ORCID Profile
0000-0001-9112-0304
Current Organisations
Université de Montréal
,
Sunshine Coast University Hospital
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Publisher: Wiley
Date: 29-04-2019
DOI: 10.1111/NEP.13530
Abstract: To compare quality of life (QOL) of caregivers of dialysis patients with the cared for patients and population norms. The ACTIVE Dialysis study randomized participants to extended (median 24 h/week) or standard (median 12 h/week) haemodialysis hours for 12 months. A subgroup of participants and their nominated caregivers completed QOL questionnaires including the EuroQOL-5 Dimension-3 Level (EQ5D-3 L), short form-36 (SF-36, also allowing estimation of the SF-6D), as well as a bespoke questionnaire and the personal wellbeing index (PWI). Caregiver QOL was compared with dialysis patient QOL and predictors of caregiver QOL were determined using multivariable regression. There were 54 patients and caregiver pairs, predominantly from China. Caregivers mean (SD) age was 53.4 (11.3) years, 60% were female, 71% cared for their spouse artner, and 36% were educated to university level. Caregivers had better physical but similar mental QOL compared with dialysis patients (mean SF-36 physical component summary: 46.9 ± 8.7 vs 40.4 ± 10.2, P < 0.001 mental component summary: 47.8 ± 9.7 vs 49.6 ± 12.0, P = 0.84). Health utility measured with EQ5D-3 L was not significantly different between caregivers and dialysis patients (mean 0.869 ± 0.185 vs 0.798 ± 0.227, P = 0.083). Caregiver PWI was 43.7 ± 15.5, significantly lower than the Chinese population norm (68.2 ± 14.2, P < 0.001). Higher physical and mental QOL among caregivers was predicted by university education but not age, gender or daily hours caring. Caregivers have higher physical and equivalent mental QOL to dialysis patients but poorer personal well-being than the Chinese population. University education predicts better QOL and may be a surrogate for socioeconomic or other factors. (NCT00649298).
Publisher: SAGE Publications
Date: 30-05-2019
Abstract: The creation and maintenance of dialysis vascular access is associated with significant morbidity. Structured management pathways can reduce this morbidity, yet practice patterns in Australia and New Zealand are not known. We aimed to describe the arteriovenous access practices in dialysis units in Australia and New Zealand. An online survey comprising 51 questions was completed by representatives from dialysis units from both countries. In addition to descriptive analysis, responses were compared between units inside and outside of major cities. Of 64 contacted units, 48 (75%) responded (Australia 43, New Zealand 5), representing 38% of dialysis units in Australia and New Zealand. While 94% of units provided pre-dialysis education, only 60% reported a structured pre-dialysis pathway and 69% had a dedicated vascular access nurse. Most units routinely monitored fistula/graft function using flow rate measurement (73%) or recirculation studies (63%). A minority used routine ultrasound (35%). Thrombectomy, fistuloplasty and peritoneal dialysis catheter insertion were rarely performed by nephrologists (4%, 4% and 17% of units, respectively). Units outside of a major city were less likely to have access to a local vascular access surgeon (6/13 (46%) vs 35/35 (100%), P 0.001). There were no other significant differences between units on the basis of location. Much variation exists in unit management of arteriovenous access. Structured pre-dialysis pathways and dedicated vascular access nurses may be underutilised in Australia and New Zealand. The use of regular access blood flow measurement and ultrasound is common in both countries despite a lack of data supporting its effectiveness. There is room for both practice improvement and a need for further evidence to ensure optimal arteriovenous access care.
Publisher: BMJ
Date: 12-04-2022
Abstract: To identify whether multifaceted interventions, or care bundles, reduce catheter related bloodstream infections (CRBSIs) from central venous catheters used for haemodialysis. Stepped wedge, cluster randomised design. 37 renal services across Australia. All adults (age ≥18 years) under the care of a renal service who required insertion of a new haemodialysis catheter. After a baseline observational phase, a service-wide, multifaceted intervention bundle that included elements of catheter care (insertion, maintenance, and removal) was implemented at one of three randomly assigned time points (12 at the first time point, 12 at the second, and 13 at the third) between 20 December 2016 and 31 March 2020. The primary endpoint was the rate of CRBSI in the baseline phase compared with intervention phase at the renal service level using the intention-to-treat principle. 1.14 million haemodialysis catheter days of use were monitored across 6364 patients. Patient characteristics were similar across baseline and intervention phases. 315 CRBSIs occurred (158 in the baseline phase and 157 in the intervention phase), with a rate of 0.21 per 1000 days of catheter use in the baseline phase and 0.29 per 1000 days in the intervention phase, giving an incidence rate ratio of 1.37 (95% confidence interval 0.85 to 2.21 P=0.20). This translates to one in 10 patients who undergo dialysis for a year with a catheter experiencing an episode of CRBSI. Among patients who require a haemodialysis catheter, the implementation of a multifaceted intervention did not reduce the rate of CRBSI. Multifaceted interventions to prevent CRBSI might not be effective in clinical practice settings. Australia New Zealand Clinical Trials Registry ACTRN12616000830493.
