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1.
Clin J Am Soc Nephrol ; 15(3): 330-340, 2020 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-32111701

RESUMO

BACKGROUND AND OBJECTIVES: The dietary self-management of CKD is challenging. Telehealth interventions may provide an effective delivery method to facilitate sustained dietary change. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This pilot, randomized, controlled trial evaluated secondary and exploratory outcomes after a dietitian-led telehealth coaching intervention to improve diet quality in people with stage 3-4 CKD. The intervention group received phone calls every 2 weeks for 3 months (with concurrent, tailored text messages for 3 months), followed by 3 months of tailored text messages without telephone coaching, to encourage a diet consistent with CKD guidelines. The control group received usual care for 3 months, followed by nontailored, educational text messages for 3 months. RESULTS: Eighty participants (64% male), aged 62±12 years, were randomized to the intervention or control group. Telehealth coaching was safe, with no adverse events or changes to serum biochemistry at any time point. At 3 months, the telehealth intervention, compared with the control, had no detectable effect on overall diet quality on the Alternative Health Eating Index (3.2 points, 95% confidence interval, -1.3 to 7.7), nor at 6 months (0.5 points, 95% confidence interval, -4.6 to 5.5). There was no change in clinic BP at any time point in any group. There were significant improvements in several exploratory diet and clinical outcomes, including core food group consumption, vegetable servings, fiber intake, and body weight. CONCLUSIONS: Telehealth coaching was safe, but appeared to have no effect on the Alternative Healthy Eating Index or clinic BP. There were clinically significant changes in several exploratory diet and clinical outcomes, which require further investigation. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: Evaluation of Individualized Telehealth Intensive Coaching to Promote Healthy Eating and Lifestyle in CKD (ENTICE-CKD), ACTRN12616001212448.

2.
Artigo em Inglês | MEDLINE | ID: mdl-32031636

RESUMO

BACKGROUND: Home-based dialysis therapies, home hemodialysis (HHD) and peritoneal dialysis (PD) are underutilized in many countries and significant variation in the uptake of home dialysis exists across dialysis centers. This study aimed to evaluate the patient- and center-level characteristics associated with uptake of home dialysis. METHODS: The Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry was used to include incident dialysis patients in Australia and New Zealand from 1997 to 2017. Uptake of home dialysis was defined as any HHD or PD treatment reported to ANZDATA within 6 months of dialysis initiation. Characteristics associated with home dialysis uptake were evaluated using mixed effects logistic regression models with patient- and center-level covariates, era as a fixed effect and dialysis center as a random effect. RESULTS: Overall, 54 773 patients were included. Uptake of home-based dialysis was reported in 24 399 (45%) patients but varied between 0 and 87% across the 76 centers. Patient-level factors associated with lower uptake included male sex, ethnicity (particularly indigenous peoples), older age, presence of comorbidities, late referral to a nephrology service, remote residence and obesity. Center-level predictors of lower uptake included small center size, smaller proportion of patients with permanent access at dialysis initiation and lower weekly facility hemodialysis hours. The variation in odds of home dialysis uptake across centers increased by 3% after adjusting for the era and patient-level characteristics but decreased by 24% after adjusting for center-level characteristics. CONCLUSION: Center-specific factors are associated with the variation in uptake of home dialysis across centers in Australia and New Zealand.

