208 results found
Brown EA, Hurst H, 2020, Delivering peritoneal dialysis for the multimorbid, frail and palliative patient., Perit Dial Int, Vol: 40, Pages: 327-332
Peritoneal dialysis (PD) is only one component of care for older multimorbid, frail and/or palliative patients. Goals of care should be determined for all patients by shared decision-making at the start of during time on PD. Burden of PD should be minimized by individualizing the prescription by allowing for residual renal function and tailored to what is acceptable to the patient. PD facilities should develop the care pathways needed for this group of patients including integration with local geriatric, palliative care and social services.
Corbett RW, Goodlet G, MacLaren B, et al., 2020, International Society for Peritoneal Dialysis Practice Recommendations: The view of the person who is doing or who has done peritoneal dialysis., Perit Dial Int, Vol: 40, Pages: 349-352
The 2019 International Society for Peritoneal Dialysis (ISPD) Practice Recommendations were prepared by a committee invited by the ISPD to develop new practice recommendations for prescribing high-quality, goal-directed peritoneal dialysis (PD). Further input was sought at the stage of the first draft of the proposed recommendations by circulating drafts of the recommendations and articles to an international selection of people who were either actively doing PD or who were previously treated with PD, as well as caregivers, to ask for their feedback. A diverse group of 22 people from 8 countries across 5 continents provided their feedback covering the main recommendations as well as the accompanying articles. Much of the feedback has been acted upon at the revision stages, however, the responses are published here in summary form to underscore the commitment to hearing the voice of those doing PD or caring for them. A key change that arose from the feedback has been the shift of language from "patient-centred" to "person-centered," reflecting the desire of these recommendations to address the patient as a person with needs and preferences beyond just the medical perspective, along with the need for the person doing PD to be central to the process of shared decision-making. Notwithstanding the challenges of an international, multi-lingual population, with people doing PD in highly diverse geographic and economic environments, the next iteration of ISPD guidelines should consider the role of people doing PD and their carers in evidence-based coproduced guidelines, from the inception of the guidelines.
Brown EA, Blake PG, Boudville N, et al., 2020, International Society for Peritoneal Dialysis practice recommendations: Prescribing high-quality goal-directed peritoneal dialysis., Perit Dial Int, Vol: 40, Pages: 244-253
Blake PG, Brown EA, 2020, Person-centered peritoneal dialysis prescription and the role of shared decision-making., Perit Dial Int, Vol: 40, Pages: 302-309
Person-centered care has become a dominant paradigm in modern health care. It needs to be applied to people with end-stage kidney disease considering the initiation of dialysis and to peritoneal dialysis (PD) prescription and care delivery. It is relevant to their decisions about goals of care, transplantation, palliative care, and discontinuation of dialysis. It is also relevant to decisions about how PD is delivered, including options such as incremental PD. Shared decision-making is the essence of this process and needs to become a standard principle of care. It requires engagement, education, and empowerment of patients. Patient-reported outcomes and patient-reported experience are also central to person-centered care in PD.
Navaratnarajah A, Clemenger M, McGrory J, et al., 2020, Flexibility in peritoneal dialysis prescription: Impact on technique survival., Perit Dial Int
BACKGROUND: Patient burnout is a major cause of technique failure on peritoneal dialysis (PD). Reducing the PD prescription on an individual basis, dependent upon residual kidney function (RKF), may have a role in prolonging time on PD by reducing dialysis burden. This retrospective study aimed to determine the safety and impact of flexible PD prescribing on technique and patient survival. METHODS: All patients (186) from our centre starting PD from 1st January 2012 to 31st December 2016 were included. Data on dialysis prescription were collected for each patient from the time they had started PD, and dialysis adequacy measured regularly (3-6 monthly) using PD Adequest. RESULTS: Median age at start of dialysis was 61 years. Only 49% started on PD 7 days a week and this dropped to 27% at 3 months following the first clearance test. Over 90% achieved creatinine clearance > 50 L/week/1.73 m2 up to 2 years of follow-up, with 87% achieving this standard at 3 years. Patient and technique survival at 1, 2 and 3 years were 91%, 81%, and 72%, and 89%, 87% and 78% respectively. Factors on univariate analysis affecting technique survival included increasing age (HR 0.98, p = 0.04, 95% CI (0.96-0.999)), two or more episodes of PD-associated peritonitis (HR 4.52, p = 0.00, 95% CI (1.87-10.91)) and increasing PD intensity (HR 3.30, p = 0.02, 95% CI (1.22-8.93)). After multivariate adjustment which included baseline kidney function, low PD intensity continued to be associated with better technique survival (HR 0.17, p = 0.03, 95% CI (0.03-0.85)). CONCLUSION: Tailoring the PD prescription to RKF enables days off dialysis while still maintaining recommended levels of small solute clearance. This approach reduces dialysis burden and is associated with higher technique survival.
