment to enhance nurses' professional self-concept and organisational commitment, and decrease burnout.

Validity and reliability of the Chinese version of the care transition measure.

BACKGROUND: The 15-item care transition measure (CTM-15) is a reliable and valid instrument assessing the quality of care transition from patients' perspectives. The aim of this study was to evaluate the psychometric properties of the CTM-15 and the CTM-3 (a 3-item short version of the CTM-15) in Mainland China. METHODOLOGY/FINDINGS: This was a cross-sectional study with a convenience sample of 646 patients in a general tertiary-level hospital in Chengdu, China. The results indicated that the Cronbach's α values of the Chinese version of the two measures were 0.90 and 0.56, and the test-retest reliability values were 0.91 and 0.87, respectively. Three factors were extracted for the CTM-15 in Chinese populations. The CTM-15 and the CTM-3 scores discriminated well between patients with and without re-hospitalization for their index condition. The CTM-15 and the CTM-3 had significant positive relationships with self-rated health status. The CTM-3 score was significantly related to the CTM-15 score, and the CTM-3 score accounted for 64.23% of the variance of the CTM-15 score. CONCLUSIONS/SIGNIFICANCE: This study has demonstrated the psychometric properties of the CTM-15 and the CTM-3 in Mainland China. Although the Cronbach's α value of the CTM-3 is suboptimal, it has exhibited high test-retest reliability, convergent validity and criterion validity. Therefore, the CTM-3 can substitute the CTM-15 as a performance measurement tool when the sample size is large enough to compensate its suboptimal reliability or the reduced response burden is a concern.

Associations of fluid overload with mortality and kidney recovery in patients with acute kidney injury: A systematic review and meta-analysis.

PURPOSE: Fluid resuscitation is commonly administered to maintain adequate renal perfusion in critically ill patients to prevent or even treat acute kidney injury (AKI). However, recent studies show that fluid overload is common and might be associated with poor outcomes in patients with AKI. Hence, the objective of this study was to assess the associations of fluid overload with mortality and kidney recovery in patients with AKI. MATERIALS AND METHODS: We electronically searched original articles published in peer-reviewed journals from their inception to January 2015 in PubMed, EMBASE, the Cochrane Library databases, Google Scholar, and Chinese database (SinoMed). We additionally searched the reference lists of all retrieved articles. We performed a systematic review and meta-analysis of all eligible cohort or case-control studies of fluid overload in patients with AKI. The primary outcomes were mortality and kidney recovery. We pooled adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) by using Review Manager 5.2 (The Cochrane Collaboration, Oxford, UK). RESULTS: A total of 5095 patients from 12 cohort studies published from 2008 to 2014 were included. A significant positive association was found between fluid overload and mortality in patients with AKI (OR, 2.23; 95% CI, 1.66-3.01), with similar findings in sepsis (OR, 2.27; 95% CI, 1.69-to 3.03) and nonsepsis subgroups (OR, 3.40; 95% CI, 2.50-4.63). There was also a significant association between mean fluid balance (continuous variables) and mortality (OR, 1.16; 95% CI, 1.07-1.27). Although there was a trend of lower rate of kidney recovery in the fluid overload group, there was no significant association between fluid overload and kidney recovery (OR, 0.66; 95% CI, 0.37-1.15), or dialysis dependence (OR, 0.72; 95% CI, 0.38-1.35). CONCLUSIONS: Fluid overload is associated with an increased risk of mortality in patients with AKI. The evidence of the relationship between fluid overload and kidney recovery is insufficient.

Peritoneal transport rate, systemic inflammation, and residual renal function determine peritoneal protein clearance in continuous ambulatory peritoneal dialysis patients.

BACKGROUND: Peritoneal protein clearance (Pcl) is related to the mortality of patients on continuous ambulatory peritoneal dialysis (CAPD) as well as technique failure. In this prospective observational study, we aimed to investigate factors associated with the level of Pcl. METHODS: We prospectively enrolled 344 prevalent CAPD patients. A standard peritoneal equilibrium test was conducted for each patient. Baseline demographics, biochemistry, and Pcl were recorded. RESULTS: The average Pcl of the patients was 97.40 ± 54.14 mL/day. Peritoneal transport level, serum high-sensitivity C-reactive protein (hsCRP), and residual glomerular filtration rate (rGFR) were independently related to Pcl. The standard ß values were 0.53, 0.17, and -0.10, respectively. Moreover, compared with non-diabetic patients, diabetic patients had a non-significantly higher level of Pcl (104.90 ± 48.65 vs. 96.15 ± 54.97 mL/day; P = 0.06). CONCLUSION: Continuous ambulatory peritoneal dialysis patients lose a high amount of protein through the peritoneum each day. The Pcl value is positively related to the level of peritoneal transport and hsCRP and negatively related to the rGFR.

Charlson comorbidity index helps predict the risk of mortality for patients with type 2 diabetic nephropathy.