3.
Perit Dial Int ; 40(1): 12-25, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32063150

RESUMO

BACKGROUND: Recognition of the discrepancy between the research priorities of patients and health professionals has prompted efforts to involve patients as active contributors in research activities, including scientific conferences. However, there is limited evidence about the experience, challenges, and impacts of patient involvement to inform best practice. This study aims to describe patient and health professional perspectives on patient involvement at the Congress of the International Society for Peritoneal Dialysis (ISPD). METHODS: Semi-structured interviews were conducted with 14 patients/caregivers and 15 health professionals from six countries who attended ISPD. Interviews were recorded and transcribed verbatim, and transcripts were analyzed thematically. RESULTS: We identified four themes: protecting and enhancing scientific learning (grounding science in stories, sharing and inspiring new perspectives, distilling the key messages of research presentations, striking a balance between accommodating patients and presenting the science); democratizing access to research (redistributing power, challenging the traditional ownership of knowledge, cultivating self-management through demystifying research); inadequate support for patient/caregiver delegates (lacking purposeful inclusion, challenges in interpreting research findings, soliciting medical advice, difficulty negotiating venue and program, limited financial assistance in attending); and amplifying impact beyond the room (sparking innovation in practice, giving patients and families hope for the future). CONCLUSIONS: Patient involvement at the ISPD Congress clarified the applicability of research to patient care and self-management, democratized science, and strengthened the potential impact of research. More structured support for patients to help them purposefully articulate their experience in relation to session objectives may enhance their contribution and their own learning experience.

4.
Perit Dial Int ; 40(1): 47-56, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32063153

RESUMO

BACKGROUND: The outcomes of culture-negative peritonitis in peritoneal dialysis (PD) patients have been reported to be superior to those of culture-positive peritonitis. The current study aimed to examine whether this observation also applied to different subtypes of culture-positive peritonitis. METHODS: This multicentre registry study included all episodes of peritonitis in adult PD patients in Australia between 2004 and 2014. The primary outcome was medical cure. Secondary outcomes were catheter removal, hemodialysis transfer, relapsing/recurrent peritonitis and peritonitis-related death. These outcomes were analyzed using mixed effects logistic regression. RESULTS: Overall, 11,122 episodes of peritonitis occurring in 5367 patients were included. A total of 1760 (16%) episodes were culture-negative, of which 77% were medically cured. Compared with culture-negative peritonitis, the odds of medical cure were lower in peritonitis caused by Staphylococcus aureus (adjusted odds ratio (OR) 0.62, 95% confidence interval (CI) 0.52-0.73), Pseudomonas species (OR 0.20, 95% CI 0.16-0.26), other gram-negative organisms (OR 0.48, 95% CI 0.41-0.56), polymicrobial organisms (OR 0.30, 95% CI 0.25-0.35), fungi (OR 0.02, 95% CI 0.01-0.03), and other organisms (OR 0.61, 95% CI 0.49-0.76), while the odds were similar in other (non-staphylococcal) gram-positive organisms (OR 1.11, 95% CI 0.97-1.28). Similar results were observed for catheter removal and hemodialysis transfer. Compared with culture-negative peritonitis, peritonitis-related mortality was significantly higher in culture-positive peritonitis except that due to other gram-positive organisms. There was no difference in the odds of relapsing/recurrent peritonitis between culture-negative and culture-positive peritonitis. CONCLUSION: Culture-negative peritonitis had superior outcomes compared to culture-positive peritonitis except for non-staphylococcal gram-positive peritonitis.

5.
Clin J Am Soc Nephrol ; 15(3): 392-400, 2020 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-32075809

RESUMO

BACKGROUND AND OBJECTIVES: Survival in pediatric kidney transplant recipients has improved over the past five decades, but changes in cause-specific mortality remain uncertain. The aim of this retrospective cohort study was to estimate the associations between transplant era and overall and cause-specific mortality for child and adolescent recipients of kidney transplants. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Data were obtained on all children and adolescents (aged <20 years) who received their first kidney transplant from 1970 to 2015 from the Australian and New Zealand Dialysis and Transplant Registry. Mortality rates were compared across eras using Cox regression, adjusted for confounders. RESULTS: A total of 1810 recipients (median age at transplantation 14 years, 58% male, 52% living donor) were followed for a median of 13.4 years. Of these, 431 (24%) died, 174 (40%) from cardiovascular causes, 74 (17%) from infection, 50 (12%) from cancer, and 133 (31%) from other causes. Survival rates improved over time, with 5-year survival rising from 85% for those first transplanted in 1970-1985 (95% confidence interval [95% CI], 81% to 88%) to 99% in 2005-2015 (95% CI, 98% to 100%). This was primarily because of reductions in deaths from cardiovascular causes (adjusted hazard ratio [aHR], 0.25; 95% CI, 0.08 to 0.68) and infections (aHR, 0.16; 95% CI, 0.04 to 0.70; both for 2005-2015 compared with 1970-1985). Compared with patients transplanted 1970-1985, mortality risk was 72% lower among those transplanted 2005-2015 (aHR, 0.28; 95% CI, 0.18 to 0.69), after adjusting for potential confounders. CONCLUSIONS: Survival after pediatric kidney transplantation has improved considerably over the past four decades, predominantly because of marked reductions in cardiovascular- and infection-related deaths.