Navaratnarajah A, El-Sherbini N, Brown EA, 2020, Long-term outcomes in patients with encapsulating peritoneal sclerosis managed with nutritional support., Perit Dial Int
BACKGROUND: Little is known about long-term survivors with encapsulating peritoneal sclerosis (EPS). Published literature focuses on patients managed surgically. We describe our experience of the long-term outcomes in patients with EPS conservatively managed with nutritional support alone. METHODS: This is a single-centre retrospective observational study of patients who had survived for ≥5 years since diagnosis. EPS survivors were invited for review of symptoms, nutritional assessment and evaluation of quality of life. Radiological progression was assessed based on serial computed tomography (CT) scores for each patient. RESULTS: A total of 23 patients with a diagnosis of EPS for at least 5 years were identified, with 18 patients alive at the time of the study. Of these 18 patients, 10 patients transferred to haemodialysis (HD) and 8 patients received kidney transplants. Commonest symptoms were nausea (91%) and vomiting (73%). Mean body mass index for patients was within the ideal and healthy range, with only 11% suffering from continued weight loss. In all, 70% EPS survivors on HD received nutritional support compared to 15% of those with transplants; 17% required ongoing parenteral nutrition. Of the 11 patients with serial CT scans at least 4 years apart, 10 had an increase in radiological score for EPS but with no apparent correlation to clinical outcomes. There were no significant differences in the reported quality of life between EPS survivors on HD and those transplanted, with self-rated health status equivalent to that reported for the general end-stage kidney disease (ESKD) population. CONCLUSION: Long-term survival following EPS managed conservatively with nutritional support is feasible, with the majority no longer requiring nutritional support and having a quality of life similar to other patients with ESKD.
Crabtree JH, Shrestha BM, Chow K-M, et al., 2019, Creating and maintaining optimal peritoneal dialysis access in the adult patient: 2019 update, Peritoneal Dialysis International, Vol: 39, Pages: 414-436, ISSN: 0896-8608
The success of peritoneal dialysis (PD) as renal replacement therapy depends upon a safe, functional, and durable catheter access to the peritoneal cavity provided in a timely fashion. Catheter complications often lead to catheter loss and contribute to technique failure. With improvements in prevention and treatment of peritonitis, the impact of catheter-related infections and mechanical problems on PD technique survival has become more apparent.Guideline committees under the sponsorship of the International Society for Peritoneal Dialysis (ISPD) periodically update best practices for optimal peritoneal access (1–4). Recent advances in our understanding of the key aspects of providing successful placement and maintenance of peritoneal catheters compels the current update. Assessment of evidence for guidelines recommendations is made using a modification of the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system for classification of the level of evidence and grade of recommendations (5). Where scientific evidence is not available, recommendations are based on a consensus opinion. The bibliography supporting the recommendations is not intended to be comprehensive. When there are multiple similar reports on the same subject, the committee prefers to cite the more recent publications.Within each recommendation, strength is indicated as Level 1 (we recommend), Level 2 (we suggest), or not graded, and the quality of the supporting evidence is shown as A (high quality), B (moderate quality), C (low quality), or D (very low quality). The recommendations are not meant to be implemented indiscriminately in every instance but adapted as necessary according to local circumstances and the clinical situation. While many of the general principles presented here may be applied to pediatric patients, the focus of these guidelines is on adults. Clinicians who take care of pediatric PD patients should refer to the latest ISPD guidelines covering this
Brown EA, Farrington K, 2019, Geriatric Assessment in Advanced Kidney Disease., Clin J Am Soc Nephrol, Vol: 14, Pages: 1091-1093
Beckwith H, Clemenger M, McGrory J, et al., 2019, Repeat peritoneal dialysis exit-site infection: definition and outcomes, Peritoneal Dialysis International, Vol: 39, Pages: 344-349, ISSN: 1718-4304
Background: The most common complication of peritoneal dialysis (PD) is infection. Despite this, there are no clear guidelines for the management of repeat exit-site infection (ESI), and best practice is not known. We describe our unit's experience of repeat ESI and clinical outcomes in this cohort.Methods: Retrospective case note review of all PD patients with positive ESI swabs at our center between 1 January 2012 and 1 January 2018. Patients were included in the study if they had 2 or more ESI with the same organism within a 12-month period and an initial positive response to antibiotic therapy.Results: Overall, 31 of 248 patients had repeat ESI. The 2 most common causative organisms were Staphylococcus aureus (n = 16, 52%) and Pseudomonas aeruginosa (n = 10, 32%). Twenty (65%) patients developed subsequent peritonitis. The infection resolved with further antibiotics alone in 10 (32%) patients and in 6 patients after PD catheter exchange. The PD catheter was removed in 16 (52%) patients (including 5 after an initial catheter exchange) requiring transfer to hemodialysis (HD). Six (19%) patients died within 12 months of repeat ESI. Both repeat Pseudomonas aeruginosa and Staphylococcus aureus infections were associated with high rates of dialysis modality change (70% and 50%, respectively).Conclusion: We have developed the first definition for repeat ESI. Repeat ESI is clinically important and results in significant morbidity and mortality. Following repeat ESI, peritonitis rates are high and a significant number of patients switch dialysis modality. Studies are needed to determine whether interventions such as early catheter exchange would improve outcomes.