Publisher: Wiley
Date: 22-12-2016
DOI: 10.1111/NEP.12720
Abstract: Advanced training programmes in nephrology should provide broad exposure to all aspects of nephrology. In Australia and New Zealand (ANZ), the Advanced Training Committee in Nephrology oversees training, and recent increases in trainee numbers have led to concern about dilution of experience. To investigate early career paths of nephrologists in ANZ and determine the adequacy of training by comparing self-determined competency and skill relevance among recently graduated nephrologists. In 2015, the Advanced Training Committee in Nephrology administered an online survey during the annual subscription for members of the Australian and New Zealand Society of Nephrology. Nephrologists who were awarded Fellowship after 2002 were invited to participate. The survey was completed by 113 Fellows with 8 respondents excluded (response rate 44.1%). Initial post-Fellowship work included full-time public hospital appointments (34.3%) or undertaking full-time higher research degrees (41.9%). The majority reported securing their desired employment. Respondents indicated adequate training in most clinical skills however, responses of 'well trained' in home haemodialysis (41.8%), conservative care (42.9%), automated peritoneal dialysis (38.8%), and assessment of kidney transplant recipients (48%) and living kidney donors (34.7%) were less adequate. Although considered highly relevant to current practice, responses of 'well trained' were low for management and research skills, including complaint management (16.3%), private practice management (2%), health system knowledge (14.3%) and regulations (6.1%), ethics approval (23.5%), research funding (11.2%) and quality assurance (26.5%). Nephrology training in ANZ generally meets clinical needs and most secure their desired employment. Training in management and research are areas for improvement.
Publisher: Wiley
Date: 28-10-2015
DOI: 10.1111/NEP.12522
Abstract: The impact of natural disasters on the provision of dialysis services has received increased attention in the last decade following Hurricane Katrina devastating New Orleans in 2005. The Asia-Pacific is particularly vulnerable to earthquakes, tsunami, typhoons (also known as cyclones and hurricanes) or storms and flooding. These events can seriously interrupt provision of haemodialysis with adverse effects for patients including missed dialysis, increased hospitalization and post-traumatic stress disorder. Furthermore, haemodialysis patients may need to relocate and experience prolonged periods of displacement from family and social supports. In contrast to haemodialysis, most literature suggests peritoneal dialysis in a disaster situation is more easily managed and supported. It has become apparent that dialysis units and patients should be prepared for a disaster event and that appropriate planning will result in reduced confusion and adverse outcomes should a disaster occur. Numerous resources are now available to guide dialysis units, patients and staff in preparation for a possible disaster. This article will examine the disaster experiences of dialysis units in the Asia-Pacific, the impact on patients and staff, methods employed to manage during the disaster and suggested plans for reducing the impact of future disasters.
Publisher: Wiley
Date: 07-2013
DOI: 10.1111/NEP.12126
Abstract: Most clinical registries in Australia, including the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), do not audit submitted data. Inaccurate data can bias registry analysis. This study aimed to audit data submitted to ANZDATA from a single region. A retrospective audit of in idual haemodialysis patient data recorded by ANZDATA at 31 December 2009 was completed by nephrologists in a blinded fashion. Original data were recorded by nursing staff. Patients received treatment at a public hospital, two affiliated satellite haemodialysis units, and three private haemodialysis units. Fifty-one audits were completed of a total 175 patients (29.1%) undertaking haemodialysis in 2009. Primary renal disease was correct in 86.3% (95%CI: 74.3-93.2), although errors in type of glomerulonephritis were common. Date of first dialysis (± 1-month error margin) was correct for 93.6%. Creatinine at first dialysis (± 10% error margin) was correct in 74.4%. Baseline comorbidity accuracy included: peripheral vascular disease (sensitivity 36.4% (95%CI: 24.6-50.1), specificity 82.8% (95%CI: 70.2-90.7)), ischaemic heart disease (sensitivity 69.2% (95%CI: 55.6-80.2), specificity 88.0% (95%CI: 76.3-94.3)), chronic lung disease (sensitivity 25.0% (95%CI: 15.2-38.3), specificity 93.6% (95%CI: 83.4-97.7)), diabetes (sensitivity 86.4% (95%CI: 74.4-93.2), specificity 96.6% (95%CI: 87.5-99.1)), cerebrovascular disease (sensitivity 75.0% (95%CI: 61.7-84.8), specificity 95.3% (95%CI: 85.8-98.6)), and ever smoked (sensitivity 83.3% (95%CI: 70.3-91.4), specificity 71.4% (95%CI: 57.3-82.3)). Non-melanoma skin cancer was under-reported and inaccurate. Data accuracy was favourable compared with other renal registry validation studies. Data accuracy may be improved by education and training of collectors. A larger audit is necessary to validate ANZDATA.