8.
Perit Dial Int ; 40(2): 153-163, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32063194

RESUMO

BACKGROUND: There is substantial variation in peritonitis rates across peritoneal dialysis (PD) units globally. This may, in part, be related to the wide variability in the content and delivery of training for PD nurse trainers and patients. AIM: The aim of this study was to test the feasibility of implementing the Targeted Education ApproaCH to improve Peritoneal Dialysis Outcomes (TEACH-PD) curriculum in real clinical practice settings. METHODS: This study used mixed methods including questionnaires and semi-structured interviews (pretraining and post-training) with nurse trainers and patients to test the acceptability and usability of the PD training modules implemented in two PD units over 6 months. Quantitative data from the questionnaires were analysed descriptively. Interviews were analysed using thematic analysis. RESULTS: Ten PD trainers and 14 incident PD patients were included. Mean training duration to complete the modules were 10.9 h (range 6-17) and 24.9 h (range 15-35), for PD trainers and patients, respectively. None of the PD patients experienced PD-related complications at 30 days follow-up. Three (21%) patients were transferred to haemodialysis due to non-PD-related complications. Ten trainers and 14 PD patients participated in the interviews. Four themes were identified including use of adult learning principles (trainers), comprehension of online modules (trainers), time to complete the modules (trainers) and patient usability of the manuals (patient). CONCLUSION: This TEACH-PD study has demonstrated feasibility of implementation in a real clinical setting. The outcomes of this study have informed refinement of the TEACH-PD modules prior to rigorous evaluation of its efficacy and cost-effectiveness in a large-scale study.

9.
Perit Dial Int ; 40(2): 132-140, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32063197

RESUMO

BACKGROUND: Peritoneal dialysis (PD)-associated peritonitis carries significant morbidity, mortality, and is a leading cause of PD technique failure. This study aimed to assess the scope and variability of PD-associated peritonitis reported in randomized trials and observational studies. METHODS: Cochrane Controlled Register of Trials, MEDLINE, and Embase were searched from 2007 to June 2018 for randomized trials and observational studies in adult and pediatric patients on PD that reported PD-associated peritonitis as a primary outcome or as a part of composite primary outcome. We assessed the peritonitis definitions used, characteristics of peritonitis, and outcome reporting and analysis. RESULTS: Seventy-seven studies were included, three were randomized trials. Thirty-eight (49%) of the included studies were registry-based observational studies. Twenty-nine percent (n = 22) of the studies did not specify how PD-associated peritonitis was defined. Among those providing a definition of peritonitis, three components were reported: effluent cell count (n = 42, 54%), clinical features consistent with peritonitis (e.g. abdominal pain and/or cloudy dialysis effluent) (n = 35, 45%), and positive effluent culture (n = 19, 25%). Of those components, 1 was required to make the diagnosis in 6 studies (8%), 2 out of 2 were required in 22 studies (29%), 2 out of 3 in 11 studies (14%), and 3 out of 3 in 4 studies (5%). Peritonitis characteristics and outcomes reported across studies included culture-negative peritonitis (n = 47, 61%), refractory peritonitis (n = 42, 55%), repeat peritonitis (n = 9, 12%), relapsing peritonitis (n = 5, 7%), concomitant exit site (n = 16, 21%), and tunnel infections (n = 8, 10%). Peritonitis-related hospitalization was reported in 38% of the studies (n = 29), and peritonitis-related mortality was variably defined and reported in 55% of the studies (n = 42). Peritonitis rate was most frequently reported as episodes per patient year (n = 40, 52%). CONCLUSION: Large variability exists in the definitions, methods of reporting, and analysis of PD-associated peritonitis across trials and observational studies. Standardizing definitions for reporting of peritonitis and associated outcomes will better enable assessment of the comparative effect of interventions on peritonitis. This will facilitate continuous quality improvement measures through reliable benchmarking of this patient-important outcome across centers and countries.

