Disease management in chronic kidney disease

Chronic kidney disease (CKD) is a growing health problem of epidemic proportions both in the United States and worldwide. The care of CKD patients, before and after starting dialysis, remains highly fragmented resulting in suboptimal clinical outcomes and high costs, creating a high burden of disease on patients and the health care system. Disease management (DM) is an approach to coordinating care for this complex population of patients that has the promise of improving outcomes and constraining costs. For CKD patients not yet on dialysis, the major goals of a DM program are (1) early identification of CKD patients and therapy to slow the progression of CKD, (2) identification and management of the complications of CKD per se, (3) identification and management of the complications of comorbid conditions, and (4) smooth transition to renal replacement therapy. For those CKD patients on dialysis, focused attention on avoidable hospitalizations is a key to a successful DM program. Multidisciplinary collaboration among physicians (nephrologist, primary care physician, cardiologist, endocrinologist, vascular surgeons, and transplant physicians) and participating caregivers (nurse, pharmacist, social worker, and dietician) is critical as well. There are several potential barriers to the successful implementation of a CKD/end-stage renal disease DM program, including lack of awareness of the disease state among patients and health care providers, late identification and referrals to a nephrologist, complex fragmented care delivered by multiple providers in many different sites of care, and reimbursement that does not align incentives for all involved. Recent experience suggests that these barriers can be overcome, with DM becoming a promising approach for improving outcomes for this vulnerable population.     

Prevention of renal failure: the Malaysian experience

Renal replacement therapy in Malaysia has shown exponential growth since 1990. The dialysis acceptance rate for 2003 was 80 per million population, prevalence 391 per million population. There are now more than 10,000 patients on dialysis. This growth is proportional to the growth in gross domestic product (GDP). Improvement in nephrology and urology services with widespread availability of ultrasonography and renal pathology has improved care of renal patients. Proper management of renal stone disease, lupus nephritis, and acute renal failure has decreased these as causes of end-stage renal disease (ESRD) in younger age groups. Older patients are being accepted for dialysis, and 51% of new patients on dialysis were diabetic in 2003. The prevalence of diabetes is rising in the country (presently 7%); glycemic control of such patients is suboptimal. Thirty-three percent of adult Malaysians are hypertensive and blood pressure control is poor (6%). There is a national coordinating committee to oversee the control of diabetes and hypertension in the country. Primary care clinics have been provided with kits to detect microalbuminuria, and ACE inhibitors for the treatment of hypertension and diabetic nephropathy. Prevention of renal failure workshops targeted at primary care doctors have been launched, opportunistic screening at health clinics is being carried out, and public education targeting high-risk groups is ongoing. The challenge in Malaysia is to stem the rising tide of diabetic ESRD.     

Organ transplantation in diabetics patients with ESRD

Because of the increased incidence of end-stage renal disease (ESRD) secondary to diabetes mellitus (DM, organ transplantation in this population is a growing issue. Renal transplantation is the best therapeutic option. Patient survival for both Type I and type II DM patients, is improved by organ transplantation compared to dialysis. For type I DM, this improvement is also observed after combined kidney-pancreas transplantation (KPT). These results have been obtained by the improvement of surgical technique and immunosuppressive treatments. The characteristics of transplantation for DM patients are: 1. The need for early pre-transplantation evaluation with a special attention for ischemic cardiopathy. 2. The possibility of SPK for Type I or Type II DM patients if they are young, non-obese and with a marked endogenous insulin secretion decrease. The perspective for organ transplantation in diabetic patients with ESRD is islet transplantation. This technique has proven its efficacy for patients with no renal disease. Recent results show that islet transplantation may be successful in patients after renal transplantation.     

Prevalence of Japanese dialysis patients with an A-to-G mutation at nucleotide 3243 of the mitochondrial tRNA(Leu(UUR)) gene.

