Progression of chronic kidney disease in non- dialysis patients: a retrospective cohort

Abstract Evidence on factors associated with the progression of chronic kidney disease (CKD) is still under construction. The present study aimed to evaluate sociodemographic, clinical, and drug use factors associated with the progression of CKD. A retrospective cohort study was conducted with 193 patients with CKD stages 3A to 5- non-dialysis followed for three years in a Brazilian city. The outcome was the evolution to renal replacement therapy (RRT) or death. A total of 52.3 % (n = 101) were men and 83.4 % (n = 161) elderly. The median age was 72.0 years, and 22.3 % (n = 44) progressed to RRT or death, and the three-year mortality rate was 20.2 %. Participants exposed to angiotensin converting enzyme inhibitors or angiotensin II receptor blockers had a lower risk of progressing to the outcome (hazard ratio (HR) 0.25; p = 0.003) and higher survival (p = 0.022) when compared to those not exposed to these drugs. Age (HR 1.06;) and use of omeprazole (HR 6.25; CI; p <0.01) and hydrochlorothiazide (HR 2.80; p = 0.028) increased the risks of RRT or death. The results highlight the importance of rational management of pharmacotherapy for patients with CKD

Implementation of nephrology subspecialty curricular milestones.

Beginning in the 2014-2015 training year, the US Accreditation Council for Graduate Medical Education (ACGME) required that nephrology Clinical Competency Committees assess fellows' progress toward 23 subcompetency "context nonspecific" internal medicine subspecialty milestones. Fellows' advancement toward the "ready for unsupervised practice" target milestone now is tracked in each of the 6 competencies: Patient Care, Medical Knowledge, Professionalism, Interpersonal Communication Skills, Practice-Based Learning and Improvement, and Systems-Based Practice. Nephrology program directors and subspecialty societies must define nephrology-specific "curricular milestones," mapped to the nonspecific ACGME milestones. Although the ACGME goal is to produce data that can discriminate between successful and underperforming training programs, the approach is at risk to produce biased, inaccurate, and unhelpful information. We map the ACGME internal medicine subspecialty milestones to our previously published nephrology-specific milestone schema and describe entrustable professional activities and other objective assessment tools that inform milestone decisions. Mapping our schema onto the ACGME subspecialty milestone reporting form allows comparison with the ACGME subspecialty milestones and the curricular milestones developed by the American Society of Nephrology Program Directors. Clinical Competency Committees may easily adapt and directly translate milestone decisions reached using our schema onto the ACGME internal medicine subspecialty competency milestone-reporting format.

Semiología renal y genitourinaria en pediatría: primera parte / Nephrologoy and urology semiology in children: first part

A pesar de los avances tecnológicos, la historia clínica y el examen físico continúan y continuarán siendo la base de un buen enfoque y aproximación diagnóstica correcta, por ésto, la semiología sigue siendo un área muy importante en la medicina. En ésta revisión se plantea una guía sistemática e integral para la evaluación del sistema nefro-urológico en el niño desde las herramienta básicas y fundamentales como la historia clínica, el examen físico con sus componentessemiológicos en lo normal y lo patológico, integrando además los métodos diagnósticos de laboratorio e imagen disponibles en la actualidad, para lograr un buen enfoque y aproximación diagnóstica en niños con enfermedad renal.

Despite technological advances, medical history and physical examination remain the foundation of a good approach and correct diagnosis; semiology remains a very important area in medicine. In this review a systematic and comprehensive guide for the evaluation of nephron urological system in children is presented, with emphasis in medical history, physical examination and semiotic aspects, in normal and pathological conditions; additionally laboratory and imaging studies available to achieve a good diagnostic approach in children with renal disease are presented.

Tubulointerstitial lesions of patients with lupus nephritis classified by the 2003 International Society of Nephrology and Renal Pathology Society system.