10.
Perit Dial Int ; 40(2): 209-219, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32063201

RESUMO

BACKGROUND: Icodextrin is a high molecular weight, starch-derived glucose polymer that is used as an osmotic agent in peritoneal dialysis (PD) to promote ultrafiltration. There has been wide variation in its use across Australia and the rest of the world, but it is unclear whether these differences are due to patient- or centre-related factors. METHODS: Using the Australia and New Zealand Dialysis and Transplant Registry, all adult patients (>18 years) who started PD in Australia between 1 January 2007 and 31 December 2014 were included. The primary outcome was icodextrin use at PD commencement. Hierarchical logistic regression clustered around the treatment centre was applied to determine the patient- and centre-related characteristics associated with icodextrin use. The impact of centre-level practice pattern variability on icodextrin uptake was estimated using the intra-cluster correlation coefficient (ICC). RESULTS: Of 5948 patients starting on PD in 58 centres during the study period, 2002 (33.7%) received icodextrin from the outset. Overall uptake of icodextrin increased from 29% in 2010 to 42.5% in 2014. Patient-level characteristics associated with an increased likelihood of commencing PD with icodextrin included male sex (adjusted odds ratio (OR) 1.55, 95% confidence interval (CI) 1.35-1.77; p < 0.001), prior haemodialysis or kidney transplantation (OR 1.26, 95% CI 1.09-1.47), obesity (OR 1.66, 95% CI 1.41-1.96), diabetes mellitus (OR 2.32, 95% CI 2.03-2.64) and residing in a postcode with the highest decile of socio-economic status (OR 1.43, 95% CI 1.11-1.85). The centre-level characteristic associated with an increased likelihood of commencing PD with icodextrin was routine assessment of a peritoneal equilibration test (OR 1.45, 95% CI 1.27-1.66). Centres with fewer patients on automated peritoneal dialysis (APD) were less likely to start on icodextrin (APD proportion <57%; OR 0.45, 95% CI 0.20-0.99). Centre factors accounted for 25% of the variation in icodextrin use solution among incident PD patients (ICC 0.25). CONCLUSIONS: Icodextrin use in incident Australian PD patients is increasing variable and associated with both patient and centre characteristics. Centre-related factors explained 25% of variability in icodextrin use.

12.
Acad Emerg Med ; 27(3): 217-227, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31894606

RESUMO

BACKGROUND: The risk of respiratory depression is increased when opioids are added to sedative agents. In our recent multicenter emergency department (ED) procedural sedation cohort, we reported a strong association between preprocedural opioids and sedation-related adverse events. We sought to examine the association between timing of opioids and the incidence of adverse sedation outcomes. METHODS: We conducted a secondary analysis of a prospective cohort of children aged 0 to 18 years who received sedation for a painful procedure in six Canadian pediatric EDs from July 2010 to February 2015. The primary risk factor was timing of opioid administration, adjusted for age, opioid type, preprocedural and sedation medications, and procedure type. Outcomes were 1) oxygen desaturation, 2) vomiting, and 3) positive pressure ventilation (PPV). RESULTS: Of the 6,295 children in the original cohort, 1,806 (29%) received a preprocedural opioid. Patients receiving preprocedural opioids had a higher incidence of oxygen desaturation (risk difference = 4.3%, 95% confidence interval [CI] = 2.9% to 5.8%), vomiting (risk difference 2.0%, 95% CI = 0.7% to 3.3%), and PPV (risk difference = 1.5%, 95% CI = 0.7% to 2.3%). Multivariable regression with timing of opioids modeled as a restricted cubic spline revealed the risk for each outcome was highest when opioids were administered in the 30 minutes prior to sedation. Timing of opioid administration was statistically significantly associated with oxygen desaturation and vomiting (p < 0.0001) but not with PPV (p = 0.113). CONCLUSIONS: Timing of opioids was significantly associated with the risk of oxygen desaturation and vomiting. Being aware of this increased risk will help clinicians prepare for sedation and the potential need for patient rescue.