BACKGROUND: A high prevalence of an A-to-G mutation at nucleotide 3243 of the mitochondrial genome in patients with diabetes mellitus (DM) and/or deafness has been reported previously. We investigated the prevalence of this mutation in Japanese dialysis patients with associated DM and/or deafness. METHODS: We studied 106 dialysis patients with DM, 26 with DM and deafness, and 26 with deafness alone, using peripheral leucocytes to detect an A-to-G transition at nucleotide 3243 of the mitochondrial gene. RESULTS: We identified this transition in 1 of 26 patients with DM and deafness. None of the 106 DM or 26 dialysis patients with deafness but no DM was positive for this mutation. A 42-year-old male patient on continuous ambulatory peritoneal dialysis (CAPD) who carried this mutation had a 20-year history of sensory hearing loss as well as hypertrophic cardiomyopathy. CONCLUSION: We found that a mitochondrial gene mutation at nucleotide 3243 was present in one dialysis patient with NIDDM and deafness. The prevalence of this mutation was found to be below 1% in diabetic end-stage renal disease patients in Japan.     

Case-mix and treatment in end-stage renal disease: hemodialysis v peritoneal dialysis

The University of Southern California School of Medicine conducted a nationwide survey of 336 nephrologists to obtain demographic and clinical data on 6,411 patients with end-stage renal disease (ESRD). Patient demographic data, along with ESRD etiology and comorbid conditions noted by the physician, were compared across various modalities of dialysis. Characteristics of the treatment provided were differentiated by the mode of dialysis and the location of the patient encounter. Results of the analysis show that patients on peritoneal dialysis are more likely to be female and have higher rates of diabetes compared with hemodialysis (HD) patients. Statistically, patients on intermittent peritoneal dialysis are older, more likely to be black, and have a higher incidence of cardiovascular conditions. Continuous ambulatory peritoneal dialysis patients have greatest problem severity and require more physician time and more complex services, whereas home HD patients require the greatest number of diagnostic tests and therapeutic procedures. Hospital inpatient care shows greater case-mix severity and more intensive treatment, but this does not differ by the mode of dialysis. Finally, patients of freestanding dialysis facilities are more likely to have hypertensive renal disease, whereas patients at hospital-based facilities are older, more likely to be seen in the hospital, have more urgent and severe problems during dialysis rounds, and require more physician time, more complex services, and more diagnostic tests and therapeutic procedures.     

Epidemiology of diabetic nephropathy in Spain

BACKGROUND: The incidence of diabetes mellitus (DM) has increased persistently in recent years and is becoming an epidemic. Some have estimated that 4.4% of the world's population will be diabetic by the year 2030. The increase incidence of DM has been accompanied by an increased incidence in diabetic nephropathy (DN), the main cause of end-stage renal disease. METHODS AND RESULTS: In 1996, a pharmaco-economic study estimated that 162,000 people in Spain had type 1 DM and 1,354,900 had type 2 DM. More recent studies have estimated that 6% to 10% of the Spanish population might be diabetic. This percentage is higher in some autonomous communities, such as Canarias, in which 12% of the population is thought to have DM. Based on these studies, we estimate that more than 33,000 residents of Canarias have DN associated with type 1 DM, and more than 405,000 have DN associated with type 2 DM. The percentage of diabetic patients starting renal replacement therapy each year is currently around 21% in Spain but much higher (35%) in Canarias, which equates to 78 patients per million population (pmp) per year. In Catalonia, the number of DM patients entering renal replacement therapy has increased from 8.6 pmp per year in 1984 to 32.4 pmp per year in 2003. We estimate that the systematic application of converting enzyme inhibitors or angiotensin receptor blockers could save more than 2.690 million over 15 years in Spain. CONCLUSION: This epidemic could be prevented, or its impact reduced, through multifactorial and multidisciplinary early intervention, under the observance of guides, Spanish consensus documents, and clinical practice recommendations, together with an integrated educational program aimed at people with diabetes and the improvement of the standard of medical care.     

Dialysis in nursing homes

The number of geriatric end-stage renal disease (ESRD) patients in the United States is increasing disproportionately to other age groups on dialysis. Thus there will be more dialysis patients that will require the assistance of nursing homes or extended care facilities. Nursing homes may be beneficial for the geriatric patient in terms of social and physical rehabilitation. Many of these facilities, however, may not take care of or may not have the capacity to adequately care for dialysis patients. Such patients have a higher rate of peritonitis when on peritoneal dialysis (PD) and have higher mortality rates on hemodialysis (HD) or PD compared to similar dialysis patients in the community. Cooperation and communication between the dialysis center and the nursing home, given the complex management issues involved in the care of these patients, are essential. One promising approach to the care of elderly dialysis patients is an integration of nursing home and dialysis unit. Although another approach could be to more fully utilize the services of adult day care centers, this has proven logistically difficult and has not been reported to be successful since it was first suggested more than a decade ago.     