Our intent is to examine the predictive role of Charlson comorbidity index (CCI) on mortality of patients with type 2 diabetic nephropathy (DN). Based on the CCI score, the severity of comorbidity was categorized into three grades: mild, with CCI scores of 1-2; moderate, with CCI scores of 3-4; and severe, with CCI scores ≥5. Factors influencing mortality and differences between groups stratified by CCI were determined by logistical regression analysis and one-way analysis of variance (ANOVA). The impact of CCI on mortality was assessed by the Kaplan-Meier analysis. A total of 533 patients with type 2 DN were enrolled in this study, all of them had comorbidity (CCI score >1), and 44.7% (238/533) died. The mortality increased with CCI scores: 21.0% (50/238) patients with CCI scores of 1-2, 56.7% (135/238) patients with CCI scores of 3-4, and 22.3% (53/238) patients with CCI scores ≥5. Logistical regression analysis showed that CCI scores, hemoglobin, and serum albumin were the potential predictors of mortality (P<0.05). One-way ANOVA analysis showed that DN patients with higher CCI scores had lower levels of hemoglobulin, higher levels of serum creatinine, and higher mortality rates than those with lower CCI scores. The Kaplan-Meier curves showed that survival time decreased when the CCI scores and mortality rates went up. In conclusion, CCI provides a simple, readily applicable, and valid method for classifying comorbidities and predicting the mortality of type 2 DN. An increased awareness of the potential comorbidities in type 2 DN patients may provide insights into this complicated disease and improve the outcomes by identifying and treating patients earlier and more effectively.

A case of focal segmental glomerulosclerosis syndrome secondary to high-altitude polycythemia.

In recent years, focal segmental glomerulosclerosis has become the commonest cause of the nephrotic syndrome seen in adults. Secondary focal segmental glomerulosclerosis is observed when glomerular workload is increased. We report a case of focal segmental glomerulosclerosis with nephrotic syndrome secondary to high-altitude polycythemia (HAPC). Our case points out that for patients with focal segmental glomerulosclerosis, who presented with nephrotic syndrome secondary to HAPC, treatments for HAPC are crucial for the reduction of proteinuria and renal protection instead of glucocorticoid and immunosuppressive drugs.

Influence of HbA1c on short-term blood pressure variability in type 2 diabetic patients with diabetic nephropathy.

The aim of this study was to understand the characteristics of blood pressure (BP) variability in subjects with diabetic nephropathy (DN), and identify the probable predictors affecting BP variability. Fifty-one chronic kidney disease (CKD)-hypertensive patients without diabetes (NDN group) and sixty type 2 diabetic patients with overt DN (DN group) were enrolled in this study. The values of short-term BP variability were obtained from 24 h ambulatory BP monitoring (ABPM). Variance analysis or nonparametric analysis revealed that 24-h systolic BP variability and nighttime systolic BP variability of the DN group were significantly higher than those of the NDN group [(12.23±3.66) vs. (10.74±3.83) mmHg, P<0.05; (11.23±4.82) vs. (9.48±3.69) mmHg, P<0.05]. Then the patients of the DN group were divided into two groups according to glycated hemoglobin (HbA1c) level: Group A (HbA1c<7%) and Group B (HbA1c≥7%), and the t-test showed that patients in Group B had larger 24-h diastolic, daytime diastolic, and nighttime systolic/diastolic BP variability compared with Group A. In the DN group, partial correlation analysis revealed that HbA1c exhibited a strong association with 24-h diastolic, daytime diastolic, nighttime systolic and diastolic BP variability (P<0.001, P<0.001, P<0.05, and P<0.001, respectively). Taken together, larger short-term BP variability was detected in hypertensive type 2 diabetic patients with overt nephropathy and renal insufficiency. It may imply that the optimal BP variability level could benefit from a better glycaemic control.

[Self-renewal signaling pathway and culture system in vitro of embryonic stem cells].

OBJECTIVE: To review the latest development of the research on the self-renwal signaling pathway and culture system in vitro of the embryonic stem cells (ESCs). METHODS: The recent articles about the self-renewal signaling pathway and culture system in vitro of the ESCs were extensively reviewed. RESULTS: Understanding of the molecular mechanism of the self-renewal in vitro and pluripotency of the ESCs was considered important for developing improved methods of deriving, culturing and differentiating these cells into the cells that could be successfully used in the clinical practice. CONCLUSION: A further research is needed to elucidate the self-renewal signaling pathway and the pluripotency of the ESCs and the culture system in vitro for the human ESCs remains to be further improved and developed.

[Hyperthermia combined with chemotherapy in the treatment of advanced non-small cell lung cancer: an initial study].

BACKGROUND: The efficacy of chemotherapy alone is still unsatisfactory in the treatment of advanced non-small cell lung cancer (NSCLC). Some kinds of solid tumors have showed good responses to chemotherapy combined with hyperthermia. This study is to investigate the feasibility and the response of hyperthermia combined with chemotherapy for advanced NSCLC. METHODS: A total of 51 patients with advanced NSCLC were eligible, in which 22 were in group HC, and the other 29 in group C. Patients in the two groups received NP (vinorelbine+cisplatin) or GP (gemcitabine+cisplatin) regimen for 2 cycles. In addition, patients in group HC received local hyperthermia twice a week, up to 12 times. RESULTS: The response rate in group HC was 22.7%, and 13.8% in group C (P > 0.05). The clinical benefit rate in group HC was significantly higher than that in group C (P < 0.05). There was no difference in change of KPS score after treatment between the two groups. CONCLUSIONS: Hyperthermia combined with chemotherapy shows good tolerance and response in patients with advanced NSCLC. Further study should be carried out.