The 2003 International Society of Nephrology/Renal Pathology Society (ISN/RPS) system for classifying patients with lupus nephritis was based on glomerular lesions exclusively, despite the fact that lupus nephritis affects all compartments of the kidney. Hence, we analyzed the tubulointerstitial lesions in patients with lupus nephritis within the different classes and subclasses of the 2003 ISN/RPS system. Among 313 patients from five centers in northern China with lupus nephritis, interstitial inflammatory cell infiltration, tubular atrophy, and interstitial fibrosis were severe in 170 patients with class IV, moderate in 55 with class III, and mild in 19 with class II and in 69 with class V disease, each with significance. The severity of tubulointerstitial lesions in classes IV-segmental and III was similar, whereas the score of interstitial inflammatory cell infiltration in patients with subclass IV-global was significantly higher than that in those with subclass IV-segmental. Interstitial fibrosis and tubular atrophy were each significantly more prominent in patients with both active and chronic lesions than in those with active lesions alone. The correlation coefficient ranged from 0.222 to 0.811 comparing glomerular and tubulointerstitial indices. In multivariate Cox hazard analysis of tubulointerstitial lesions, indices of interstitial infiltration, tubular atrophy, and interstitial fibrosis were confirmed as significant independent risk factors for renal outcome. Thus, we found that the 2003 ISN/RPS classification system of lupus nephritis, based on glomerular lesions, could also reflect related tubulointerstitial lesions. Hence, we suggest that the extent of tubulointerstitial lesions may be helpful in predicting renal outcome in patients with lupus nephritis.

Adult nephrology fellowship training in the United States: trends and issues.

This article reviews trends and issues related to adult nephrology fellowship education in the United States. The number of nephrology fellowship programs and trainees has continued to increase slowly despite limitations in funding of graduate medical education. The use of the Electronic Residency Application System has provided information for the first time on the number, demographics, and behavior of applicants that can be used as baseline data for tracking trends in fellowship applications and for formulating training policies. Issues that nephrology training programs face are discussed in this review: (1) A more stringent graduate medical education regulatory environment, (2) the use of the National Resident Matching Program to enhance the nephrology fellowship applicant selection process, (3) future nephrology workforce shortages, and (4) the continued subspecialization of nephrology. By working together, nephrology fellowship programs can overcome barriers that are raised by these issues and improve the fellowship training experience.

Current Procedural Terminology (CPT) coded services provided by nurse specialists.

In this exploratory study, a random sample of nurses from nine nursing specialties was surveyed to identify which Current Procedural Terminology (CPT) coded procedures they perform and how frequently they perform them. CPT codes are used universally to file claims for physician payment. The sample included 74 school nurses, 67 enterostomal nurses, 53 family nurse practitioners, 43 critical care nurses, 43 oncology nurses, 40 rehabilitation nurses, 39 orthopaedic nurses, 34 nephrology nurses and 25 nurse-midwives. Specific questionnaires were developed for each specialty with codes identified by expert panels. The number of CPT codes ranged from 233 for family nurse practitioners to 58 for school nurses. The mean number of coded services performed by individual respondents ranged from 79 (FNP) to 18 (school nurses); individual respondents performed 0-162 codes. Supervision by physicians was very infrequent. Charges to Medicare in 1988 for the coded services included in the survey were $22,793,427.34 (aggregate allowable charges). The study provides some documentation of the degree to which nurses perform the same services and procedures for which physicians are being paid. If policy makers are serious about reaching innovative solutions to the problems of quality, access and cost, everything must be "on the table," including the contributions of nurses.

ARCANE. A new medical patient information system.

ARCANE is a new medical patient information system developed at Necker Enfants-malades University Hospital. It was initially dedicated to pediatric nephrology, using microcomputers directly accessible to the physicians. It is however designed for general use and could be directly adapted to many domains in Medicine. ARCANE's referential is based on conceptual slicing close to SNOMED's. The thesaurus is built on keywords or key-expressions. Combination with adjectives and modifiers reduces the volume of the thesaurus to about 1000 entries. Multipurpose use of the data is made available by automatic transcodification to ICD classification and SNOMED nomenclature. External formatting by semantic fields allows the physicians to attribute medical expressions dynamically to concepts of the thesaurus. This system, devoted to daily practice, is also conceived as a clinical research aid and an activity analysis tool.