13.
BMJ Open ; 10(1): e032626, 2020 Jan 20.
Artigo em Inglês | MEDLINE | ID: mdl-31964667

RESUMO

OBJECTIVE: To review the evidence to assess effectiveness of vitamin D supplementation during pregnancy and associations of serum vitamin D levels with perinatal outcomes. DESIGN: Overview of systematic reviews (SRs). DATA SOURCES: Searches conducted in January 2019: Ovid Medline (1946-), Cochrane Library databases. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Two reviewers independently screened titles and abstracts, and full texts using predefined inclusion criteria: SRs evaluating vitamin D supplementation in pregnant women and/or examining the association between serum vitamin D levels reporting at least one predefined perinatal outcome. Only SRs with high AMSTAR scores were analysed. DATA EXTRACTION AND SYNTHESIS: Data were extracted independently by one reviewer and checked by a second. Results were assessed for quality independently by two reviewers using GRADE criteria. RESULTS: Thirteen SRs were included, synthesising evidence from 204 unique primary studies. SRs of randomised controlled trials (RCTs) with the highest level of evidence showed no significant benefit from vitamin D in terms of preterm birth (RR 1.00 (95% CI 0.77, 1.30); high quality), pre-eclampsia (RR 0.91 (0.45, 1.86); low quality), gestational diabetes (RR 0.65 (0.39, 1.08); very low quality), stillbirth (RR 0.75 (0.50, 1.12); high quality), low birth weight (RR 0.74 (0.47, 1.16); low quality), caesarean section (RR 1.02 (0.93, 1.12); high quality). A significant difference was found for small for gestational age (RR 0.72 (0.52, 0.99); low quality). SRs of observational studies showed associations between vitamin D levels and preterm birth (RR 1.19 (1.08, 1.31); moderate quality), pre-eclampsia (RR 1.57 (1.21, 2.03) for 25-hydroxy vitamin D (25 (OH)D)<50 nmol/L subgroup; low quality), gestational diabetes (RR 1.12 (1.02, 1.22) for 25 (OH)D<50 nmol/L and RR 1.09 (1.03, 1.15)<75 nmol/L; moderate quality) and small for gestational age (RR 1.35 (1.18, 1.54)<50 nmol/L; low quality). SRs showed mixed results for associations between vitamin D and low birth weight (very low quality) and caesarean section (very low quality). CONCLUSION: There is some evidence from SRs of observational studies for associations between vitamin D serum levels and some outcomes; however SRs examining effectiveness from RCTs showed no effect of vitamin D supplementation in pregnancy with the exception of one predefined outcome, which had low quality evidence. Credibility of the evidence in this field is compromised by study limitations (in particular, the possibility of confounding among observational studies), inconsistency, imprecision and potential for reporting and publication biases.

