Historia y desarrollo de las técnicas continuas de reemplazo renal (TCRR): el papel realizado por la enfermería / History and development of continuous renal replacement therapy (CRRT): the role of nursing

Objetivo: Conocer la historia de las técnicas continuas de reemplazo renal (TCRR), y el papel de la enfermería, desde su descubrimiento hasta su evolución técnica, y desde su uso temprano en el tratamiento de la insuficiencia renal aguda hasta las actuales terapias extracorpóreas secuenciales y su aplicación en cuidados intensivos (UCI). Metodología: Se han utilizado diversas fuentes documentales procedentes de libros y literatura científica relacionada con nuestro tema. Resultados principales: La historia de cómo se comenzó a conocer el funcionamiento del sistema renal y sus patologías, está ligada a la propia historia del hombre que abarca desde las primeras civilizaciones hasta nuestros días. Una sucesión gradual de descubrimientos e inventos, llegarán a sentar las bases de lo que será la futura diálisis. Pero no será hasta 1977 cuando la hemodiálisis se introdujo en UCI como terapia continua. La vinculación de la enfermera, desde los inicios de la diálisis y de la TCRR ha sido esencial para la implementación y desarrollo de esta técnica. Conclusión principal: Los progresivos avances científicos y tecnológicos han dado lugar a que las TCRR sean una de las técnicas más utilizadas y seguras realizadas en cuidados intensivos, donde la enfermera, desde sus inicios, juega un papel fundamental en la implementación de esta técnica (AU)

Objective: To know the history of continuous renal replacement techniques (CRRT), and the role of nursing, from its discovery to its technical evolution, and from its early use in the treatment of acute renal failure to current sequential extracorporeal therapies and their application in intensive care (ICU). Methodology: Various documentary sources from books and scientific literature related to our subject have been used. Main results: The history of how the functioning of the renal system and its pathologies began to be known is linked to the history of man itself, from the first civilisations to the present day. A gradual succession of discoveries and inventions laid the foundations for the future of dialysis. But it was not until 1977 that haemodialysis was introduced in the ICU as a continuous therapy. The involvement of the nurse, from the beginning of dialysis and CRRT, has been essential for the implementation and development of this technique. Main conclusion: Progressive scientific and technological advances have led to CRRT being one of the most widely used and safest techniques performed in intensive care, with the nurse playing a fundamental role in the implementation of this technique from its beginnings (AU)

Intervenciones enfermeras en las técnicas de depuración extrarrenal continuas con citrato en una unidad de cuidados intensivos / Nursing interventions in continuous extra-renal depuration techniques with citrate in an Intensive Care Unit

Objetivo: describir la utilización de filtros en la terapia de hemodiafiltración venovenosa continua (HDFVCC) durante el primer año de uso de citrato como anticoagulante en la unidad de cuidados intensivos (UCI) del Hospital Clínic de Barcelona, así como las intervenciones enfermeras y la generación de alarmas asociadas a esta terapia.Método: se realizó un estudio descriptivo transversal de serie de casos (dic 2016- dic 2017) con un componente longitudinal -para el análisis de las intervenciones enfermeras y las alarmas-. Se incluyó a mayores de 18 años ingresados en cuidados intensivos que precisaron HDFVVC con citrato. A través de la historia clínica y observación directa se recogieron variables relacionadas con el paciente, la terapia, las alarmas e intervenciones asociadas. Se realizaron índices de estadística descriptiva y análisis bivariantes.Resultados: se incluyeron 17 pacientes que utilizaron 38 filtros en total. El tiempo mediano de duración de la HDFVVC fue de cinco días y el de cada filtro de 52 horas. El motivo más habitual de cambio de filtro fue la coagulación (34%). Se efectuaron un total de 2,9 intervenciones enfermeras por hora (el 70% específicas de la terapia). Se observó una tendencia decreciente, no significativa estadísticamente, de las intervenciones y las alarmas en los tres primeros días.Conclusión: la anticoagulación con citrato en la HDFVVC se asocia con frecuentes intervenciones enfermeras, así como con un aumento de la vida media del filtro. Teniendo en cuenta además la reducción del riesgo hemorrágico, los beneficios del tratamiento globalmente parecen superar sus inconvenientes desde el punto de vista de intervenciones de Enfermería.(AU)

