Diet in Intestinal Fibrosis: A Double-Edged Sword

The natural history of inflammatory bowel diseases, especially Crohn’s disease, is frequently complicated by intestinal fibrosis. Because of the lack of effective treatments for intestinal fibrosis, there is an urgent need to develop new therapies. Factors promoting intestinal fibrosis are currently unclear, but diet is a potential culprit. Diet may influence predisposition to develop intestinal fibrosis or alter its natural history by modification of both the host immune response and intestinal microbial composition. Few studies have documented the effects of dietary factors in modulating IBD-induced intestinal fibrosis. As the mechanisms behind fibrogenesis in the gut are believed to be broadly similar to those from extra-intestinal organs, it may be relevant to investigate which dietary components can inhibit or promote fibrosis factors such as myofibroblasts progenitor activation in other fibrotic diseases.     

End-Stage Renal Disease in Nursing Homes: A Systematic Review

Objectives/IntroductionDemand for nursing home (NH) care by patients with end-stage renal disease (ESRD) is likely to increase with growing numbers of older adults initiating chronic dialysis. We completed a systematic review to summarize the literature on NH residents with ESRD.MethodsMEDLINE, CINAHL, EMBASE, and relevant conference proceedings were searched to identify articles using the following MESH terms or related key words in the title or abstract: “residential facilities”, “renal dialysis”, “renal replacement therapy”, and “chronic kidney failure”. We selected case control, cohort studies, and clinical trials that included older adults with ESRD (defined as those receiving chronic dialysis or those with stage 5 chronic kidney disease) living in residential care facilities. We abstracted information on study design, quality, and results.ResultsOf 198 unique citations identified by the search strategy, 14 articles met eligibility criteria. Most articles were multicenter studies that were conducted in the 1990s. One study focused on patients with stage 5 chronic kidney disease, and the remaining 13 studies focused on patients receiving chronic dialysis, of which eight studies included only those receiving peritoneal dialysis, four studies included patients receiving both peritoneal dialysis and hemodialysis, and one study included only patients receiving hemodialysis. All studies were observational, no clinical trials were identified, and study design limitations and heterogeneity within study populations were common. Summarizing results across these studies suggests that NH residents with ESRD have limited survival, particularly early after dialysis initiation. Functional impairment is highly prevalent in this population and independently associated with poor outcomes.ConclusionsNH residents with ESRD appear to be a particularly vulnerable population, but current information on their prevalence, characteristics, and outcomes is limited. Further research is needed to provide a better understanding of modifiable predictors of survival and functional decline in this population.     

The Effects of α-Tocopherol on Bone: A Double-Edged Sword?

Recent studies have found conflicting evidence on the role of α-tocopherol (αTF) on bone health. This nonsystematic review aimed to summarize the current evidence on the effects of αTF on bone health from cell culture, animal, and human studies in order to clarify the role of αTF on bone health. Our review found that αTF exerted beneficial, harmful or null effects on bone formation cells. Animal studies generally showed positive effects of αTF supplementation on bone in various models of osteoporosis. However, high-dose αTF was possibly detrimental to bone in normal animals. Human studies mostly demonstrated a positive relationship between αTF, as assessed using high performance liquid chromatography and/or dietary questionnaire, and bone health, as assessed using bone mineral density and/or fracture incidence. Three possible reasons high dosage of αTF can be detrimental to bone include its interference with Vitamin K function on bone, the blocking of the entry of other Vitamin E isomers beneficial to bone, and the role of αTF as a prooxidant. However, these adverse effects have not been shown in human studies. In conclusion, αTF may have a dual role in bone health, whereby in the appropriate doses it is beneficial but in high doses it may be harmful to bone.     

A Social Work Perspective on Ethical Practice in End-Stage Renal Disease

Social workers increasingly are defining problems that they encounter in practice in health settings as ethical dilemmas. A distinction is made between those practice questions that can best be answered by an appeal to theoretical or empirical knowledge and expertise (clinical questions) and those with invoke values and ethical imperatives (ethical questions). End-stage renal disease poses in high relief the practice dilemmas that are encountered by social workers and offers an opportunity to explore and clarify issues resolving them. Using an exchange framework as a basis for analysis, common ethical problems of end-stage renal services are discussed.     

Ethical Issues in Treatment of Patients with End-Stage Renal Disease

Ethical issues in the care and treatment of patients with end-stage renal disease are illustrative of problems that confront social workers who practice in a medical setting. Chief among these are dilemmas of informed consent and dealing with the problem patient. Patient advocacy may pose a conflict between respect for a patient's autonomy and acting in the patient's best medical interest. Pressures of resource allocation on a dialysis unit also require a just resolution.     