14.
Blood Purif ; : 1-11, 2020 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-31968346

RESUMO

BACKGROUND: A new class of dialysis membrane, the mid cut-off (MCO) dialyzer, has been developed to improve the clearance of uremic toxins in hemodialysis (HD). The a tRial Evaluating Mid cut-Off Value membrane clearance of Albumin and Light chains in HemoDialysis patients (REMOVAL-HD) study aimed to determine if regular use of MCO dialyzer was safe and specifically did not result in a significant loss of albumin. METHODS: This investigator initiated, crossover, longitudinal, device study was conducted across 9 centers in Australia and New Zealand (n = 89). Participants had a 4-week wash-in with high-flux HD, followed by 24-week intervention with MCO HD and a subsequent 4-week wash-out with high-flux HD. The primary outcome was change in serum albumin between weeks 4 and 28. Secondary outcomes included trends in serum albumin, changes in kappa- and lambda-free light chains (FLC), 6-min walk test (6MWT), malnutrition inflammation score (MIS), restless legs score and quality of life. RESULTS: Participants had a mean age of 66 ± 14 years, 62% were men, 45% were anuric, and 51% had -diabetes. There was no reduction in serum albumin following treatment with MCO HD (mean reduction -0.7 g/L, 95% CI -1.5 to 0.1). A sustained, unexplained reduction in serum albumin (>25%) was not observed in any participant. A reduction in FLC was observed 2 weeks into MCO HD (lambda-FLC: Δ -9.1 mg/L, 95% CI -14.4 to -3.7; kappa-FLC: Δ -5.7 mg/L, 95% CI -9.8 to -1.6) and was sustained for the rest of the study intervention. Both FLC increased after the cessation of MCO use. There was no improvement in restless legs symptoms, quality of life, 6MWT or MIS scores. CONCLUSIONS: Regular HD using the MCO dialyzer did not result in a significant fall in serum albumin. There were no effects on quality of life, functional status or nutrition. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry Number (ANZCTRN) 12616000804482.

15.
Am J Kidney Dis ; 2020 Jan 10.
Artigo em Inglês | MEDLINE | ID: mdl-31932094

RESUMO

RATIONALE & OBJECTIVE: Peritoneal dialysis (PD)-related peritonitis carries high morbidity for PD patients. Understanding the characteristics and risk factors for peritonitis can guide regional development of prevention strategies. We describe peritonitis rates and the associations of selected facility practices with peritonitis risk among countries participating in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS). STUDY DESIGN: Observational prospective cohort study. SETTING & PARTICIPANTS: 7,051 adult PD patients in 209 facilities across 7 countries (Australia, New Zealand, Canada, Japan, Thailand, United Kingdom, United States). EXPOSURES: Facility characteristics (census count, facility age, nurse to patient ratio) and selected facility practices (use of automated PD, use of icodextrin or biocompatible PD solutions, antibiotic prophylaxis strategies, duration of PD training). OUTCOMES: Peritonitis rate (by country, overall and variation across facilities), microbiology patterns. ANALYTICAL APPROACH: Poisson rate estimation, proportional rate models adjusted for selected patient case-mix variables. RESULTS: 2,272 peritonitis episodes were identified in 7,051 patients (crude rate, 0.28 episodes/patient-year). Facility peritonitis rates were variable within each country and exceeded 0.50/patient-year in 10% of facilities. Overall peritonitis rates, in episodes per patient-year, were 0.40 (95% CI, 0.36-0.46) in Thailand, 0.38 (95% CI, 0.32-0.46) in the United Kingdom, 0.35 (95% CI, 0.30-0.40) in Australia/New Zealand, 0.29 (95% CI, 0.26-0.32) in Canada, 0.27 (95% CI, 0.25-0.30) in Japan, and 0.26 (95% CI, 0.24-0.27) in the United States. The microbiology of peritonitis was similar across countries, except in Thailand, where Gram-negative infections and culture-negative peritonitis were more common. Facility size was positively associated with risk for peritonitis in Japan (rate ratio [RR] per 10 patients, 1.07; 95% CI, 1.04-1.09). Lower peritonitis risk was observed in facilities that had higher automated PD use (RR per 10 percentage points greater, 0.95; 95% CI, 0.91-1.00), facilities that used antibiotics at catheter insertion (RR, 0.83; 95% CI, 0.69-0.99), and facilities with PD training duration of 6 or more (vs <6) days (RR, 0.81; 95% CI, 0.68-0.96). Lower peritonitis risk was seen in facilities that used topical exit-site mupirocin or aminoglycoside ointment, but this association did not achieve conventional levels of statistical significance (RR, 0.79; 95% CI, 0.62-1.01). LIMITATIONS: Sampling variation, selection bias (rate estimates), and residual confounding (associations). CONCLUSIONS: Important international differences exist in the risk for peritonitis that may result from varied and potentially modifiable treatment practices. These findings may inform future guidelines in potentially setting lower maximally acceptable peritonitis rates.