Objective: to describe the use of filters in continuous venovenous hemodiafiltration therapy (CVVHDF) during the first year of use of citrate as anticoagulant in the Intensive Care Unit (ICU) of the Hospital Clínic of Barcelona, as well as nursing interventions and generation of alarms associated to this therapy.Method: a cross-sectional descriptive study was conducted on a series of cases (December, 2016 to December, 2017), with a longitudinal component for the analysis of nursing interventions and alarms. The study included >18-year-old patients hospitalized in Intensive Care who required CVVHDF with citrate. Through clinical records and direct observation, there was a collection of patient and therapy-related variables, as well as of the alarms and the interventions associated. Descriptive statistics indexes were conducted, as well as bivariate analysis.Results: seventeen (17) patients were included, using 38 filters in total. The median time of CVVHDF duration was five days, and 52 hours for each filter. The most common reason for change of filter was coagulation (34%). In total, 2.9 nursing interventions were conducted per hour (70% were specific for the therapy). A decreasing tendency was observed, not statistically significant, for interventions and alarms during the first three days.Conclusion: anticoagulation with citrate in CVVHDF was associated with frequent nursing interventions, as well as with an increase in the half-life of the filter. Taking also into account the reduction in risk of hemorrhage, the benefits of the treatment overall seem to overcome its drawbacks from the point of view of nursing interventions.(AU)

Use of Electronic Patient-Reported Outcomes in the Care of Patients with Kidney Failure.

This article in the "Exploring the Evidence" series provides nephrology nurses and clinicians with a description of what electronic patient-reported outcomes (ePROs) and patient-reported outcome measures (PROMs) entail, as well as an understanding of how they can be used in nephrology patient care. Specifically highlighted are some questions and issues that clinicians have raised in our various research studies that have explored ePRO use and integration in the movement toward person-centered kidney care (Schick-Makaroff, 2017; Schick-Makaroff and Molzahn, 2014, 2015, 2017; Schick-Makaroff, Tate et al., 2019).

Approaches to Medication Management in Patients with Kidney Failure Opting for Conservative Management.

After consideration of risks and benefits, some patients with kidney failure choose conservative management. Conservative management of kidney failure (CM-KF) does not include dialysis or transplant and utilizes primarily pharmacologic strategies for symptom management, which can be challenging due to the number and complexity of symptoms. Additionally, there are safety concerns regarding altered pharmacokinetics and the adverse effects induced by some of the therapies that may be selected to treat symptoms. This review describes common kidney failure symptoms and provides recommendations for pharmacologic management in CM-KF. Selection of medication should be individualized to the patient and comorbidities, drug interactions, cost, and adverse effects should be carefully considered. Additional studies specifically focused on CM-KF are needed.

Improved Quality of Life in the Pediatric Patient on Hemodialysis: Academic Success with Implementation of a Full-Time Schoolteacher.

Children living with kidney failure who are on hemodialysis are at risk for having a poor quality of life. Within the pediatric hemodialysis unit, patients were not receiving adequate educational services. Alternative school options available for patients on hemodialysis were insufficient to meet their needs. This deficit contributed to patients' academic failures, and decreased their self-esteem and quality of life. To improve academic services for patients on hemodialysis, a full-time schoolteacher was employed. The addition of the hemodialysis schoolteacher supported patients' academic success, which led to a significant improvement in the patients' quality of life.

Direct costs of integrated procedures of conventional hemodialysis performed by nursing professionals.

OBJECTIVE: to analyze the mean direct cost of the constituent procedures of conventional hemodialysis, performed in three public teaching and research hospitals. METHOD: quantitative, exploratory-descriptive study, of the multiple case study type. The mean direct cost was calculated by multiplying the time (timed) spent by nursing professionals, on the execution of procedures, by the unit cost of direct labor, added to the cost of materials and solutions/medications. RESULTS: the total mean direct cost, in patients with an arteriovenous fistula corresponded to US$25.10 in hospital A, US$37.34 in hospital B and US$25.01 in hospital C, and in patients with a dual lumen catheter, US$32.07 in hospital A, US$40.58 in hospital B and US$30.35 in hospital C. The weighted mean values obtained were US$26.59 for hospital A, US$38.96 for hospital B and US$27.68 for hospital C. It was noted that the "installation and removal of hemodialysis fistula access" caused a significantly lower economic impact compared to "installation and removal of hemodialysis catheter access". CONCLUSION: with the knowledge developed it will be possible to support hospital managers, technical managers and nursing professionals in the decision making process, with a view to the rational allocation of the necessary inputs for the performance of conventional hemodialysis.