Iyasere O, Brown EA, Johansson L, et al., 2019, Quality of life with conservative care compared with assisted peritoneal dialysis and haemodialysis, Clinical Kidney Journal, Vol: 12, Pages: 262-268, ISSN: 2048-8505
BackgroundThere is little information about quality of life (QoL) for patients with end-stage kidney disease (ESKD) choosing conservative kidney management (CKM). The Frail and Elderly Patients on Dialysis (FEPOD) study demonstrated that frailty was associated with poorer QoL outcomes with little difference between dialysis modalities [assisted peritoneal dialysis (aPD) or haemodialysis (HD)]. We therefore extended the FEPOD study to include CKM patients with estimated glomerular filtration rate ≤10 mL/min/1.73 m2 (i.e. individuals with ESKD otherwise likely to be managed with dialysis).MethodsCKM patients were propensity matched to HD and aPD patients by age, gender, ethnicity, diabetes status and index of deprivation. QoL outcomes measured were Short Form-12 (SF12), Hospital Anxiety and Depression Scale depression score, symptom score, Illness Intrusiveness Rating Scale (IIRS) and Renal Treatment Satisfaction Questionnaire. Frailty was assessed using the Clinical Frailty Scale. Generalized linear modelling was used to assess the impact of treatment modality on QoL outcomes, adjusting for baseline characteristics.ResultsIn total, 84 (28 CKM, 28 HD and 28 PD) patients were included. Median age for the cohort was 82 (79–88) years. Compared with CKM, aPD was associated with higher SF12 physical component score (PCS) [Exp B (95% confidence interval) = 1.20 (1.00–1.45), P < 0.05] and lower symptom score [Exp B = 0.62 (0.43–0.90), P = 0.01]; depression score was lower in HD compared with CKM [Exp B = 0.70 (0.52–0.92), P = 0.01]. Worsening frailty was associated with higher depression scores [Exp B = 2.59 (1.45–4.62), P < 0.01], IIRS [Exp B = 1.20 (1.12–1.28), P < 0.01] and lower SF12 PCS [Exp B = 0.87 (0.83–0.93), P < 0.01].ConclusionTr
Iyasere O, Brown E, Gordon F, et al., 2019, LONGITUDINAL TRENDS IN QUALITY OF LIFE AND PHYSICAL FUNCTION IN FRAIL OLDER DIALYSIS PATIENTS: A COMPARISON OF ASSISTED PERITONEAL DIALYSIS AND IN-CENTER HEMODIALYSIS, PERITONEAL DIALYSIS INTERNATIONAL, Vol: 39, Pages: 112-118, ISSN: 0896-8608
Brown EA, 2019, Influence of Reimbursement Policies on Dialysis Modality Distribution around the World, Clinical Journal of the American Society of Nephrology, Vol: 14, Pages: 10-12, ISSN: 1555-9041
Tong A, Manns B, Wang AYM, et al., 2018, Implementing core outcomes in kidney disease: report of the Standardized Outcomes in Nephrology (SONG) implementation workshop., Kidney Int, Vol: 94, Pages: 1053-1068
There are an estimated 14,000 randomized trials published in chronic kidney disease. The most frequently reported outcomes are biochemical endpoints, rather than clinical and patient-reported outcomes including cardiovascular disease, mortality, and quality of life. While many trials have focused on optimizing kidney health, the heterogeneity and uncertain relevance of outcomes reported across trials may limit their policy and practice impact. The international Standardized Outcomes in Nephrology (SONG) Initiative was formed to identify core outcomes that are critically important to patients and health professionals, to be reported consistently across trials. We convened a SONG Implementation Workshop to discuss the implementation of core outcomes. Eighty-two patients/caregivers and health professionals participated in plenary and breakout discussions. In this report, we summarize the findings of the workshop in two main themes: socializing the concept of core outcomes, and demonstrating feasibility and usability. We outline implementation strategies and pathways to be established through partnership with stakeholders, which may bolster acceptance and reporting of core outcomes in trials, and encourage their use by end-users such as guideline producers and policymakers to help improve patient-important outcomes.