16.
Am J Kidney Dis ; 75(3): 404-412, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31955922

RESUMO

Outcomes reported in randomized controlled trials in peritoneal dialysis (PD) are diverse, are measured inconsistently, and may not be important to patients, families, and clinicians. The Standardized Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD) initiative aims to establish a core outcome set for trials in PD based on the shared priorities of all stakeholders. We convened an international SONG-PD stakeholder consensus workshop in May 2018 in Vancouver, Canada. Nineteen patients/caregivers and 51 health professionals attended. Participants discussed core outcome domains and implementation in trials in PD. Four themes relating to the formation of core outcome domains were identified: life participation as a main goal of PD, impact of fatigue, empowerment for preparation and planning, and separation of contributing factors from core factors. Considerations for implementation were identified: standardizing patient-reported outcomes, requiring a validated and feasible measure, simplicity of binary outcomes, responsiveness to interventions, and using positive terminology. All stakeholders supported inclusion of PD-related infection, cardiovascular disease, mortality, technique survival, and life participation as the core outcome domains for PD.

17.
Am J Kidney Dis ; 75(3): 361-372, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31515137

RESUMO

RATIONALE & OBJECTIVE: Clinical practice guidelines for dietary intake in hemodialysis focus on individual nutrients. Little is known about associations of dietary patterns with survival. We evaluated the associations of dietary patterns with cardiovascular and all-cause mortality among adults treated by hemodialysis. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 8,110 of 9,757 consecutive adults on hemodialysis (January 2014 to June 2017) treated in a multinational private dialysis network and with analyzable dietary data. EXPOSURES: Data-driven dietary patterns based on the GA2LEN food frequency questionnaire. Participants received a score for each identified pattern, with higher scores indicating closer resemblance of their diet to the identified pattern. Quartiles of standardized pattern scores were used as primary exposures. OUTCOMES: Cardiovascular and all-cause mortality. ANALYTICAL APPROACH: Principal components analysis with varimax rotation to identify common dietary patterns. Adjusted proportional hazards regression analyses with country as a random effect to estimate the associations between dietary pattern scores and mortality. Associations were expressed as adjusted HRs with 95% CIs, using the lowest quartile score as reference. RESULTS: During a median follow-up of 2.7 years (18,666 person-years), there were 2,087 deaths (958 cardiovascular). 2 dietary patterns, "fruit and vegetable" and "Western," were identified. For the fruit and vegetable dietary pattern score, adjusted HRs, in ascending quartiles, were 0.94 (95% CI, 0.76-1.15), 0.83 (95% CI, 0.66-1.06), and 0.91 (95% CI, 0.69-1.21) for cardiovascular mortality and 0.95 (95% CI, 0.83-1.09), 0.84 (95% CI, 0.71-0.99), and 0.87 (95% CI, 0.72-1.05) for all-cause mortality. For the Western dietary pattern score, the corresponding estimates were 1.10 (95% CI, 0.90-1.35), 1.11 (95% CI, 0.87-1.41), and 1.09 (95% CI, 0.80-1.49) for cardiovascular mortality and 1.01 (95% CI, 0.88-1.16), 1.00 (95% CI, 0.85-1.18), and 1.14 (95% CI, 0.93-1.41) for all-cause mortality. LIMITATIONS: Self-reported food frequency questionnaire, data-driven approach. CONCLUSIONS: These findings did not confirm an association between mortality among patients receiving long-term hemodialysis and the extent to which dietary patterns were either high in fruit and vegetables or consistent with a Western diet.