Relación entre las complicaciones y la calidad de vida del paciente en hemodiálisis / Relationship between complications and the quality of life of the patient on hemodialysis

Introducción: Los pacientes con Enfermedad Renal Crónica (ERC) son tratados con terapias de diálisis. Dentro de este tipo de tratamiento se encuentran la Diálisis Peritoneal (DP) y Hemodiálisis (HD). Los pacientes sometidos a HD tienen una evolución imprevisible por las complicaciones del tratamiento y/o complicaciones propias de la ERC. Estas aumentan el número de hospitalizaciones y deterioran la calidad de vida (CV). Objetivos: Evaluar la calidad de vida de pacientes en hemodiálisis y determinar la asociación entre las complicaciones y la CV. Material y Método: Estudio transversal analítico en 157 pacientes en HD (75 hombres, 82 mujeres), mayores de 18 años y con más de 3 meses en tratamiento. La CV se evaluó con el instrumento KDQOL-36, el cual, mide 5 dimensiones en escala del 0 al 100. Se realizó un análisis bivariado, ANOVA y regresión múltiple para evaluar la relación de cada una de las dimensiones con edad, sexo, ocupación, estado civil, escolaridad, tipo de acceso venoso, tiempo con la ERC, con la HD y complicaciones de la ERC y la HD. Resultados: La edad promedio fue de 50.9 años. El 77% de los participantes presentaron complicaciones, 69.4% por HD, 5% por evolución de la ERC y 25.6% ambas complicaciones. En el análisis multivariado se encontró que la presencia de ambas complicaciones deteriora más la calidad de vida que las ocasionadas únicamente por el tratamiento de HD. Conclusión: Las complicaciones del tratamiento de hemodiálisis aunadas a las de la ERC deterioran en gran medida la calidad de vida del paciente (AU)

Introduction: Patients with Cronic Kidney Disease (CKD) are treated with dialysis therapies. Within this type of treatment are Peritoneal Dialysis (PD) and Hemodialysis (HD). Patients undergoing HD have unexpected turn for treatment complications and / or complications of CKD. These increase the number of hospitalizations and deteriorate the quality of life (QOL). Objective: Evaluate the Quality of Life of Patients on hemodialysis and determine the association between complications and QoL. Material and Method: Analytical cross-sectional study in 157 patients in HD (75 men, 82 women), aged 18 years and over 3 months treatment. QoL was assessed with the KDQOL-36 instrument, which, measuring 5 dimensions on a scale of 0 to 100. Was conducted of the bivariate analysis, ANOVA and and multiple regression to assess the ratio v Each Dimensions with Age, sex, occupancy, marital status, education, access type venous access time with the ERC, with HD and complications of CKD and HD. Results: Average age was 50.9 m years. 77% of participants had complications, 69.4% for HD, 5% Evolution of CKD and 25.6% Complications Both. In the multivariate analysis it was found that the presence of both complications deteriorates the complications caused only by the HD tratment. Conclusion: Hemodialysis tratment complication together with CKD complications greatly deteriorate patinents quality of (AU)

Estado nutricional del paciente en hemodiálisis y factores asociados / Nutritional status of the patient on hemodialysis and associated factors

