Andreas Pierratos Tribute: Personal Reflections.

Since the passing of Andreas Pierratos on November 15, 2022, we have had many occasions to reflect on what our relationship with a friend and colleague has meant. We have done this in solitude, with colleagues while at work and more recently, in a tribute organized at Humber River Hospital on March 26, 2023. We also had the opportunity to expand, in the February 2023 issue of the Nephrology News & Issues, on his many contributions to nephrology and to the betterment of patients' lives. For this collaboration, we thought we would share our personal reflections of this unique individual, with the hope that this effort would provide a deeper appreciation of his unique humanity.

Nephrologists' Attitudes Regarding Psychosocial Care in Hemodialysis Units.

BACKGROUND: There is a high prevalence of psychosocial issues affecting patients with kidney failure. OBJECTIVE: We sought to examine Canadian nephrologists' attitudes and opinions regarding the importance of renal patient psychosocial care, nephrologists' roles, and experience with psychosocial care in addition to what barriers, if any, prevent these physicians from providing psychosocial care to their patients. DESIGN: A self-administered, survey questionnaire. SETTING: Online. SAMPLE: Canadian Society of Nephrology members who predominantly work in clinical care with adult, in-center hemodialysis patients. MEASUREMENTS: Measurements of the survey include demographics, training, and nephrologists' opinions regarding their role in administering psychosocial care, potential administrative and patient time constraints, accessibility of other health care workers for this activity, and factors that influence or impede physicians' ability to address their patients' psychosocial needs. METHODS: A self-administered survey was sent to almost 500 members of the Canadian Society of Nephrology between November 2018 and December 2018. The survey questionnaire was designed to gather opinions and attitudes on psychosocial care delivery as well as potential influencing factors on nephrologists' ability to provide this care. A univariate statistical analysis was used to analyze survey responses. RESULTS: A total of 30 nephrologists responded to the survey, generating a 6% response rate. Respondents varied across provinces, with the majority being staff nephrologists (80%). While over 94% of respondents either agreed or strongly agreed that focus on psychosocial care improves patient outcomes, only 43% felt that staff nephrologists were suited to provide this care to patients; 97% of respondents believed social workers to be the most suited to provide this. Lack of additional supporting health care members, the need for additional training, too many administrative duties, and empathy fatigue were some of the predominant barriers respondents felt prevented them from addressing the psychosocial care of their patients. LIMITATIONS: A low response rate for the survey was obtained, roughly 6%, limiting our ability to draw definitive conclusions. Survey answers by respondents may be different from those by nonrespondents. Answers may be subject to social desirability and/or selection bias. CONCLUSION: Nephrologists believe that the current psychosocial care of patients in hemodialysis units is inadequate. However, further research is necessary to elucidate the barriers nephrologists face in providing psychosocial care and the changes required to most effectively implement optimal psychosocial care for patients with kidney failure in hemodialysis units.

CONTEXTE: La prévalence des problèmes psychosociaux chez les patients atteints d'insuffisance rénale est élevée. OBJECTIFS: Nous souhaitions connaître les attitudes et opinions des néphrologues canadiens sur l'importance de prodiguer des soins psychosociaux aux patients atteints d'insuffisance rénale, sur leurs rôles et leur expérience en matière de soins psychosociaux et, le cas échéant, sur les obstacles qui les empêchent de prodiguer des soins psychosociaux à leurs patients. TYPE D'ÉTUDE: Un sondage auto-administré. CADRE: Sondage en ligne. ÉCHANTILLON: Les membres de la Société canadienne de néphrologie travaillant principalement dans les soins cliniques de patients adultes hémodialysés en centre hospitalier. MESURES: Le questionnaire permettait de recueillir les données démographiques, de l'information sur la formation, ainsi que l'avis des néphrologues sur leur rôle dans la prestation de soins psychosociaux, sur les possibles contraintes de temps du côté administratif et des patients, sur l'accessibilité des autres professionnels de la santé pour cette activité et sur les facteurs qui empêchent les médecins de répondre aux besoins psychosociaux de leurs patients. MÉTHODOLOGIE: Un sondage a été envoyé à près de 500 membres de la Société canadienne de néphrologie entre novembre 2018 et décembre 2018. Le questionnaire était conçu pour recueillir les attitudes et opinions des répondants sur la prestation des soins psychosociaux et sur les facteurs susceptibles de limiter la capacité des néphrologues à fournir ces soins. Une analyse statistique univariée a été employée pour analyser les réponses. RÉSULTATS: Seulement 30 néphrologues ont répondu au sondage, soit un taux de réponse de 6 %. Les répondants variaient selon les provinces; la majorité étant des néphrologues impliqués dans les soins aux patients (80 %). Bien qu'une très grande majorité des répondants (94 %) ait mentionné être d'accord ou fortement d'accord pour dire que les soins psychosociaux améliorent les résultats des patients, seulement 43 % ont estimé que les néphrologues étaient en mesure d'offrir ces soins aux patients; 97 % des répondants ont par ailleurs jugé que les travailleurs sociaux seraient mieux placés pour le faire. Le manque de personnel de soutien supplémentaire dans le secteur de la santé, la nécessité d'une formation supplémentaire, un trop grand nombre de tâches administratives et la fatigue liée à l'empathie sont quelques-uns des principaux obstacles nommés par les répondants comme des facteurs les ayant empêchés de prodiguer des soins psychosociaux à leurs patients. LIMITES: Le faible taux de réponse (environ 6 %) limite notre capacité à tirer des conclusions définitives. Les réponses offertes par les participants pourraient différer de celles des non-répondants. Les réponses sont sujettes à des biais dus à la désirabilité sociale ou à des biais de sélection. CONCLUSION: Les néphrologues estiment que les soins psychosociaux actuels pour les patients des unités d'hémodialyse sont insuffisants. D'autres recherches sont nécessaires pour mieux comprendre les obstacles auxquels font face les néphrologues dans la prestation de soins psychosociaux. Ces recherches pourraient également préciser les changements nécessaires pour mettre en œuvre le plus efficacement possible des soins psychosociaux optimaux pour les patients atteints d'insuffisance rénale dans les unités d'hémodialyse. ENREGISTREMENT DE L'ESSAI: Sans objet en raison de la nature de l'étude (il ne s'agit pas d'un essai clinique).