18.
Biochem Biophys Res Commun ; 522(3): 736-742, 2020 Feb 12.
Artigo em Inglês | MEDLINE | ID: mdl-31787234

RESUMO

There is an increasing interest in studying the crosstalk between tumor-associated adipose tissue and tumor progression. In proximity to the primary site of kidney tumors, perinephric adipose tissue has direct contact with cancer cells when kidney cancer becomes invasive. To mimic the perinephric adipose tissue microenvironment, we applied the liquid overlay-based technique, which cost-effectively generated functional adipocyte spheroids using mesenchymal stem cells isolated from human perinephric adipose tissue. Thereafter, we co-cultured adipocyte spheroids with unpolarized macrophages and discovered an M2 phenotype skew in macrophages. Moreover, we discovered that, in the presence of adipocyte spheroids, M2 macrophages exhibited stronger invasive capacity than M1 macrophages. We further showed that the perinephric adipose tissue sampled from metastatic kidney cancer exhibited high expression of M2 macrophages. In conclusion, the liquid overlay-based technique can generate a novel three-dimensional platform enabling investigation of the interactions of adipocytes and other types of cells in a tumor microenvironment.

19.
Nephrology (Carlton) ; 25(1): 63-72, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30838737

RESUMO

BACKGROUND: The use of haemodiafiltration (HDF) for the management of patients with end-stage kidney failure is increasing worldwide. Factors associated with HDF use have not been studied and may vary in different countries and jurisdictions. The aim of this study was to document the pattern of increase and variability in uptake of HDF in Australia and New Zealand, and to describe patient- and centre-related factors associated with its use. METHODS: Using the Australian and New Zealand Dialysis and Transplant Registry, all incident patients commencing haemodialysis (HD) between 2000 and 2014 were included. The primary outcome was HDF commencement over time, which was evaluated using multivariable logistic regression stratified by country. RESULTS: Of 27 433 patients starting HD, 3339 (14.4%) of 23 194 patients in Australia and 810 (19.1%) of 4239 in New Zealand received HDF. HDF uptake increased over time in both countries but was more rapid in New Zealand than Australia. In Australia, HDF use was more likely in males (odds ratio (OR) 1.13, 95% confidence interval (CI) = 1.03-1.24, P = 0.009) and less likely with older age (reference <40 years; 40-54 years OR = 0.85; 95% CI = 0.72-0.99; 55-69 years OR = 0.79; 95% CI = 0.67-0.91; >70 years OR = 0.48; 95% CI = 0.41-0.56); higher body mass index (body mass index (BMI) < 18.5 kg/m2 OR = 0.62; 95% CI = 0.46-0.84; 18.5-29.9 kg/m2 reference; >30 kg/m2 OR = 1.46; 95% CI = 1.33-1.61), chronic lung disease (OR = 0.84; 95% CI = 0.76-0.94; P < 0.001), cerebrovascular disease (OR = 0.76; 95% CI = 0.67-0.85; P < 0.001) and peripheral vascular disease (OR = 0.77; 95% CI = 0.70-0.85; P < 0.001). No association was identified with race. In New Zealand, HDF use was more likely in Maori and Pacific Islanders (OR = 1.32; 95% CI = 1.05-1.66) and Asians (OR = 1.75; 95% CI = 1.15-2.68) compared to Caucasians, and less likely in males (OR = 0.76; 95% CI = 0.62-0.94; P = 0.01). No association was identified with BMI or co-morbidities. In both countries, centres with a higher ratio of HD to peritoneal dialysis (PD) were more likely to prescribe HDF. Larger Australian centres were more likely to prescribe HDF (36-147 new patients/year OR = 26.75, 95% CI = 18.54-38.59; 17-35/year OR = 7.51, 95% CI = 5.35-10.55; 7-16/year OR = 3.00; 95% CI = 2.19-4.13; ≤6/year reference). CONCLUSION: Haemodiafiltration uptake is increasing, variable and associated with both patient and centre characteristics. Centre characteristics not explicitly captured elsewhere explained 36% of variability in HDF uptake in Australia and 48% in New Zealand.

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