Publisher: BMJ
Date: 15-09-2020
DOI: 10.1136/BMJ.M2864
Publisher: Wiley
Date: 25-04-2018
DOI: 10.1111/NEP.13053
Abstract: Low socio-economic status (SES) is associated with increased incidence of end-stage kidney disease and in the USA, poorer dialysis survival. All Australians have access to a universal healthcare system. The study included all non-indigenous adult Australians registered with the Australia and New Zealand Dialysis and Transplant Registry who commenced dialysis between 2003 and 2013. SES at dialysis start was classified into quartiles of advantaged through to disadvantaged using Australian Bureau of Statistics socio-economic indexes for areas. The primary outcome was survival assessed using a competing risk regression model with renal transplantation as a competing risk. There was a significant interaction between age and SES, and hence, age-stratified survival analyses were performed. A total 20 810 commenced dialysis during the study period. Mortality for the most advantaged quartile was 102.4/1000 person-years (95% confidence interval (CI) 98.0-106.9) compared with 110.7/1000 person-years (95% CI 105.8-115.7) in the disadvantaged quartile. In adjusted analysis, dialysis survival, compared with quartile 1 (advantaged), was inferior in quartile 3 (sub-hazard ratio 1.10, 95% CI 1.03-1.17) and the disadvantaged quartile (sub-hazard ratio 1.09, 85% CI 1.02-1.16) and was significantly modified by age. This disparity in survival outcome between the different SES quartiles was only observed in younger patients but was attenuated in the older ones following an age-stratified analysis. In Australia, low SES has an adverse effect on dialysis patient survival despite universal healthcare. This effect is mainly among younger patients where SES may have a greater proportional impact than co-morbidities.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2014
DOI: 10.2215/CJN.08770813
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2017
Abstract: The relationship between increased hemodialysis hours and patient outcomes remains unclear. We randomized (1:1) 200 adult recipients of standard maintenance hemodialysis from in-center and home-based hemodialysis programs to extended weekly (≥24 hours) or standard (target 12–15 hours, maximum 18 hours) hemodialysis hours for 12 months. The primary outcome was change in quality of life from baseline assessed by the EuroQol 5 dimension instrument (3 level) (EQ-5D). Secondary outcomes included medication usage, clinical laboratory values, vascular access events, and change in left ventricular mass index. At 12 months, median weekly hemodialysis hours were 24.0 (interquartile range, 23.6–24.0) and 12.0 (interquartile range, 12.0–16.0) in the extended and standard groups, respectively. Change in EQ-5D score at study end did not differ between groups (mean difference, 0.04 [95% confidence interval, −0.03 to 0.11] P =0.29). Extended hours were associated with lower phosphate and potassium levels and higher hemoglobin levels. Blood pressure (BP) did not differ between groups at study end. Extended hours were associated with fewer BP-lowering agents and phosphate-binding medications, but were not associated with erythropoietin dosing. In a substudy with 95 patients, we detected no difference between groups in left ventricular mass index (mean difference, −6.0 [95% confidence interval, −14.8 to 2.7] g/m 2 P =0.18). Five deaths occurred in the extended group and two in the standard group ( P =0.44) two participants in each group withdrew consent. Similar numbers of patients experienced vascular access events in the two groups. Thus, extending weekly hemodialysis hours did not alter overall EQ-5D quality of life score, but was associated with improvement in some laboratory parameters and reductions in medication burden. (Clinicaltrials.gov identifier: NCT00649298).
Publisher: BMJ
Date: 12-2022
DOI: 10.1136/BMJOPEN-2022-066156
Abstract: Shared treatment decision-making and planning of care are fundamental in advanced chronic kidney disease (CKD) management. There are limited data on several key outcomes for the elderly population including survival, quality of life, symptom burden, changes in physical functioning and experienced burden of healthcare. Patients, caregivers and clinicians consequently face significant uncertainty when making life-impacting treatment decisions. The Elderly Advanced CKD Programme includes quantitative and qualitative studies to better address challenges in treatment decision-making and planning of care among this increasingly prevalent elderly cohort. The primary component is OUTcomes of Older patients with Kidney failure (OUTLOOK), a multicentre prospective observational cohort study that will enrol 800 patients ≥75 years with kidney failure (estimated glomerular filtration rate ≤15 mL/min/1.73 m 2 ) across a minimum of six sites in Australia. Patients entered are in the decision-making phase or have recently made a decision on preferred treatment (dialysis, conservative kidney management or undecided). Patients will be prospectively followed until death or a maximum of 4 years, with the primary outcome being survival. Secondary outcomes are receipt of short-term acute dialysis, receipt of long-term maintenance dialysis, changes in biochemistry and end-of-life care characteristics. Data will be used to formulate a risk prediction tool applicable for use in the decision-making phase. The nested substudies Treatment modalities for the InfirM ElderLY with end stage kidney disease (TIMELY) and Caregivers of The InfirM ElderLY with end stage kidney disease (Co-TIMELY) will longitudinally assess quality of life, symptom burden and caregiver burden among 150 patients and 100 caregivers, respectively. CONsumer views of Treatment options for Elderly patieNts with kiDney failure (CONTEND) is an additional qualitative study that will enrol a minimum of 20 patients and 20 caregivers to explore experiences of treatment decision-making and care. Ethics approval was obtained through Sydney Local Health District Human Research Ethics Committee (2019/ETH07718, 2020/ETH02226, 2021/ETH01020, 2019/ETH07783). OUTLOOK is approved to have waiver of in idual patient consent. TIMELY, Co-TIMELY and CONTEND participants will provide written informed consent. Final results will be disseminated through peer-reviewed journals and presented at scientific meetings.