The prognostic value of renal biopsy in type 2 diabetes mellitus patients affected by diabetic glomerulosclerosis

BACKGROUND: Although several studies have dealt with clinicopathological correlations in diabetic glomerulosclerosis (DGS), few have investigated the prognostic value of the renal biopsy. METHODS: One hundred and thirty-five type2 diabetes mellitus (DM) patients with bioptically proven DGS and a mean follow-up of 56.1 months were subdivided in 5 groups according to the outcome: 1) living with preserved renal function; 2) living with renal failure, not requiring dialysis; 3) living in dialysis; 4) dead in dialysis; 5) dead with preserved renal function. Duration of DM, creatininemia and proteinuria values at the time of biopsy and a histologic scoring (from 0 to 3) of 10 morphologic features were considered for statistical analysis. RESULTS: Statistically significant differences were observed in the distribution of the above mentioned parameters in the 5 groups with the exception of the duration of DM. The prognosis of DGS is poor: 79 patients needed dialysis and 60 died. Univariate analysis demonstrated the prognostic value of creatininemia (>or= 1.5 mg/dL), proteinuria (>or= 3 g/d) and histologic score (>or= 10) in assessing the relative risk of progression to dialysis (OR= 9.75, 4.12 and 11 respectively). The prognostic value of the histologic score (or= 2) was maintained when each morphologic parameter was separately evaluated (OR ranging from 2.8 to 8.5). Multivariate analysis was applied and only serum creatinine and histological score maintained their statistical significance (OR=4.45 and 2.46). The independence of these two variables means that the risk of progression to dialysis is multiplied in each single patient. CONCLUSIONS: Renal biopsy adds reliable information to that supplied by clinical and laboratory findings in DGS and therefore its extensive adoption should be recommended. Thanks to the prognostic value of the single morphologic parameters, also small tissue samples can give reliable results.     

Hemodialysis as renal replacement therapy of choice for diabetic patients

Diabetes mellitus (DM) has become over the last decade the third cause of CKD-5 requiring launch of renal replacement therapy. Type 2 diabetes (DM2) representing 90% is a severe comorbid condition that is associated in almost 20% of dialysis patients in France. In spite major progresses in the management of diabetic dialysis patients, the cardiovascular morbidity and mortality is still very high. Recent reports indicate that mortality of DM2 patients in hemodialysis is close to 50% at two years. Hemodialysis or its alternatives (hemodiafiltration, hemofiltration) is still the most employed renal replacement modality in diabetic patients. Optimizing management of diabetic patients on hemodialysis relies on 6 major principles that are: early referral to nephrologist and start of RRT; early creation of native arteriovenous fistula; regular assessment of cardiovascular system; specific adaptation of the hemodialysis schedule (frequency, duration, type of membrane and dialysis fluid composition); fine tuning of medical treatment; specific and protocolized follow-up. Improving outcomes of diabetic patient with CKD-5 requires a multidisciplinary approach and a specific expertise of the nursing and medical team. Indeed, diabetic patient still pay a serious tribute to cardiovascular complications.     