Introducción: La desnutrición en pacientes crónicos en diálisis tiene una alta prevalencia e importante repercusión en la morbimortalidad. Dado que no existen estudios previos en nuestro servicio, planteamos un estudio cuyo objetivo es evaluar el estado nutricional y los factores asociados. Material y Método: Estudio descriptivo, observacional, transversal, el segundo trimestre de 2015, en los pacientes en programa de hemodiálisis de un hospital comarcal. Se registró la edad, sexo, I. de Charlson, técnica de diálisis, IMC, tiempo en diálisis, albúmina, PCR, colesterol y transferrina séricas. Se utilizó como instrumento la Valoración global subjetiva y el Score Malnutrición Inflamación. Resultados: Se analizaron 35 pacientes, la edad media fue 72,2 años (DS: 11,8), 34,3% fueron mujeres, el IMC es 27,1 (DS: 4,9), I. de Charlson 6,4 (DS: 1,7), 77,1% hacían diálisis convencional y 22,9% hemodiafiltración en línea. Según el test MIS el 46% tenía buen estado nutricional y 54% estaba mal nutrido. Según la VGS 66% tenía buen estado nutricional, 31% riesgo de desnutrición y 3% desnutrición severa. La VGS se relaciona con el IMC (p: 0,02), creatinina (p: 0,001), colesterol total (p: 0,02) y PCR (p: 0,01); no con la edad, tiempo en hemodiálisis, I. Charlson, transferrina y albúmina(p> 0,05). El Score Malnutrición Inflamación (MIS) se relaciona con el IMC (p: 0,002), I. Charlson (p: 0,01), creatinina (p: 0,009) y PCR (p: 0,02); no con la edad, tiempo en hemodiálisis, colesterol total, transferrina y albúmina (p> 0,05). Conclusión: Existe buena correlación entre las dos herramientas y los parámetros analíticos utilizados. Los pacientes en hemodiafiltración en línea tienen buen estado nutricional. No existe un único parámetro que valore la nutrición. Se sugiere que es necesaria la valoración nutricional dada la alta prevalencia que existe (AU)

Introduction: Malnutrition in chronic dialysis patients has a high prevalence and important repercussion in morbidity and mortality. Since there are no previous studies in our service, we propose a study whose objective is to evaluate the nutritional status and associated factors. Material and Method: A descriptive, observational, cross-sectional study, in the second trimester of 2015, in patients in the hemodialysis program of a county hospital. Age, sex, Charlson’s index, dialysis technique, BMI, time on dialysis, albumin, CRP, cholesterol and serum transferrin were recorded. Subjective global assessment and Score Malnutrition Inflammation were used as instrument. Results: We analyzed 35 patients, mean age was 72.2 years (SD: 11.8), 34.3% were women, BMI was 27.1 (SD: 4.9), Charlson index 6.4 (DS: 1.7), 77.1% were on conventional dialysis and 22.9% were on-line hemodiafiltration. Regarding the MIS test, 46% had good nutritional status and 54% were malnourished. According to the VGS, 66% had good nutritional status, 31% risk of malnutrition and 3% severe malnutrition. VGS was related to BMI (p: 0.02), creatinine (p: 0.001), total cholesterol (p: 0.02), and CRP (p: 0.01); and it was not related to age, time on hemodialysis, Charlson’s index, transferrin and albumin (p> 0.05). The Score Malnutrition Inflammation (MIS) was related to BMI (p: 0.002), Charlson’s index (p: 0.01), creatinine (p: 0.009) and CRP (p: 0.02); not with age, time on hemodialysis, total cholesterol, transferrin and albumin (p> 0.05). Conclusions: There is good correlation between the two tools and analytical parameters used. Patients in on-line hemodiafiltration have good nutritional status. There is no single parameter that evaluate nutrition. The inclusion of nutritional assessment is suggested given the high prevalence (AU)

Resultados de un programa educativo con refuerzo audiovisual durante la sesión, en pacientes en hemodiálisis / Results of an educational program with audio-visual reinforcement during the session in hemodialysis patients

Los medios audiovisuales son imprescindibles para reforzar la información del paciente. El objetivo del trabajo es describir la utilidad del uso de presentaciones educativas para los pacientes en hemodiálisis y los medios audiovisuales disponibles en la unidad. Se elaboraron tres presentaciones educativas en Microsoft Office Power Point y se pasaron una serie de cuestionarios con 13 preguntas que hacían referencia a aspectos fundamentales del cuidado tratados en las presentaciones, antes y después de éstas. Se realizó un análisis estadístico descriptivo con la distribución de frecuencias y porcentajes de las variables categóricas y con la media y la desviación típica de las variables cuantitativas. Para comprobar los resultados de las respuestas antes y después de las presentaciones/micropíldoras se ha utilizado la prueba de McNemar para dos muestras relacionadas con un nivel de significación estadística de p<0,05. El estudio consta de 45 pacientes, 73,3% varones con una edad media de 63,82 años. Se encontraron resultados estadísticamente significativos con p=0,031 y p=0,004, referentes a cuestiones sobre la desinfección de la fístula y el aporte proteico. El presente estudio ha servido para demostrar que la herramienta ha abierto nuevas posibilidades de formación a los pacientes (AU)