Publisher: Elsevier BV
Date: 02-2013
DOI: 10.1053/J.AJKD.2012.08.032
Abstract: Recent evidence suggests that increased frequency and/or duration of dialysis are associated with improved outcomes. We aimed to describe the outcomes associated with patients starting extended-hours hemodialysis and assess for risk factors for these outcomes. Case series. Patients were from 6 Australian centers offering extended-hours hemodialysis. Cases were patients who started treatment for 24 hours per week or longer at any time. All-cause mortality, technique failure (withdrawal from extended-hours hemodialysis therapy), and access-related events. Baseline patient characteristics (sex, primary cause of end-stage kidney disease, age, ethnicity, diabetes, and cannulation technique), presence of a vascular access-related event, and dialysis frequency. 286 patients receiving extended-hours hemodialysis were identified, most of whom performed home (96%) or nocturnal (77%) hemodialysis. Most patients performed alternate-daily dialysis (52%). Patient survival rates using an intention-to-treat approach at 1, 3, and 5 years were 98%, 92%, and 83%, respectively. Of 24 deaths overall, cardiac death (n = 7) and sepsis (n = 5) were the leading causes. Technique survival rates at 1, 3, and 5 years were 90%, 77%, and 68%, respectively. Access event-free rates at the same times were 80%, 68%, and 61%, respectively. Access events significantly predicted death (HR, 2.85 95% CI, 1.14-7.15) and technique failure (HR, 3.76 95% CI, 1.93-7.35). Patients with glomerulonephritis had a reduced risk of technique failure (HR, 0.31 95% CI, 0.14-0.69). Higher dialysis frequency was associated with elevated risk of developing an access event (HR per dialysis session, 1.56 95% CI, 1.03-2.36). Selection bias, lack of a comparator group. Extended-hours hemodialysis is associated with excellent survival rates and is an effective treatment option for a select group of patients. The major treatment-associated adverse events were related to complications of vascular access, particularly infection. The risk of developing vascular access complications may be increased in extended-hours hemodialysis, which may negatively affect long-term outcomes.
Publisher: Massachusetts Medical Society
Date: 12-08-2010
Publisher: Elsevier BV
Date: 11-2022
DOI: 10.1016/J.IDH.2022.05.003
Abstract: Patients undergoing haemodialysis colonised with multi-drug resistant organisms (MDROs) are commonly managed with transmission-based precautions (TBP) to prevent nosocomial transmission. TBP have been linked to mixed effects on patient psychological well-being and clinical care. This study was designed to report the lived experience of dialysis patients managed with TBP. A qualitative study of 15 patients undergoing haemodialysis managed with TBP was performed. Participants took part in in idual semi-structured interviews. Data was analysed utilising an interpretive phenomenological approach. Four themes were identified. 1. Communication of what MDRO screening meant, the results, and implications of MDRO positivity was perceived by many patients as insufficient and inconsistent. 2. Experiences of care in isolation were described, with both positive (privacy) and negative (reduced interaction) experiences identified. 3. Psychosocial and emotional responses including concern about health implications and stigma were reported, but also screening was described by some as increasing their perception of being cared for by health care workers, as they felt all health risks were being managed. 4. Confusion around perceived inconsistencies of management, particularly across different environments (eg hospital vs home) and staff. TBP have complex positive and negative impacts on patients which should be considered when developing MDRO management policy and communication around such policy. Strategies to improve communication, patient and staff education, and remove (or explain) perceived inconsistencies of practice may reduce the negative consequences of TBP leading to improved delivery of quality, person-centred care.