彩色多普勒超声对糖尿病患者肾脏大小与肾血流动力学关系的分析

目的:应用彩色多普勒超声观察对糖尿病患者肾脏大小形态、结构及各级肾动脉阻力指数(RI)的改变,分析肾脏大小与阻力指数之间的关系,以期寻找更早期的、无创性的糖尿病肾病(DN)辅助诊断方法.方法:选择120例糖尿病(DM)患者,病程＜5年为DM1组60例,病程＞5年为DM2组60例,排除合并心衰、泌尿系感染、结石、肾血管疾病及其他原因致肾脏原发、继发病变,所有患者尿常规蛋白阴性,血尿素氮、肌酐正常.同时选择120例健康者作为对照组.应用彩色多普勒超声仪检查受试者肾脏大小、各级肾动脉阻力指数.应用SPSS统计软件包进行统计处理.结果:DN2组糖尿病患者肾脏较正常对照组及DM1组者大,两者比较有统计学意义.DM2组RI较DM1组及正常组高.DM2组肾脏大小与肾各级动脉RI之间有线性关系,呈正相关(r=0.85,P＜0.05).结论:彩色多普勒超声(CDFI)检测能提示DM患者肾脏大小和肾血流动力学情况,对早期DN的诊断是有价值的.     

Early referral to the nephrologist and timely initiation of renal replacement therapy: a paradigm shift in the management of patients with chronic renal failure

The high mortality rate among dialysis patients has spawned investigation into potentially correctable factors that are associated with an increased risk of death. Several studies have demonstrated a strong association between an increased risk of death in dialysis patients and suboptimal delivered dose of dialysis, malnutrition, and non-renal comorbidity. In addition, the use of unsubstituted cellulose dialyzers and reprocessed dialyzers also has been associated with an increased risk of death. Increased attention to these factors has resulted in a significant improvement in patient survival. Nonetheless, the mortality of dialysis patients remains unacceptably high and indicates that other factors may be operative. One of the factors that has thus far received scant attention, but could significantly affect morbidity and mortality in dialysis patients, is the timing and quality of care before initiation of dialysis. Optimal pre-end-stage renal disease care involves early interventions aimed at delaying progression of chronic renal failure, judicious management of uremic complications, timely placement of vascular access, timely initiation of renal replacement therapy, and implementation of educational programs targeted at maximum rehabilitation. Given the fact that early referral to the nephrologist is likely to result in optimal pre-dialysis care, the 1993 National Institutes of Health Consensus Statement on Morbidity and Mortality of Dialysis recommended that referral of a patient to a renal team should occur at a serum creatinine of 1.5 mg/dL in women and 2.0 mg/dL in men. Several investigators also have argued that patients with chronic renal failure who begin dialysis at a relatively "high level of residual renal function" (early start) may have lower morbidity and mortality compared with patients who begin dialysis at a more traditional "low level of renal function" (late start). This hypothesis is based on evidence that declining renal function is associated with malnutrition and that malnutrition at the start of dialysis is associated with poor clinical outcomes. Furthermore, patients are started on dialysis at an endogenous solute clearance that is lower than that accepted as optimum for patients on dialysis. Finally, limited clinical studies have demonstrated the benefit of early initiation of dialysis. Consequently, the Peritoneal Dialysis Adequacy Work Group of the National Kidney Foundation-Dialysis Outcomes Quality Initiative recommends that dialysis be initiated when the weekly renal Kt/Vurea decreases to below 2.0 unless all three of the following criteria are fulfilled: (1) stable or increased edema-free body weight, (2) normalized protein equivalent of total nitrogen appearance greater than 0.8, and (3) absence of clinical symptoms and signs attributable to uremia.     

Dialysis in diabetic patients: hemodialysis and peritoneal dialysis. Pros and cons

Both hemodialysis (HD) as well as peritoneal dialysis (PD), are efficient renal replacement therapies in uremic patients with and without diabetes. PD is less expensive dialysis modality and may provide a survival advantage over hemodialysis in first 2 to 4 years of treatment. Chronic ambulatory peritoneal dialysis (CAPD) as well as Continuous Cycler-Assisted Peritoneal Dialysis (CCPD) have additional advantages in patients with diabetes. PD therapy will be better tolerated than HD, the blood pressure is more stable and vascular access is not necessary. Preserving residual renal function (RRF) is of paramount importance to prolong the survival outcomes in PD patients. In insulin-dependent diabetic patients intraperitoneal insulin substitution can be used. The development of new, more biocompatible PD solutions holds promise for the future. Nevertheless, in many countries HD is further more favoured in the treatment of patients with ESRD.     

