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Am J Nephrol ; 45(1): 14-21, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-27842302


BACKGROUND AND OBJECTIVES: Preemptive placement of permanent dialysis access is recommended in order to reduce the morbidity associated with central venous catheters. We assessed the effect of a dialysis access coordinator on preemptive access placement in veterans who are at high risk for end-stage renal disease (ESRD). DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Pre-post evaluation of a dialysis access coordinator in the nephrology clinics of the Veterans Affairs Palo Alto. The access coordinator streamlined access referrals, prioritized surgical waiting lists and addressed patient barriers. We compared the frequency of preemptive access referral, surgery, and use for dialysis during the intervention period, July 1, 2013 to May 31, 2016, to a pre-intervention period, January 1, 2011 to December 31, 2013, among all patients with a predicted 1-year risk for ESRD ≥20%. RESULTS: There were 156 patients in the historical cohort and 131 in the intervention cohort. The mean age was 69.9 ± 11.6 years and the mean estimated glomerular filtration rate was 14.5 ± 5.7 ml/min/1.73 m2. The intervention was associated with an 11.8% increase in access referral (p value = 0.03), and a 9.4% increase in completed access surgery (p value = 0.05). Increases in permanent access at the start of dialysis (15.2%), and functional permanent access at the start of dialysis (12.4%) did not reach statistical significance. Among patients who received access surgery, there was no significant difference in the prevalence of unused access. CONCLUSIONS: Implementation of an access coordinator was associated with a modest increase in preemptive access placement among patients who are at high risk for ESRD without increasing the prevalence of unused access.

Anastomose Cirúrgica , Falência Renal Crônica/terapia , Melhoria de Qualidade , Diálise Renal/métodos , Insuficiência Renal Crônica/terapia , Procedimentos Cirúrgicos Vasculares/organização & administração , Veteranos , Idoso , Idoso de 80 Anos ou mais , Artérias/cirurgia , Cateterismo , Cateterismo Venoso Central , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Diálise Peritoneal/métodos , Encaminhamento e Consulta , Procedimentos Cirúrgicos Operatórios , Veias/cirurgia
Curr Opin Nephrol Hypertens ; 15(2): 111-6, 2006 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-16481875


PURPOSE OF REVIEW: This review summarizes recent studies designed to identify improved treatments for diabetic nephropathy. RECENT FINDINGS: Recent data support the concept that angiotensin converting enzyme inhibitors and angiotensin II receptor blockers have similar renoprotective effects. Aggressive blockade of the renin-angiotensin system appears to have benefits beyond those achieved with conventional doses of single agents. Dual blockade using angiotensin converting enzyme inhibitors and angiotensin II receptor blockers is effective. Aldosterone receptor antagonists may potentiate the effect of these two classes of compounds. It remains unclear, however, whether maximum benefit can be obtained by the combination of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers or aldosterone receptor antagonists as compared to larger doses of single agents. Not enough data are available currently to recommend thiazolidinedione hypoglycemic agents for renal protection. Trials are being conducted with several new classes of agents. SUMMARY: Evidence from short-term studies favors aggressive blockade of the renin-angiotensin system. Long-term studies, however, remain to be performed. A multifactorial approach that incorporates established interventions affords our best means to retard the progression of diabetic nephropathy.

Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Bloqueadores dos Canais de Cálcio/uso terapêutico , Nefropatias Diabéticas/diagnóstico , Nefropatias Diabéticas/tratamento farmacológico , Diuréticos/uso terapêutico , Nefropatias Diabéticas/mortalidade , Quimioterapia Combinada , Feminino , Humanos , Testes de Função Renal , Masculino , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do Tratamento