Publisher: Oxford University Press (OUP)
Date: 15-06-2020
DOI: 10.1093/NDT/GFAA084
Abstract: Chronic kidney disease (CKD) is a progressive multisystem condition with yet undefined mechanistic drivers and multiple implicated soluble factors. If identified, these factors could be targeted for therapeutic intervention for a disease that currently lacks specific treatment. There is increasing preclinical evidence that the heparin/endothelial glycocalyx-binding molecule midkine (MK) has a pathological role in multiple CKD-related, organ-specific disease processes, including CKD progression, hypertension, vascular and cardiac disease, bone disease and CKD-related cancers. Concurrent with this are studies documenting increases in circulating and urine MK proportional to glomerular filtration rate (GFR) loss in CKD patients and evidence that administering soluble MK reverses the protective effects of MK deficiency in experimental kidney disease. This review summarizes the growing body of evidence supporting MK’s potential role in driving CKD-related multisystem disease, including MK’s relationship with the endothelial glycocalyx, the deranged MK levels and glycocalyx profile in CKD patients and a proposed model of MK organ interplay in CKD disease processes and highlights the importance of ongoing research into MK’s potential as a therapeutic target.
Publisher: Wiley
Date: 11-2014
DOI: 10.1111/IMJ.12519
Abstract: Knowledge about kidney disease among the general population is poor but has not been assessed in the population selected for referral to nephrology care. This study aimed to determine patients' understanding of chronic kidney disease (CKD) when first presenting to a nephrology clinic. Newly referred patients to a nephrology clinic were surveyed with open-ended questions about their understanding of CKD causes, symptoms and management. Two hundred and ten patients were surveyed. Median age was 66.5 years (interquartile range 52-77), 50.5% female and mean body mass index 29.7 ± 6.8 kg/m(2) . Prevalence of risk factors for CKD included 31% diabetic, 62% hypertension, 19% family history of CKD and 2% Aboriginal or Torres Strait Islander. CKD stage prevalence was 0 (8%), 1 (24%), 2 (11%), 3 (38.5%), 4 (18%) and 5 (0.5%). Eighty-two per cent were referred by their primary care physician and 29% had seen a nephrologist previously. Kidney Health Australia was mentioned by 2.4%. Sixteen per cent were unsure why they had been referred. CKD causes identified by patients were unsure (40%), alcohol (29%), hypertension (16%) and diabetes (14%). Symptoms identified included asymptomatic (16%), kidney pain (17%) and other (42%). Management suggested by patients was uncertain (51%), dialysis (32%) and anti-hypertensive medication (16%). Eighty-two per cent reported unsatisfactory education from their primary care physician. New patients referred to a renal outpatient department had poor knowledge about kidney disease. Education of patients should begin in primary care prior to referral. For most patients, education programmes need to be targeted at a simplistic level.
Publisher: Wiley
Date: 02-2022
DOI: 10.1111/IMJ.15535
Abstract: There has been considerable growth in nephrology advanced trainee numbers in Australia and New Zealand, with uncertain effects on clinical experience, competence and employment outcomes. To review the perceived adequacy and temporal trends of advanced training in nephrology in Australia and New Zealand by evaluating training experiences, personal views on important aspects of training and nephrology, career paths and early employment outcomes. An online survey was distributed to members of the Australian and New Zealand Society of Nephrology through email in December 2020. Responses were sought from current trainees and from nephrologists qualifying since 2014. Likert scale proportions were calculated and group comparisons made using the Chi‐squared test. A total of 88 participants returned the survey yielding a response rate of 32%, with a representative s le of trainees and consultants from across Australia and New Zealand. Training was reported as adequate in most aspects of clinical nephrology, although 88% of respondents felt poorly prepared for entering private practice and 61% reported inadequate training in kidney histopathology. Exposure to clinical procedures was variable, with adequate training in percutaneous kidney biopsy, but mostly inadequate training in dialysis access insertion. Sixty‐nine percent of nephrologists completed their advanced training entirely in large urban centres and 85% worked in an urban area after training. Only 23% of consultants were engaged in full‐time clinical employment in their first‐year post‐training and 78% were undertaking at least one of dual specialty training or a higher degree by research. Demand for subspecialty fellowships was high. Trainees and nephrologists in Australia and New Zealand are currently satisfied with their training in most aspects of nephrology however, some clinical experiences are perceived as inadequate and early career paths after advanced training are increasingly erse.
Publisher: Wiley
Date: 27-10-2011
DOI: 10.1111/J.1440-1797.2011.01482.X
Abstract: The Australian Pharmaceutical Benefits Scheme (PBS) commenced cost subsidization for haemodialysis patients of sevelamer in December 2007, cinacalcet in July 2008 and lanthanum in May 2009. To determine the impact of PBS listing of these medications, we performed a single centre cross-sectional, longitudinal study. Dialysis parameters and biochemistry were prospectively collected at 6 monthly intervals for all prevalent haemodialysis patients from October 2007 to April 2010. Medications prescribed to manage chronic kidney disease mineral and bone disorder were recorded. Univariate regression analysis was undertaken for each variable against time. Patient numbers ranged from 87 to 114 in each period. At baseline, mean age was 68.8 ± 14.3 years, 71% male, 15.1 ± 3.5 haemodialysis hours/week and urea reduction ratio 71.9 ± 9.8%. These variables were unchanged over time. The use of sevelamer, cinacalcet and lanthanum increased (P < 0.001). There was a decrease in the use of aluminium- and calcium-based phosphate binders (P < 0.001) but no change in the use of magnesium based phosphate binders (P = 0.09) or calcitriol (P = 0.11). Serum phosphate (P = 0.13) and parathyroid hormone (PTH) (P = 0.87) were unchanged. Mean 'bone pill' burden fell from 60.3/week to 51.9/week (P = 0.02). Mean pill cost increased from Australian dollars (AUD) 12.85 atient per week to AUD 59.85 atient per week (P < 0.001). The PBS subsidization of sevelamer, cinacalcet and lanthanum has changed prescribing patterns, although serum phosphate and PTH remain unchanged. These changes have been at an additional cost of AUD 2444 atient per year. Data to address clinical end-points of mortality and hospitalization is needed to determine if the cost of these newer agents is warranted.