Different kidney function trajectory patterns before dialysis in elderly patients: clinical implications and outcomes

Background. Identifying trajectories of kidney disease progression in chronic kidney disease (CKD) patients may help to deliver better care. We aimed to identify and characterize trajectories of renal function decline in CKD patients and to investigate their association with mortality after dialysis.Methods. This retrospective cohort study included 378 CKD patients who initiated dialysis (aged 65 years and over) between 2009 and 2016. Were considered mixed models using linear quadratic and cubic models to define the trajectories, and we used probabilistic clustering procedures. Patient characteristics and care practices at and before dialysis were examined by multivariable multinomial logistic regression. The association of these trajectories with mortality after dialysis was examined using Cox models.Results. Four distinct groups of eGFR trajectories decline before dialysis were identified: slower decline (18.3%), gradual decline (18.3%), early rapid decline (41.2%), and rapid decline (22.2%). Patients with rapid eGFR decline were more likely to have diabetes, more cognitive impairment, to have been hospitalized before dialysis, and were less likely to have received pre-dialysis care compared to the patients with a slower decline. They had a higher risk of death within the first and fourth year after dialysis initiation, and after being more than 4 years in dialysis.Conclusions. There are different patterns of eGFR trajectories before dialysis initiation in the elderly, that may help to identify those who are more likely to experience an accelerated decline in kidney function, with impact on pre ESKD care and in the mortality risk after dialysis.     

A Quality Improvement Model for Optimizing Care of the Diabetic End‐Stage Renal Disease Patient

Persons with diabetes mellitus whose kidney disease progresses to end‐stage requiring dialysis have poorer outcomes compared to nondiabetic patients who commence maintenance dialysis. In the diabetic patient without renal failure, sustained strict glycemic, lipid, and blood pressure (BP) control can retard or thwart diabetic complications such as retinopathy, neuropathy, coronary disease, and peripheral vascular disease. Achieving these outcomes requires multidisciplinary collaborative care. Best care of the diabetic person requires a dedicated clinician who knows the patient well, who closely follows the course of clinical problems, who provides frequent assessments and interventions, and who also directs care to other agencies, clinics, and specialized clinicians who provide expert focused evaluations and interventions aimed at specific clinical concerns. Diabetic patients who reach end‐stage renal disease (ESRD) have even greater clinical need of a dedicated principal care clinician than the diabetic patient who has minimal or moderate kidney disease. The diabetic patient with ESRD exhibits greater fluctuations in glucose and BP due to dialysis‐related diet patterns and fluid balances and has more active cardiovascular problems due to the combined influences of calcium, phosphorus, and lipid imbalances. These problems warrant exceptional care that includes frequent surveillance and monitoring with timely interventions if patient outcomes are to be improved. We present here a quality improvement model for optimizing care of the diabetic dialysis patient that relies on a dedicated practitioner who can evaluate and intervene on the multiple variables within and beyond the dialysis clinic that impact the patient’s health. We present three detailed clinical care pathways that the dedicated clinician can follow. We believe that patient outcomes can be improved with this approach that provides customized problem‐focused care, collaborates with the dialysis‐provider team, and extends and directs diabetic self‐care, home‐care, and specialized clinical care in the challenging areas of cardiac and peripheral vascular disease, glycemic control, lipid control, infection prevention, and BP management.     

