Impact of Remote Monitoring on Standardized Outcomes in Nephrology-Peritoneal Dialysis.

Introduction: This study aimed to evaluate the association between the use of remote patient monitoring (RPM) in patients on automated peritoneal dialysis (APD) and the Standardized Outcomes in Nephrology in peritoneal dialysis (SONG-PD) clinical outcomes. Methods: A prospective and multicenter cohort study was conducted on patients with advanced chronic kidney disease on APD, recruited at 16 Spanish Hospitals, between June 1 and December 31, 2021. Patients were divided into 2 cohorts, namely patients on APD with RPM (APD-RPM) and patients on APD without RPM. The primary endpoints were the standardized outcomes of the SONG-PD clinical outcomes: PD-associated infection, cardiovascular disease (CVD), mortality rate, technique survival, and life participation (assessed as health-related quality of life [QoL]). Propensity score matching (PSM) was used to evaluate the association of RPM exposure with the clinical outcomes. Results: A total of 232 patients were included, 176 (75.9%) in the APD-RPM group and 56 (24.1%) in the APD-without-RPM group. The mean patient follow-up time was significantly longer in the APD-RPM group than in the APD-without-RPM group (10.4 ± 2.8 vs. 9.4 ± 3.1 months, respectively; P = 0.02). In the overall study sample, the APD-RPM group was associated with a lower mortality rate (hazard ratio [HR]: 0.08; 95% confidence interval [CI]: 0.01 to 0.69; P = 0.020) and greater technique survival rate (HR: 0.25; 95% CI: 0.11 to 0.59; P = 0.001). After PSM, APD-RPM continued to be associated with better technique survival (HR: 0.23; 95% CI: 0.06 to 0.83; P = 0.024). Conclusion: The use of RPM programs in patients on APD was associated with better survival of the technique and lower mortality rates. However, after PSM, only technique survival was significant.

Association of Healthcare Fragmentation and the Survival of Patients With Colorectal Cancer in Colombia.

OBJECTIVES: The objective of this study was to identify the association between healthcare fragmentation and survival for patients with colorectal cancer in Colombia. METHODS: A retrospective cohort study was performed using administrative databases, with an electronic algorithm to identify patients with colorectal cancer based on codes. The patients were enrolled between January 1, 2013, and December 31, 2016. The exposure variable was fragmentation, which was measured based on the number of different healthcare institutions that treated a patient during the first year after diagnosis. Matching was performed using propensity scores to control for confounding, and the hazard ratio for exposure to higher fragmentation was calculated for the matched sample. RESULTS: A total of 5036 patients with colorectal cancer were identified, 2525 (49.88%) of whom were women. The mean number of network healthcare institutions for the total sample was 5.71 (SD 1.98). The patients in the quartile with higher fragmentation had the highest mortality rate, 35.67 (95% CI 33.63-38.06) per 100 patients. The comparison of higher and lower quartiles of fragmentation resulted in an incidence rate ratio of 1.23 (95% CI 1.04-1.45; P = .02). Of the 5036 patients, 422 (8.38%) were classified as the exposed cohort (higher fragmentation). The total matched sample consisted of 844 subjects, and an HR of 1.26 (95%CI; 1.05-1.51) was estimated. CONCLUSIONS: Exposure to more highly fragmented healthcare networks decreases overall 4-year survival for patients with colorectal cancer in Colombia.

Opportunities to improve the management of anemia in peritoneal dialysis patients: lessons from a national study in routine clinical practice.

Background: Current guidelines establish the same hemoglobin (Hb) and iron biomarkers targets for hemodialysis (HD) and peritoneal dialysis (PD) in patients receiving erythropoiesis-stimulating agents (ESAs) even though patients having PD are usually younger, more active and less comorbid. Unfortunately, specific renal anemia [anemia in chronic kidney disease (aCKD)] trials or observational studies on PD are scanty. The aims of this study were to describe current aCKD management, goals and adherence to clinical guidelines, identifying opportunities for healthcare improvement in PD patients. Methods: This was a retrospective, nationwide, multicentre study including patients from 19 PD units. The nephrologists collected baseline data, demographics, comorbidities and data related to anemia management (laboratory values, previously prescribed treatments and subsequent adjustments) from electronic medical records. The European adaptation of KDIGO guidelines was the reference for definitions, drug prescriptions and targets. Results: A total of 343 patients (mean age 62.9 years, 61.2% male) were included; 72.9% were receiving ESAs and 33.2% iron therapy [20.7% intravenously (IV)]. Eighty-two patients were receiving ESA without iron therapy, despite 53 of them having an indication according to the European Renal Best Practice guidelines. After laboratory results, iron therapy was only started in 15% of patients. Among ESA-treated patients, 51.9% had an optimal control [hemoglobin (Hb) 10-12 g/dL] and 28.3% between 12-12.9 g/dL. Seventeen patients achieved Hb >13 g/dL, and 12 of them remained on ESA after overshooting. Only three patients had Hb <10 g/dL without ESAs. Seven patients (2%) met criteria for ESA resistance (epoetin dose >300 IU/kg/week). The highest tertile of erythropoietin resistance index (>6.3 UI/kg/week/g/dL) was associated with iron deficiency and low albumin corrected by renal replacement therapy vintage and hospital admissions in the previous 3 months. Conclusion: Iron therapy continues to be underused (especially IV). Low albumin, iron deficiency and prior events explain most of the ESA hyporesponsiveness. Hb targets are titrated to/above the upper limits. Thus, several missed opportunities for adequate prescriptions and adherence to guidelines were identified.