Audiovisual media are essential to reinforce patient information. The objective of this study is to describe the usefulness of educational presentations for hemodialysis patients and available audiovisual media in the unit. Three educational presentations were developed in Microsoft Office Power Point and questionnaires were used with 13 questions regarding fundamental aspects of care approached in the presentations, before and after these presentations. A descriptive statistical analysis was performed with the distribution of frequencies and percentages of the categorical variables and with the mean and standard deviation of the quantitative variables. To test the results of the responses before and after the presentations, the McNemar’s test was used for two related samples, with a statistical significance level of p<0.05. The study included 45 patients, 73.3% males with a mean age of 63.82 years. Statistically significant results were found with p=0.031 and p=0.004, concerning questions about fistula disinfection and protein intake (AU)

Factores que influyen en la adherencia al tratamiento del paciente en diálisis peritoneal / Influential factors in adherence to treatment peritoneal dialysis patient

Introducción: Actualmente, los profesionales de enfermería al implementar los cuidados para el paciente con enfermedad renal crónica mediante diálisis peritoneal, encuentran como principal dificultad la poca adherencia del mismo en las áreas correspondientes al dominio en la técnica, control de factores nutricionales, control hídrico y manejo farmacológico entre otros; los cuales conllevan un impacto negativo en la permanencia en la terapia así como en la supervivencia. Objetivo: Explorar los factores que influyen en la adherencia de los pacientes adultos a la terapia dialítica peritoneal y las consecuencias de la falta de ésta reportadas en la literatura. Material y Método: La búsqueda electrónica se realizó utilizando las bases de datos PUBMED, meta buscadores como google académico, Epistemonikos, Scielo, entre otros. Se consideraron estudios primarios realizados en pacientes adultos de 18 a 80 años, entre los años 2008-2015, en idioma inglés y español. Resultado: Los pacientes en DP presentan problemas de falta de adherencia en mayor proporción en los parámetros nutricionales, restricción de fluidos seguida del manejo correcto de la técnica y pautas farmacológicas indicadas por el profesional de la salud. Conclusión: La adherencia al tratamiento del paciente en diálisis peritoneal debe ser explorada por enfermería por su diversa complejidad mediante estudios fenomenológicos (AU)

Introduction: Currently, when nurse practitioners try to implement patients care with chronic kidney disease on peritoneal dialysis, the main difficulty is the lack of adherence in the areas related with the domain in the art, nutritional factors control, water control and pharmacological management among others; these carry a negative impact on therapy permanence and survival. Objective: To explore factors that influence the adherence of adult patients on peritoneal dialysis therapy and the consequences of this lack reported in the literature. Material and Method: The electronic search was conducted using PubMed databases, meta search engines like Google Scholar, Epistemonikos, Scielo, among others. They were considered primary studies conducted in adults 18 to 80, between 2008-2015, in English and Spanish language. Results: PD patients have problems with lack of grip in greater proportion in nutritional parameters; fluid restriction followed the correct handling of technical and pharmacological guidelines given by the health care professional. Conclusion: Due to its complexity, the adherence should be explored by nursing professionals through phenomenological studies (AU)

El método buttonhole como técnica de punción de la fístula arteriovenosa en hemodiálisis: una revisión de la literatura / The buttonhole method like puncture technical of arteriovenous fistula in hemodialysis. A literature review