Publisher: Elsevier BV
Date: 03-2019
DOI: 10.1053/J.AJKD.2018.09.006
Abstract: Dialysis is a burdensome and complex treatment for which many recipients require support from caregivers. The impact of caring for people dependent on dialysis on the quality of life of the caregivers has been incompletely characterized. Systematic review of quantitative studies of quality of life and burden to caregivers. Caregivers of adults receiving maintenance dialysis. The Cochrane Library, Embase, PsycINFO, CINAHL, PubMed, and MEDLINE were systematically searched from inception until December 2016 for quantitative studies of caregivers. Pediatric and non-English language studies were excluded. Study quality was assessed using a modified Newcastle-Ottawa scale. 2 independent reviewers selected studies and extracted data using a prespecified extraction instrument. Descriptive reports of demographics, measurement scales, and outcomes. Quantitative meta-analysis using random effects when possible. 61 studies were identified that included 5,367 caregivers from 21 countries and assessed the impact on caregivers using 70 different scales. Most (85%) studies were cross-sectional. The largest identified group of caregivers was female spouses who cared for recipients of facility-based hemodialysis (72.3%) or peritoneal dialysis (20.6%). Caregiver quality of life was poorer than in the general population, mostly comparable with caregivers of people with other chronic diseases, and often better than experienced by the dialysis patients cared for. Caregiver quality of life was comparable across dialysis modalities. Heterogeneity in study design and outcome measures made comparisons between studies difficult and precluded quantitative meta-analysis. Study quality was generally poor. Quality of life of caregivers of dialysis recipients is poorer than in the general population and comparable to that of caregivers of in iduals with other chronic diseases. The impact of caring for recipients of home hemodialysis or changes in the impact of caring over time have not been well studied. Further research is needed to optimally inform dialysis programs how to educate and support caregivers.
Publisher: Elsevier BV
Date: 04-2021
Publisher: Wiley
Date: 08-2012
DOI: 10.1111/J.1445-5994.2012.02795.X
Abstract: Clinical outcomes for patients treated in public and private hospitals may be different. The aim of the study was to compare the characteristics and outcomes of patients receiving dialysis at public and private hospitals in Queensland. Incident adult dialysis patients in Queensland registered with the Australia and New Zealand Dialysis and Transplant Registry between 1999 and 2009 were classified by dialysis modality at either a public or private hospital. Outcomes were dialysis patient characteristics and survival. Three thousand, three hundred and ten patients commenced dialysis in public hospitals, 1939 haemodialysis (HD) and 1371 peritoneal dialysis (PD). Seven hundred and ninety-three patients commenced dialysis in private hospitals, 757 HD and 36 PD. Compared with public HD, private HD patients were older, had more coronary artery disease and less diabetes, and were more likely to live in an urban area. Public HD patients were more likely to be obese and referred late to a nephrologist. Nearly all indigenous patients were managed in public hospitals. Private patients were more likely to have an arteriovenous fistula or graft at first HD (P < 0.001) but not after excluding late referrals (P = 0.09). Public hospitals provided longer HD sessions and more HD hours per week for all age groups except 75+ years. Compared with public hospital HD, patient survival adjusted for multiple variables was comparable for private hospital HD (hazard ratio 1.20 (95% confidence interval 0.98-1.46, P = 0.07)) but worse for public PD (hazard ratio 1.14 (95% confidence interval 1.05-1.24, P = 0.002)). Private HD patients are older and less likely to be diabetic than public patients. Patient survival is worse for public PD than public HD.