Chronic kidney disease and its prevention in India

Chronic kidney disease (CKD) is an important, chronic, noncommunicable disease epidemic that affects the world, including India. Because of the absence of a renal registry in India, the true magnitude of CKD/end-stage renal disease (ESRD) is unknown. Two community-based studies, although methodologically different, have shown a prevalence of chronic renal failure of 0.16% and 0.79%. The cost of maintenance hemodialysis for a single session varies between 10 US dollars to 40 between government-run and private hospitals. The average cost of erythropoetin is approximately 150 US dollars to 200 per month. The cost of chronic ambulatory peritoneal dialysis with "Y" set at 3 exchanges per week, which most patients in India do, is US 400 US dollars per month. The cost of a renal transplant (RT) procedure is approximately US 700 US dollars to 800 in the government sector and 6000 US dollars in the private sector. The cost of immunosuppression with basic triple immunosuppression drugs (cyclosporine, steroid, and azathioprin) is US 250 US dollars per month. There are hardly any state-funded medical treatment and medical insurance facilities for CKD and ESRD patients in India. India has nearly 700 nephrologists and approximately 400 dialysis units with 1000 dialysis stations, with the majority being in the private sector. A maximum of 2% of patients can be subjected to maintenance hemodialysis. Until now, approximately 3000 patients have been initiated on chronic ambulatory peritoneal dialysis. India has approximately 100 RT centers, mostly in private setup, and not more than 3000 to 4000 RTs are performed annually. Thus, only 3% to 5% of all patients with ESRD in India get some form of renal replacement therapy. Thus, planning for prevention of CKD on a long-term basis is the only practical solution for India. It appears that even in India, diabetes and hypertension are responsible for 40% to 50% of all cases of chronic renal failure. Screening for these 2 diseases and CKD is simple and easy to perform. The best approach will be to start screening for CKD in a high-risk group, like first-degree relatives of patients with diabetes, hypertension, and CKD, and simultaneously making a platform to run the program through the existing health care system of the country. The key issue of funding the program needs to be explored. Initial funding may come from international agencies like the World Health Organization, World Bank, and International Society of Nephrology, along with support from the country itself. Ultimately, funding has to be sustained from our own existing health care system.     

Mortality caused by sepsis in patients with end-stage renal disease compared with the general population

BACKGROUND: In the United States, infection is second to cardiovascular disease as the leading cause of death in patients with end-stage renal disease (ESRD), and septicemia accounts for more than 75% of this category. This increased susceptibility to infections is partly due to uremia, old age, and comorbid conditions. Although it is intuitive to believe that mortality caused by sepsis may be higher in patients with ESRD compared with the general population (GP), no such data are currently available. METHODS: We compared annual mortality rates caused by sepsis in patients with ESRD (U.S. Health Care Financing Administration 2746 death notification form) with those in the GP (death certificate). Data were abstracted from the U.S. Renal Data System (1994 through 1996 Special Data request) and the National Center for Health Statistics. Data were stratified by age, gender, race, and diabetes mellitus (DM). Sensitivity analyses were performed to account for potential limitations of the data sources. RESULTS: Overall, the annual percentage mortality secondary to sepsis was approximately 100- to 300-fold higher in dialysis patients and 20-fold higher in renal transplant recipients (RTRs) compared with the GP. Mortality caused by sepsis was higher among diabetic patients across all populations. After stratification for age, differences between groups decreased but retained their magnitude. These findings remained robust despite a wide range of sensitivity analyses. Indeed, mortality secondary to sepsis remained approximately 50-fold higher in dialysis patients compared with the GP, using multiple cause-of-death analyses; was approximately 50-fold higher in diabetic patients with ESRD compared with diabetic patients in the GP, when accounting for underreporting of DM on death certificates in the GP; and was approximately 30-fold higher in RTRs compared with the GP, when accounting for the incomplete ascertainment of cause of death among RTRs. Furthermore, despite assignment of primary cause-of-death to major organ infections in the GP, annual mortality secondary to sepsis remained 30- to 45-fold higher in the dialysis population. CONCLUSIONS: Patients with ESRD treated by dialysis have higher annual mortality rates caused by sepsis compared with the GP, even after stratification for age, race, and DM. Consequently, this patient population should be considered at high-risk for the development of lethal sepsis.     

Perceived health-related quality of life and comorbidity in diabetic patients starting dialysis (CALVIDIA study)