Outcomes Associated with a Disease Management Program for End-Stage Renal Disease

Disease-state management is gaining in use for the management of chronically ill individuals including those with diabetes mellitus, congestive heart failure, asthma, and some forms of cancer. Recently, disease management (DM) has been applied to patients with chronic kidney disease (CKD), a growing population of patients with high annual costs. CKD is ideally suited to DM since the definition of the condition is unambiguous and current care is highly fragmented. There are currently over 240 000 patients receiving dialysis for end-stage renal disease (ESRD), with projected numbers of nearly 600 000 by 2010, and nearly 9 million individuals with CKD not yet on dialysis. The total cost of care for patients with ESRD alone exceeded $US17 billion in 2000. Over 40% of costs for patients with ESRD result from hospitalizations, many of which can be avoided. In addition, much of the clinical morbidity and cost relates to associated comorbidities rather than ESRD per se, with little management presently provided for these conditions in the dialysis facility setting.DM for CKD uses field-based nurse care managers who can risk-assess patients and provide coordination of care so that the renal issues as well as comorbidities are identified and appropriately managed. Although few results from such efforts have been published, those that have, from RMS Disease Mnagement Inc., show remarkable improvements in a variety of clinical outcomes including mortality and hospitalization.Challenges to expanding DM for CKD include up-front funding to provide the needed DM, the availability of robust information systems to manage and analyze clinical and financial data, and the interest and participation of nephrologists, primary care providers and dialysis facilities, as well as other key providers to ensure that the DM approach is effective. With continuing increases in the number of patients with CKD in managed health plans, DM for this population will be even more important in the future to optimize clinical outcomes while constraining the costs of care.     

终末期肾病透析服务的国际经验

世界范围内,终末期肾病发病率都在激增,是威胁人类健康的重大疾病。本文通过介绍欧美发达国家和泰国、墨西哥、印度等发展中国家透析服务的组织、提供和支付,为我国透析服务的支付方式改革和管理机制完善提供借鉴。     

A Fully Integrated Clinical Information System to Support Management of End-Stage Renal Disease

End-stage renal disease (ESRD) is relatively rare, but very costly. The ESRD population in the US is elderly, over 40% have diabetes mellitus, and most have additional comorbid conditions. Concerns about the quality and cost of care for people with ESRD in the US prompted the Healthcare Financing Administration (HCFA) to launch a demonstration project to determine whether disease management might improve care at reduced cost. It also stimulated health plans in the private sector to begin contracting with newly formed ESRD disease management organizations (DMOs).We describe the clinical information system developed by one such organization, RMS Disease Management, an affiliate of Baxter Healthcare Corporation. The system was designed to function within disparate medical care delivery systems and regions, without adding work for providers or health plans. A point-of-care system was implemented using a client server configuration. Data were entered on laptops and uploaded over high-speed lines to a central site. The system was developed over 14 months and implemented in 12 regions in 1998 under a contract with Humana, a national health plan. Highly experienced, locally recruited nephrology nurses co-ordinated care and entered data. The data included standard quality indicators, performance measures and key outcomes, along with data on patient assessment, care management, and comorbid conditions.We have compiled 35 000 months of patient care experience in the past three years, and entered 4000 patients with ESRD into the program. The system has provided comparisons of data at the regional and national levels, an independent reference for auditing claims, rapid turn-around of data to drive outcomes management, and the ability to link all components of care management. The system configuration is scalable and has functioned well across multiple sites of care while maintaining the privacy and security of patient data.Future plans include migration to an internet-based platform, adoption of handheld devices for data entry, and development of an Internet site where patients, their caregivers and their providers can interact. The system is designed to accomodate the evolving scope of disease management for ESRD, broadening to embrace multiple comorbid conditions and increasing its focus on prevention Wellness.     

终末期肾病血液透析和腹膜透析的经济学评价

通过文献综述,系统评价国际上终末期肾病血液透析和腹膜透析经济学研究现状。结论显示,前期研究在研究设计和方法选择上普遍存在设计缺陷,未能收集到可信的数据对腹透和血透进行经济学比较,大部分文献只针对肾替代治疗的成本或效果进行分析,将治疗效果和成本分析同时纳入进行比较研究的文章较少,大多数文献都未对成本组成和成本测算方法做出明确的阐述,缺乏前瞻性大样本多中心的RCT研究。     

Measuring and Managing Health Outcomes and Quality of Care in End-Stage Renal Disease

Health outcomes measurement has become increasingly important in the care of patients with end-stage renal disease (ESRD). Interest has been stimulated by the relatively poor outcomes of patients with ESRD, variations in the process of care, the high costs of ESRD care, and the development of practice guidelines.There are a number of key outcome measures that can contribute to improving the care of patients with ESRD. Mortality, measured as the standardized mortality rate, remains a commonly used outcome measure. The standardized hospitalization rate is one measure of morbidity. Other important measures include: (i) transplantation rates; (ii) the proportion of patients with an appropriate hematocrit; (iii) the proportion of patients with usable vascular access at the initiation of hemodialysis; (iv) rates of vascular access failure; and (v) the mean urea reduction ratio. Quality-of-life measurement is becoming increasingly useful to providers of ESRD care. More experience is being gained with disease-specific quality-of-life instruments.Providers must be aware of the challenges that remain in health outcomes measurement and disease management. Resolving problems with case mix adjustment, managing the costs of measurement, extending outcomes measurement to pre-ESRD care, and developing strategies to couple outcomes measurement with efforts to improve patient care are important goals.