Fragmentation of Care and Its Association With Survival and Costs for Patients With Breast Cancer in Colombia.

PURPOSE: Breast cancer care requires a multimodal approach and a multidisciplinary team who must work together to obtain good clinical results. The fragmentation of care can affect the breast cancer care; however, it has not been measured in a low-resource setting. The aim of this study was to identify fragmentation of care, the geographic variation of this and its association with 4-year overall survival (OS), and costs of care for patients with breast cancer enrolled in Colombia's contributory health care system. MATERIALS AND METHODS: A retrospective cohort study was conducted using administrative databases. Women with breast cancer who were treated from January 1, 2013, to December 31, 2015, were included. Fragmentation of care was the exposure, which was measured by the number of different health care provider institutions (HCPIs) that treated a patient during the first year after diagnosis. Crude mortality rates were estimated, survival functions were calculated using the nonparametric Kaplan-Meier approach, and adjusted hazard ratios (HRs) were estimated using multivariate Cox regression model to identify the association of fragmentation with 4-year OS. The association between fragmentation and costs of care was assessed using a multivariate linear regression model. RESULTS: A total of 10,999 patients with breast cancer were identified, and 1,332 deaths were observed. The 4-year crude mortality rate was 31.97 (95% CI, 30.25 to 33.69) per 1,000 person-years for the whole cohort, and the highest rate was in the cohort defined for the fourth quartile of the fragmentation measurement (eight or more HCPIs), 40.94 (95% CI, 36.49 to 45.39). The adjusted HR for 4-year OS was 1.04 (95% CI, 1.01 to 1.07) for each HCPI additional. The cost of care is increased for each additional HCPIs (cost ratio, 1.25; 95% CI, 1.23 to 1.26). CONCLUSION: Fragmentation of care decreases overall 4-year OS and increases the costs of care in women with breast cancer for Colombia.

Real-world management of hyperphosphataemia with sucroferric oxyhydroxide: the VELREAL multicentre study.

BACKGROUND: The efficacy and safety of sucroferric oxyhydroxide (SO) have been reported in clinical trials. However, real-life data are scarce. This study presents data on the use, efficacy and safety of SO in real clinical practice. METHODS: We performed a retrospective multicentre study, without any influence on the prescription decisions, that included 220 patients from 11 Spanish centres. Demographic, treatment, analytical and nutritional parameters and adherence, side effects and dropout rates were collected during 6 months. RESULTS: SO was initiated due to inadequate control of serum phosphate (P) in 70% of participants and in 24.5% to reduce the number of tablets. Monotherapy with SO increased from 44% to 74.1%, with a reduction in the average daily number of sachets/tablets from six to two. Serum P decreased by 20% (4.6 ± 1.2 versus 5.8 ± 1.3 mg/dL; P < 0.001), with a significant reduction in intact parathyroid hormone levels (P < 0.01). The percentage of patients with adequate serum P control at threshold levels of 5 and 4.5 mg/dL increased by 45.4% and 35.9%, respectively. Serum ferritin was not modified, while the transferrin saturation index increased significantly (P = 0.04). Serum albumin and normalized protein catabolic rate, when normalized by serum P, increased, averaging 37% and 39%, respectively (P < 0.001). Adherent patients increased from 28.2% to 52.7%. Adverse effects were reported by 14.1% of participants, with abandonment of treatment in 9.5%. CONCLUSIONS: The use of SO in real-life results in better control of serum P, a reduction in the number of tablets and an improvement in therapeutic adherence. In addition, it may be beneficial with regards to secondary hyperparathyroidism and nutritional status.

Ischemic stroke and purpuric dermatitis as COVID-19-related complications in a peritoneal dialysis patient.

Patients on dialysis may have an elevated risk of severe coronavirus disease 2019 (COVID-19) and its complications due to their high prevalence of comorbidities. Here we describe the case of an 80-year-old male undergoing peritoneal dialysis with a moderate SARS-CoV-2 infection who developed a purpuric dermatitis and ischemic stroke after successful recovery from his bilateral pneumonia. Erythemato-papular lesions affecting trunk and lower limbs appeared 17 days after the onset of SARS-CoV-2 symptoms. These kind of lesions are an infrequent cutaneous manifestation of COVID-19. The pathology revealed a moderate purpuric dermatitis affecting superficial dermis and corticoesteroids were prescribed achieving complete resolution. Arterial thrombosis affecting cerebellar vermis emerged 30 days after the onset of COVID-19 symptoms. It occurred 5 days after withdrawal of antithrombotic prophylaxis that the patient received from his admission until 2 weeks after discharge. He completely recovered from his paresis and continued on his regular antiaggregation therapy. This is the first case report published of a patient with PD with such COVID-19-related complications. More experience is needed to determine the appropriate length of antithrombotic prophylaxis especially in high-risk individuals.