Corbett RW, Brown E, Conventional Dialysis in The Elderly: How Lenient Should Our Guidelines Be?, Seminars in Dialysis, ISSN: 0894-0959
Manera K, Johnson D, Craig J, et al., 2018, PATIENT AND CAREGIVER PRIORITIES FOR OUTCOMES IN PERITONEAL DIALYSIS: AN INTERNATIONAL NOMINAL GROUP STUDY, 55th Congress of the European-Renal-Association (ERA) and European-Dialysis-and-Transplantation-Association (EDTA), Publisher: OXFORD UNIV PRESS, ISSN: 0931-0509
Pillay C, Arulkumaran N, Navaratnarajah A, et al., 2018, FACTORS CONTRIBUTING TO ACUTE RENAL REPLACEMENT THERAPY INITIATION IN PATIENTS WITH END-STAGE RENAL DISEASE - OUTCOMES FROM A LARGE RETROSPECTIVE COHORT STUDY, 55th Congress of the European-Renal-Association (ERA) and European-Dialysis-and-Transplantation-Association (EDTA), Publisher: OXFORD UNIV PRESS, Pages: 563-564, ISSN: 0931-0509
Manera KE, Tong A, Craig JC, et al., 2017, STANDARDIZED OUTCOMES IN NEPHROLOGY-PERITONEAL DIALYSIS (SONG-PD): STUDY PROTOCOL FOR ESTABLISHING A CORE OUTCOME SET IN PD, PERITONEAL DIALYSIS INTERNATIONAL, Vol: 37, Pages: 639-647, ISSN: 0896-8608
Vanholder R, Annemans L, Brown E, et al., 2017, Further approaches to reduce the cost of renal replacement therapy, NATURE REVIEWS NEPHROLOGY, Vol: 13, ISSN: 1759-5061
Van Biesen W, Brown EA, 2017, Diagnostic and therapeutic approach to peritonitis, NEPHROLOGY DIALYSIS TRANSPLANTATION, Vol: 32, Pages: 1283-1284, ISSN: 0931-0509
Vanholder R, Annemans L, Brown E, et al., 2017, Reducing the costs of chronic kidney disease while delivering quality health care: a call to action, NATURE REVIEWS NEPHROLOGY, Vol: 13, Pages: 393-409, ISSN: 1759-5061
Brown EA, Bargman J, van Biesen W, et al., 2017, LENGTH OF TIME ON PERITONEAL DIALYSIS AND ENCAPSULATING PERITONEAL SCLEROSIS - POSITION PAPER FOR ISPD: 2017 UPDATE, PERITONEAL DIALYSIS INTERNATIONAL, Vol: 37, Pages: 362-374, ISSN: 0896-8608
Szeto C-C, Li PK-T, Johnson DW, et al., 2017, ISPD CATHETER-RELATED INFECTION RECOMMENDATIONS: 2017 UPDATE, PERITONEAL DIALYSIS INTERNATIONAL, Vol: 37, Pages: 141-154, ISSN: 0896-8608
Brown EA, Finkelstein FO, Iyasere OU, et al., 2017, Peritoneal or hemodialysis for the frail elderly patient, the choice of 2 evils?, KIDNEY INTERNATIONAL, Vol: 91, Pages: 294-303, ISSN: 0085-2538
Sulemane S, Panoulas VF, Bratsas A, et al., 2017, Subclinical markers of cardiovascular disease predict adverse outcomes in chronic kidney disease patients with normal left ventricular ejection fraction, INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING, Vol: 33, Pages: 687-698, ISSN: 1569-5794
Emerging cardiovascular biomarkers, such as speckle tracking echocardiography (STE) and aortic pulse wave velocity (aPWV), have recently demonstrated the presence of subclinical left ventricular dysfunction and arterial stiffening in patients with chronic kidney disease (CKD) and no previous cardiovascular history. However, limited information exists on the prognostic impact of these biomarkers. We aimed to investigate whether STE and aPWV predict major adverse cardiac events (MACE) in this patient population. In this cohort study we prospectively analysed 106 CKD patients with no overt cardiovascular disease (CVD) and normal left ventricular ejection fraction. Cardiac deformation was measured using STE while aPWV was measured using arterial tonometry. The primary end-point was the composite of all-cause mortality, acute coronary syndrome, stable