BACKGROUND: Diabetes mellitus (DM) is a widespread prevalent illness, currently the main cause of end-stage renal disease (ESRD). MATERIAL AND METHODS: In a longitudinal, prospective study we compared two cohorts of patients starting dialysis therapy, diabetic and non-diabetic ESRD patients. Perceived health was measured by the Medical Outcomes Study Short-Form 36 (SF-36) questionnaire, functional status by the Karnofsky scale and comorbidity by the Charlson age-comorbidity index. A broad spectrum of variables in relation to diabetes, ESRD, comorbidity and renal replacement therapy (RRT) were studied, as well as the distribution of comorbidity frequencies at dialysis start. RESULTS: Thirty-four Spanish centers included 232 diabetic patients, 43 type 1 and 189 type 2, mean diabetes duration 18 +/- 9 yrs, and five centers included 121 non-diabetic patients. Out of the 232 diabetic patients, 187 patients (81%) started hemodialysis (HD) and 45 patients (19%) started peritoneal dialysis (PD) (vs. 82% and 18%, respectively in non-diabetic patients). Transient vascular access (VA) for starting RRT was required in 54% of the diabetic patients vs. 53% in the nondiabetic patients. When both study groups were compared, diabetic patients required antihypertensive drugs more frequently than non-diabetic patients and showed higher systolic blood pressure (BP), as well as higher cardiovascular (CV) complication incidences, poorer SF-36 physical component summary scores and mental component summary scores and worse Karnofsky scale scores, with the Charlson age-comorbidity score being higher. CONCLUSION: Diabetic patients starting dialysis in Spain are more often type 2 diabetics, have worse perceived health-related quality of life (HRQoL) in relation to non-diabetic patients, worse functional status and higher incidences of prognostic mortality markers.     

Withholding and withdrawing dialysis: the role of physician specialty and education and patient functional status

Withholding and withdrawing dialysis are subjects of major concern to nephrologists, because both result in a significant number of end-stage renal disease (ESRD) patient deaths. The medical literature on withholding dialysis is extremely limited, and that on withdrawing dialysis consists mainly of retrospective studies from the 1980s. The present study was conducted to identify ways to improve dialysis decision making by providing a current understanding of how decisions to withhold or withdraw dialysis are being made and by examining whether some patients who might benefit from dialysis are not being referred. In 1995, 22 of 27 (82%) nephrologists practicing in West Virginia agreed to participate in a year-long prospective study in which they completed forms on each patient from whom they withheld or withdrew dialysis. Seventy-six of a random sample of 214 (36%) primary care physicians returned questionnaires describing their practice experience in 1995 with patients with advanced chronic renal failure. The nephrologists withdrew dialysis from 60 of 822 (7%) patients. Academic nephrologists who had received education in the ethics and law of stopping dialysis withdrew it from a greater percentage of patients than those in private practice (12% v 6%; P = 0.009). Patients who were withdrawn more often resided in nursing homes (37% v 2%; P < 0.0001). Twenty-one patients (37%) lacked decision-making capacity at the time the decision was made to withdraw dialysis. Advance directives were available for 13 of the 21 (62%) patients: eight of the 10 treated by academic nephrologists and five of the 11 treated by private practice nephrologists. Academic nephrologists found advance directives to be helpful in decision making to withdraw dialysis of incapacitated patients more often than nephrologists in private practice (70% v 9%; P = 0.004). Nephrologists withheld dialysis from 25 of 357 (7%) ESRD patients compared with 42 of 193 (22%) withheld by primary care physicians (P < 0.001). In deciding not to refer a patient for a dialysis evaluation, 25% of primary care physicians did not consult a nephrologist; 60% cited age as a reason not to refer. These findings suggest that dialysis decision making might be improved by educating nephrologists about the ethics and law of withdrawing dialysis and about how to implement successfully advance care planning so that advance directives will be present and helpful when decisions need to be made for incapacitated dialysis patients. Education of primary care physicians about when to refer patients with chronic renal failure for a dialysis evaluation might also result in more referrals for patients who will benefit from dialysis.     

Cryptococcal peritonitis in patients on peritoneal dialysis

Peritonitis is an unusual complication of infections caused by Cryptococcus neoformans and has rarely been reported in patients with end-stage renal disease who are maintained on peritoneal dialysis. We report two patients on chronic peritoneal dialysis in whom the first known manifestation of cryptococcal infection was dialysate cultures positive for Cryptococcus neoformans. One patient was on prednisone for systemic lupus erythematosis. The other patient was severely malnourished with type I diabetes mellitus. Both patients were found to have cryptococcal meningitis. Both patients were treated with intravenous (IV) amphotericin B and removal of the dialysis catheter. Evaluation and care of peritoneal dialysis patients with cryptococcal peritonitis include serial cryptococcal cultures and antigen titers, investigation for cryptococcal meningitis, removal of the peritoneal dialysis catheter, and IV amphotericin B.