Development and utility of a multi-dimensional grid to assess individual mineral metabolism control in hemodialysis patients: A potential aid for therapeutic decision making?

A grid was developed to evaluate control of serum calcium, phosphate, and parathyroid hormone levels in hemodialysis patients, based on guideline recommendations (National Kidney Foundation Kidney Disease Outcomes Quality Initiative and Canadian Society of Nephrology), and its face validity was examined in a representative sample of Canadian patients. A retrospective chart review was undertaken in hemodialysis patients from 7 Canadian units. Patients >18 years, on hemodialysis for > or =12 months, and > or =3 parathyroid hormone levels measured > or =1 month apart were included. The grid classified mineral metabolism control as optimal, suboptimal, or poor (mean of 3 measurements). Medication use, hospitalization, and Emergency Department visits were evaluated in relation to grid occupancy. A second comparative analysis of grid occupancy was undertaken on prevalent hemodialysis cases in British Columbia in 2008. Data from 268 patients (mean age 62.3 years) were analyzed. Using National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines, 17.5%, 28.8%, and 53.7% of patients had optimal, suboptimal, and poor control, respectively, of all 3 parameters (calcium, phosphate, and parathyroid hormone). Using Canadian Society of Nephrology criteria, optimal, suboptimal, and poor control rates were 6.3%, 4.2%, and 89.5%, respectively. Poor control was a possible or a probable cause of hospitalization or Emergency Department attendance in 8 patients. Data from British Columbia in 2008 (n=1858) show optimal, suboptimal, and poor control rates of 15.8%, 24.5%, and 59.7%, respectively. Poor mineral metabolism control among Canadian hemodialysis patients is not showing improvement. The therapeutic grid is a valid tool and may help guide therapeutic decisions, quality control initiatives, and patient counseling. http://www.ukidney.com/bone-and-mineral-metabolism-resource.

The effects of discontinuing cinacalcet at the time of kidney transplantation.

Background. The calcimimetic, cinacalcet, is approved for treating secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD) on dialysis. Biochemical profiles and clinical outcomes in patients discontinuing cinacalcet at kidney transplantation have not been previously described.Methods. We performed a retrospective observational study evaluating post-transplant biochemical profiles and clinical outcomes in patients who had enrolled in phase 2 or 3 randomized, placebo-controlled studies of cinacalcet before receiving a kidney transplant.Results. The study included 28 former cinacalcet and 10 former placebo patients. Post-kidney transplant, there were no obvious differences between the two groups in levels of serum intact parathyroid hormone, calcium or phosphorus. One patient in each group underwent post-transplant parathyroidectomy. Kidney transplant failure was apparent in one former cinacalcet-treated patient (4%) and three former placebo patients (30%). The duration of hospitalization (mean +/- standard error) immediately post-transplant in these two groups was 2.3 +/- 0.3 and 3.4 +/- 0.8 weeks, respectively.Conclusions. Using cinacalcet to treat SHPT in patients with CKD awaiting kidney transplantation does not appear to modify SHPT-related post-transplant biochemical profiles, or clinical outcomes, compared with placebo.

Cinacalcet for secondary hyperparathyroidism in patients receiving hemodialysis.

BACKGROUND: Treatment of secondary hyperparathyroidism with vitamin D and calcium in patients receiving dialysis is often complicated by hypercalcemia and hyperphosphatemia, which may contribute to cardiovascular disease and adverse clinical outcomes. Calcimimetics target the calcium-sensing receptor and lower parathyroid hormone levels without increasing calcium and phosphorus levels. We report the results of two identical randomized, double-blind, placebo-controlled trials evaluating the safety and effectiveness of the calcimimetic agent cinacalcet hydrochloride. METHODS: Patients who were receiving hemodialysis and who had inadequately controlled secondary hyperparathyroidism despite standard treatment were randomly assigned to receive cinacalcet (371 patients) or placebo (370 patients) for 26 weeks. Once-daily doses were increased from 30 mg to 180 mg to achieve intact parathyroid hormone levels of 250 pg per milliliter or less. The primary end point was the percentage of patients with values in this range during a 14-week efficacy-assessment phase. RESULTS: Forty-three percent of the cinacalcet group reached the primary end point, as compared with 5 percent of the placebo group (P<0.001). Overall, mean parathyroid hormone values decreased 43 percent in those receiving cinacalcet but increased 9 percent in the placebo group (P<0.001). The serum calcium-phosphorus product declined by 15 percent in the cinacalcet group and remained unchanged in the placebo group (P<0.001). Cinacalcet effectively reduced parathyroid hormone levels independently of disease severity or changes in vitamin D sterol dose. CONCLUSIONS: Cinacalcet lowers parathyroid hormone levels and improves calcium-phosphorus homeostasis in patients receiving hemodialysis who have uncontrolled secondary hyperparathyroidism.