ACV y covid-19: una revisión de los estudios observacionales publicados en época de pandemia / Stroke and COVID-19: A review of observational studies published during the pandemic

RESUMEN INTRODUCCIÓN: En marzo 2020 la Organización Mundial de la Salud decretó la pandemia por covid-19. Se han informado casos de ACV relacionados con esta infección viral. OBJETIVOS: Conocer la experiencia de diferentes partes del mundo respecto al ACV y covid-19 con el fin de mejorar el reconocimiento y saber qué hacer cuando se empiecen a presentar estos pacientes en nuestro medio. MÉTODOS: Se hizo una revisión de los estudios observacionales disponibles utilizando PubMed, Scopus, así como otras fuentes de literatura gris para las publicaciones sobre ACV y covid-19. Se identificaron datos demográficos, tiempo de aparición del ACV desde el diagnóstico de covid-19. Principales hallazgos radiológicos, laboratorios y pronóstico. RESULTADOS: Se obtuvieron ocho estudios, con 43 sujetos que tuvieron ACV isquémico e infección por SARS-CoV-2. La edad promedio fue de 67,4 años, siendo en su mayoría hombres (58,1%).Un hallazgo importante fue el número de casos de ACV con oclusión de vaso grande en 22 de 31 casos reportados (71%). La mediana de NIHSS fue de 14,5 puntos. Se presentó una mortalidad del 27,5% de los sujetos con ACV El estadio más frecuente por covid-19 fue el de condición severa 58,3%. La aparición del ACV luego de la infección por SARS-CoV-2 fue de 10,6 días en promedio. En los laboratorios se identificó una elevación del fibrinógeno (92%), dímero-D (76%) y LDH (82%) respectivamente. El tratamiento recibido de forma más frecuente para el ACV fue la antiagregación, en 51%, mientras que las terapias de reperfusión se hicieron en el 30% de los casos. La mayoría de los pacientes (93%) presentaron síntomas de covid-19, solo 3 pacientes (7%) no presentaron síntomas típicos de esta enfermedad, sin embargo tuvieron alteración del estado de conciencia asociado al ACV CONCLUSIÓN: Los estados de inflamación e hipercoagulabilidad que se presentan durante la infección por SARS-CoV-2 probablemente están en relación con el desarrollo de ACV, lo cual en este caso podrá explicar el gran número de oclusiones de vaso grande. Los marcadores de inflamación generalmente están presentes. Establecer códigos protegidos de ACV es una medida a efectuar en nuestro medio.

SUMMARY INTRODUCTION: In March 2020, COVID-19 was declared a pandemic by the World Health Organization and cases of stroke related to the virus soon were reported. OBJECTIVES: To become aware of the experiences different parts of the world have encountered with stroke and COVID 19 in order to enhance our knowledge, improve recognition and response to patients in our clinical setting. METHODS: A review of the available observational studies was done using PubMed, Scopus and other sources of gray literature for the publications on stroke and COVID-19. Demographic data, time of stroke onset since the diagnosis of COVID-19, main radiological findings, lab tests and prognosis were identified. RESULTS: Eight studies were selected with 43 subjects who had ischemic stroke and SARS-CoV-2 infection. The average age was 67.4 years, being mostly men (58%). An important finding was the number of stroke cases with large vessel occlusion, with 22 of 31 cases reported (71%). The NIHSS median was 14.5 points, and 27.5% of subjects with stroke and COVID-19 died. The most frequent disease severity for COVID-19 was "severe", accounting for 58% of the cases. The onset of stroke after SARS-CoV-2 infection was 10.6 days on average. In the laboratories an elevation of fibrinogen (92%), D-Dimer (76%) and LDH (82%) were respectively identified. The most frequent treatment received for stroke were antiplatelet medications (51%), while reperfusion therapy was done in 30% of cases. Most patients presented to the hospital with typical symptoms of COVID-19 (93%), (7%) 3 patients did not have respiratory symptoms, however they presented with a decreased level of consciousness associated with stroke findings. CONCLUSION: Inflammation and hypercoagulability, both present during the infection by SARS-CoV-2, are probably related to the development of a stroke, which in this case could explain the large number of large vessel occlusions. Protected stroke code is a protocol that should be implemented in our region.

Ictus isquémico asociado a COVID-19 en pacientes en diálisis / Ischaemic stroke associated with COVID-19 in dialysis patients

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