Introducción: La hemodiálisis es el tratamiento de elección en los pacientes con insuficiencia renal crónica. La clave para un tratamiento adecuado es tener un buen acceso vascular. Por ello, las fístulas arteriovenosas son consideradas la mejor opción. Uno de los principales factores que influyen en la supervivencia de estas es la técnica de punción realizada. El objetivo principal del estudio fue conocer el método buttonhole como técnica de punción de la fístula arteriovenosa en la hemodiálisis. Metodología: Se realizó una revisión de la literatura científica a través de las siguientes bases de datos: PubMed/Medline, Scopus, Cinahl y Cuiden Plus, desde 2011 hasta 2016. Además, se realizó una búsqueda secundaría manual. Resultados: Las estrategias iniciales de búsquedas identificaron un total de 84 resultados, siendo finalmente seleccionados 7 estudios. Los resultados encontrados han sido muy diversos, encontrándose resultados para el dolor, tasas de infección, tiempo de hemostasia, dilataciones aneurismáticas, flujo sanguíneo, presión venosa, número de intentos de canulación, seguridad, estética del brazo portador de la fístula y calidad de vida del paciente. Conclusiones: El método buttonhole parece ser una buena alternativa de punción, ya que está prácticamente exenta de las complicaciones habituales existentes en otras técnicas, como extravasaciones, hematomas, aneurismas, entre otras. Además, facilita la auto-punción en los domicilios. Por otro lado, es necesario un buen aprendizaje previo a la incorporación de esta técnica y un periodo de adaptación por parte de los profesionales, requiriendo implicación por parte de los mismos y del centro (AU)

Introduction: Hemodialysis is the treatment of choice in patients with chronic renal failure. The key to proper treatment is having a good vascular access. Therefore, arteriovenous fistulas are considered the best option. One of the main factors that influence the survival of these is the technique of puncture performed. The main objective of the study was to know the method buttonhole like puncture technique arteriovenous fistula in hemodialysis. Methods: A review of the scientific literature was conducted through the following databases: PubMed/Medline, Scopus, Cinahl and Cuiden Plus, from 2011 to 2016. In addition, a secondary manual search was conducted. Results: The initial search strategies identified a total of 84 results that finally being selected 7 studies. The results have been mixed, finding results for pain, infection rates, hemostasis time, aneurysmal dilations, blood flow, venous pressure, number of cannulation attempts, security, aesthetics of the carrier arm of the fistula and quality of life of the patient. Conclusions: The method buttonhole seems to be a good alternative lancing because it is substantially free of existing common complications in other techniques, like extravasations, hematomas and aneurysms, among others. It also facilitates self-lancing at home. Furthermore, a good prior learning incorporating this technique is needed and a period of adaptation by professionals, requiring involvement by them and the center (AU)

Aspectos fundamentales en la elección de la terapia renal sustitutiva / Fundamental aspects in the choice of renal replacement therapy

La insuficiencia renal crónica (IRC) es una enfermedad con una gran prevalencia en nuestro medio, y las personas que sufren dicha enfermedad deben tener claro que la terapia renal sustitutiva (TRS) puede adaptarse mejor a su forma de vida. Es importante que el paciente tenga la suficiente información sobre las técnicas a las que puede acceder de una manera clara, para así valorar las diferentes posibilidades, ventajas y desventajas. El momento de esta elección es crucial y estresante en la vida del paciente, no solo por los efectos de la propia enfermedad, sino también por la asimilación de un nuevo estilo de vida con el que debe mantenerse el resto de la misma. Este trabajo ha sido realizado pensando en la necesidad de los pacientes y de los profesionales sanitarios a la hora de adquirir un conocimiento holístico e integral sobre todas las características que puede tener tanto la diálisis peritoneal (DP) como la hemodiálisis (HD); desde los factores propios del paciente (dieta, entorno familiar, etc.), hasta los relacionados con los profesionales de enfermería (cuidados, información facilitada, etc.), sin olvidarnos de los condicionantes ajenos tanto al paciente como al profesional de enfermería, como pueden ser los aspectos estructurales y económicos (AU)

Chronic kidney disease (CKD) is a disease with a high prevalence in our environment, and those suffering the disease should be as clear as possible that renal replacement therapy (RRT) may better suit your lifestyle. It is important that the patient has enough information about the techniques that can be accessed in a clear manner, so as to evaluate the different possibilities, advantages and disadvantages. The timing of this election is crucial and stressful for the patient’s life, not only by the effects of the disease itself, but also by the assimilation of a new lifestyle that should keep the rest of it. This work was done thinking about the need for patients and health professionals in acquiring a holistic and comprehensive understanding of all the features that can have both peritoneal dialysis (PD) and hemodialysis (HD); from own patient factors (diet, family environment, etc.) related to nurses (care, information provided, etc.) without forgetting the conditions outside the patient and the nurse as they can be structural and economic aspects (AU)

Interpretation of Renal Quality of Life Profile scores in routine clinical practice: an aid to treatment decision-making.