Publisher: Wiley
Date: 04-2022
DOI: 10.1111/IMJ.15735
Abstract: The prevalence of complementary and alternative medicine (CAM) use in kidney transplant recipients in Australia is unknown. Chronic transplant recipients completed a questionnaire, and participants who did not report CAM use also had medical chart audits. Among 127 participants, CAM use was reported by 26.8%, considerably lower than the general population. These findings may reflect underreporting due to misperception about what constitutes CAM (commonly vitamin use was not reported by the group denying CAM use), or perhaps a motivated population who are receptive to education efforts from the transplant team.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2020
Abstract: Patients with hemodialysis central venous catheters (HD CVCs) are susceptible to health care-associated infections, particularly hemodialysis catheter-related bloodstream infection (HD-CRBSI), which is associated with high mortality and health care costs. There have been few systematic attempts to reduce this burden and clinical practice remains highly variable. This manuscript will summarize the challenges in preventing HD-CRBSI and describe the methodology of the REDUcing the burden of dialysis Catheter ComplicaTIOns: a National approach (REDUCCTION) trial. The REDUCCTION trial is a stepped-wedge cluster randomized trial of a suite of clinical interventions aimed at reducing HD-CRBSI across Australia. It clusters the intervention at the renal-service level with implementation randomly timed across three tranches. The primary outcome is the effect of this intervention upon the rate of HD-CRBSI. Patients who receive an HD CVC at a participating renal service are eligible for inclusion. A customized data collection tool allows near-to-real-time reporting of the number of active catheters, total exposure to catheters over time, and rates of HD-CRBSI in each service. The interventions are centered around the insertion, maintenance, and removal of HD CVC, informed by the most current evidence at the time of design (mid-2018). A total of 37 renal services are participating in the trial. Data collection is ongoing with results expected in the last quarter of 2020. The baseline phase of the study has collected provisional data on 5385 catheters in 3615 participants, representing 603,506 days of HD CVC exposure. The REDUCCTION trial systematically measures the use of HD CVCs at a national level in Australia, accurately determines the rate of HD-CRBSI, and tests the effect of a multifaceted, evidence-based intervention upon the rate of HD-CRBSI. These results will have global relevance in nephrology and other specialties commonly using CVCs.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 31-10-2019
DOI: 10.2215/CJN.06800619
Abstract: Little is known about the effect of changes in dialysis hours on patient-reported outcome measures. We report the effect of doubling dialysis hours on a range of patient-reported outcome measures in a randomized trial, overall and separately for important subgroups. The A Clinical Trial of IntensiVE Dialysis trial randomized 200 participants to extended or standard weekly hours hemodialysis for 12 months. Patient-reported outcome measures included two health utility scores (EuroQOL-5 Dimensions-3 Level, Short Form-6 Dimension) and their derived quality-adjusted life year estimates, two generic health scores (Short Form-36 Physical Component Summary, Mental Component Summary), and a disease-specific score (Kidney Disease Component Score). Outcomes were assessed as the mean difference from baseline using linear mixed effects models adjusted for time point and baseline score, with interaction terms added for subgroup analyses. Prespecified subgroups were dialysis location (home- versus institution-based), dialysis vintage (≤6 months versus months), region (China versus Australia, New Zealand, Canada), and baseline score (lowest, middle, highest tertile). Multiplicity-adjusted P values (Holm–Bonferroni) were calculated for the main analyses. Extended dialysis hours was associated with improvement in Short Form-6 Dimension (mean difference, 0.027 95% confidence interval [95% CI], 0.00 to 0.05 P =0.03) which was not significant after adjustment for multiple comparisons ( Padjusted =0.05). There were no significant differences in EuroQOL-5 Dimensions-3 Level health utility (mean difference, 0.036 95% CI, −0.02 to 0.09 P =0.2 Padjusted =0.2) or in quality-adjusted life years. There were small positive differences in generic and disease-specific quality of life: Physical Component Summary (mean difference, 2.3 95% CI, 0.6 to 4.1 P =0.01 Padjusted =0.04), Mental Component Summary (mean difference, 2.5 95% CI, 0.5 to 4.6 P =0.02 Padjusted =0.05) and Kidney Disease Component Score (mean difference, 3.5 95% CI, 1.5 to 5.5 P =0.001 Padjusted =0.005). The results did not differ among predefined subgroups or by baseline score. The effect of extended hours hemodialysis on patient-reported outcome measures reached statistical significance in some but not all measures. Within each measure the effect was consistent across predefined subgroups. The clinical importance of these differences is unclear.
Publisher: Springer Science and Business Media LLC
Date: 12-2013
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-10-2016
DOI: 10.2215/CJN.11861115
Abstract: We aimed to determine the proportion of patients who switched to dialysis after confirmed plans for conservative care and compare survival and end-of-life care among patients choosing conservative care with those initiating RRT. A cohort study of 721 patients on incident dialysis, patients receiving transplants, and conservatively managed patients from 66 Australian renal units entered into the Patient Information about Options for Treatment Study from July 1 to September 30, 2009 were followed for 3 years. A two–sided binomial test assessed the proportion of patients who switched from conservative care to RRT. Cox regression, stratified by center and adjusted for patient and treatment characteristics, estimated factors associated with 3-year survival. In total, 102 of 721 patients planned for conservative care, and median age was 80 years old. Of these, 8% (95% confidence interval, 3% to 13%), switched to dialysis, predominantly for symptom management. Of 94 patients remaining on a conservative pathway, 18% were alive at 3 years. Of the total 721 patients, 247 (34%) died by study end. In multivariable analysis, factors associated with all-cause mortality included older age (hazard ratio, 1.55 95% confidence interval, 1.36 to 1.77), baseline serum albumin .0 versus 3.7–5.4 g/dl (hazard ratio, 4.31 95% confidence interval, 2.72 to 6.81), and management with conservative care compared with RRT (hazard ratio, 2.18 95% confidence interval, 1.39 to 3.40). Of 247 deaths, patients managed with RRT were less likely to receive specialist palliative care (26% versus 57% P .001), more likely to die in the hospital (66% versus 42% P .001) than home or hospice, and more likely to receive palliative care only within the last week of life (42% versus 15% P .001) than those managed conservatively. Survival after 3 years of conservative management is common, with relatively few patients switching to dialysis. Specialist palliative care services are used more frequently and at an earlier time point for conservatively managed patients, a practice associated with better symptom management and quality of life.