angina requiring revascularization (either using percutaneous coronary intervention or coronary artery bypass surgery), hospitalization for heart failure and stroke. Over a median follow up period of 49 months (interquartile range 11–63 months), 26 patients (24.5%) reached the primary endpoint. In a multivariable Cox hazards model, global longitudinal strain (GLS) (HR 1.12, 95% CI 1.02–1.29, p = 0.041) and aPWV (HR 1.31, 95% CI 1.05–1.41, p = 0.021) were significant, independent predictors of MACE. GLS and aPWV independently predict MACE in CKD patients with normal EF and no clinically overt CVD.
Segall L, Nistor I, Van Biesen W, et al., 2017, Dialysis modality choice in elderly patients with end-stage renal disease: a narrative review of the available evidence, NEPHROLOGY DIALYSIS TRANSPLANTATION, Vol: 32, Pages: 41-49, ISSN: 0931-0509
Bartholomew C, Jones C, Brown E, 2016, CKD and frailty: outcomes from a quality initiative for older patients, Journal of Kidney Care, Vol: 1, Pages: 153-157, ISSN: 2397-9534
Finkelstein FO, Zhao J, Bieber B, et al., 2016, INTERNATIONAL VARIATIONS IN THE EXPERIENCE OF PATIENTS ON PERITONEAL DIALYSIS (PD) IN THE PERITONEAL DIALYSIS OUTCOMES AND PRACTICE PATTERNS STUDY (PDOPPS), 53rd ERA-EDTA Congress, Publisher: OXFORD UNIV PRESS, Pages: 239-240, ISSN: 0931-0509
Sulemane S, Panoulas VF, Konstantinou K, et al., 2016, Erratum to: ‘Left ventricular twist mechanics and its relation with aortic stiffness in chronic kidney disease patients without overt cardiovascular disease’, Cardiovascular Ultrasound, Vol: 14, ISSN: 1476-7120
Sulemane S, Panoulas VF, Konstantinou K, et al., 2016, Left ventricular twist mechanics and its relation with aortic stiffness in chronic kidney disease patients without overt cardiovascular disease., Cardiovascular Ultrasound, Vol: 14, ISSN: 1476-7120
BACKGROUND: Recent studies hypothesized left ventricular (LV) twist as a potential biomarker for evaluation of sub clinical myocardial disease, however its relationship with aortic stiffness has yet to be investigated. Chronic kidney disease (CKD) has been identified as a risk factor for both myocardial and arterial disease. As such we sought to explore the relationship between aortic stiffness and LV twist in CKD patients without known cardiovascular disease (CVD). METHODS: In this prospective, observational study we enrolled 106 CKD patients (Stages 1 to 5) with normal LVEF as assessed by conventional echocardiography. Aortic stiffness was measured using aortic pulse wave velocity (aPWV). We defined increased aPWV as ≥10 m/s. LV Twist was measured using two-dimensional speckle tracking echocardiography. RESULTS: Patients with increased aPWV had higher LV twist (p = 0.002) but similar LVEF (p = 0.486). Aortic PWV correlated crudely with age (p < 0.001), the presence of diabetes (p < 0.001), hypertension (p < 0.001), eGFR (p < 0.001), LVMI (p = 0.01), e/e' (p < 0.001) and LV twist (p = 0.003). In multivariable analyses after adjusting for age, gender, cardiovascular risk factors and hypertensive medication, aPWV was independently associated with LV twist (β = 0.163, p = 0.025). CONCLUSIONS: Aortic stiffness independently associates with LV Twist in asymptomatic CKD patients. These findings suggest a close interaction between LV twist mechanics and arterial remodeling even before CVD becomes clinically relevant.
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