PURPOSE: High Renal Quality of Life Profile (RQLP) scores are associated with impaired health-related quality of life; however, the clinical meaning of the scores is difficult for clinicians and healthcare planners to interpret. The aim of this study was to determine clinical significance of RQLP scores which could be used to aid clinical decision-making. METHODS: The anchor-based technique (a method for categorizing numeric scores to ease interpretation) was used to develop a categorization system for the RQLP scores using a global question (GQ). The GQ scores (i.e. no effect to extremely large effect) were mapped against the RQLP scores, and intraclass correlation coefficient (ICC) was used to test their agreement. The RQLP and the GQ were administered to 260 adult patients (males = 165 and females = 95) with chronic renal failure (CRF). RESULTS: The mean RQLP score was 67.2, median = 61, SD = 41.5, and range 0-172. The mean GQ score was 1.74, median = 2, SD = 1.27, and range 0-4. The mean, mode, and median of the GQ scores for each RQLP score were used to devise several sets of categories of RQLP score, and the ICC test of agreement was calculated. The proposed set of RQLP score banding for adoption includes: 0-20 = no effect on patient's life (GQ = 0, n = 35); 21-51 = small effect on patient's life (GQ = 1, n = 66); 52-93 = moderate effect on patient's life (GQ = 2, n = 87); 94-134 = very large effect on patient's life (GQ = 3, n = 54); and 135-172 = extremely large effect on patient's life (GQ = 4, n = 18). The ICC coefficient for the proposed banding system was 0.80. CONCLUSION: The proposed categorization of the RQLP will aid the clinical interpretation of change in RQLP score informing treatment decision-making in routine practice.

Impacting the Trajectory of Chronic Kidney Disease With ARPN-Led Renal Teams.

Health care reform demands improvements in population health and the patient experience while reducing costs. This demand is referred to as The Triple Aim of Improvement. A sense of urgency must be created for development of new models of care that impact outcomes earlier in the disease process. One new model of care addressing the triple aim is the Advanced Practice Registered Nurse (APRN)-Led Specialty Care Team. APRN-Led Specialty Care Team members engage patients and implement evidence at a point in the disease trajectory that is most likely to influence population outcomes, resources, and cost. In the pilot described in this article, a nurse practitioner, a registered nurse, a licensed practice nurse, a registered nurse certified diabetes educator, a registered dietitian, and a clinical pharmacist provided care to 20 patients with diabetes and chronic kidney disease, using the chronic disease trajectory model. The team was trained and supported through virtual technology and chronic kidney disease clinical decision-making tools. This APRN-Led Renal Specialty Care Team was embedded into primary care, using group appointments with nephrology support. Lessons learned regarding implementation, with a focus on the role of the nursing executive, are presented along with recommendations for future implementation.

Adherence in paediatric renal failure and dialysis: an ethical analysis of nurses' attitudes and reported practice.

Minors have difficulty adhering to the strict management regimen required whilst on renal dialysis for chronic renal failure. This leads to ethical tensions as healthcare professionals (HCPs) and parents try, in the minor's best interests, to ensure s/he adheres. All 11 dialysis nurses working in a large, regional paediatric dialysis unit were interviewed about their perceptions and management of non-adherence and the ethical issues this raised for them. Participants reported negative attitudes to non-adherence alongside sympathy and feelings of frustration. They discussed the competing responsibilities between nurses, parents and minors, and how responsibility ought to be transferred to the minor as s/he matures; the need for minors to take responsibility ahead of transferring to adult services; and, the process of transferring this responsibility. Our discussion concentrates on the ethical issues raised by the participants' reports of how they respond to non-adherence using persuasion and coercion. We consider how understandings of capacity, traditional individual autonomy, and willpower can be used to comprehend the issue of non-adherence. We consider the relational context in which the minor receives, and participates in, healthcare. This exposes the interdependent triad of relationships between HCP, parent and minor and aids understanding of how to provide care in an ethical way. Relational ethics is a useful alternative understanding for professionals reflecting upon how they define their obligations in this context.