Publisher: Frontiers Media SA
Date: 03-03-2015
DOI: 10.1111/TRI.12542
Abstract: Greater compatibility of human leucocyte antigen (HLA) alleles between kidney donors and recipients may lead to improved graft outcomes. This study aimed to compare the incidence of acute rejection and graft failure in zero-HLA-mismatched recipients of living-related (LD) and deceased donor (DD) kidney transplants. Using data from the Australia and New Zealand Dialysis and Transplant Registry, we compared the risk of any acute rejection and biopsy-proven acute rejection (BPAR) and graft failure in recipients of zero-HLA-mismatched kidneys between LD and DD using logistic and Cox regression models. Of the 931 zero-HLA-mismatched recipients transplanted between 1990 and 2012, 19 (2.0%) received kidneys from monozygotic/dizygotic twins (twin), 500 (53.7%) from nontwin LD and 412 (44.3%) from DD. Twin kidney transplant recipients did not experience rejection. Compared to DD transplant recipients, the risk of any acute rejection (adjusted odds ratio 0.52, 95%CI 0.34-0.79, P = 0.002) and overall graft failure (adjusted hazard ratio 0.55, 95%CI 0.41-0.73, P < 0.001) was significantly lower in LD recipients independent of initial immunosuppression, but not for BPAR (adjusted odds ratio 0.52, 95%CI 0.16-1.64, P = 0.263). Zero-HLA-mismatched DD kidney transplant recipients have a significantly higher risk of any acute rejection episodes and graft loss compared to zero-HLA-mismatched LD kidney transplant recipients. A cautious and careful approach in reducing immunosuppression appears to be warranted in this group of transplant recipients.
Publisher: Wiley
Date: 2019
DOI: 10.1111/IMJ.14036
Abstract: Secondary hyperparathyroidism (SHPT) in chronic kidney disease is associated with cardiovascular and bone pathology. Measures to achieve parathyroid hormone (PTH) target values and control biochemical abnormalities associated with SHPT require complex therapies, and severe SHPT often requires parathyroidectomy or the calcimimetic cinacalcet. In Australia, cinacalcet was publicly funded for dialysis patients from 2009 to 2015 when funding was withdrawn following publication of the EVOLVE study, which resulted in most patients on cinacalcet ceasing therapy. We examined the clinical and biochemical outcomes associated with this change at Australian renal centres. To assess changes to biochemical and clinical outcomes in dialysis patients following cessation of cinacalcet. We conducted a retrospective study of dialysis patients who ceased cinacalcet after August 2015 in 11 Australian units. Clinical outcomes and changes in biochemical parameters were assessed over a 24- and 12-month period, respectively, from cessation of cinacalcet. A total of 228 patients was included (17.7% of all dialysis patients from the units). Patients were aged 63 ± 15 years with 182 patients on haemodialysis and 46 on peritoneal dialysis. Over 24 months following cessation of cinacalcet, we observed 26 parathyroidectomies, 3 episodes of calciphylaxis, 8 fractures and 50 deaths. Eight patients recommenced cinacalcet, meeting criteria under a special access scheme. Biochemical changes from baseline to 12 months after cessation included increased levels of serum PTH from 54 (interquartile range 27-90) pmol/L to 85 (interquartile range 41-139) pmol/L (P < 0.0001), serum calcium from 2.3 ± 0.2 mmol/L to 2.5 ± 0.1 mmol/L (P < 0.0001) and alkaline phosphatase from 123 (92-176) IU/L to 143 (102-197) IU/L (P < 0.0001). Significant increases in serum PTH, calcium and alkaline phosphatase occurred over a 12-month period following withdrawal of cinacalcet. Longer-term follow up will determine if these biochemical and therapeutic changes are associated with altered rates of parathyroidectomies and cardiovascular mortality and morbidity.
Publisher: Wiley
Date: 25-03-2014
DOI: 10.1111/NEP.12385
Abstract: Observational reports suggest extended dialysis hours are associated with improved outcomes. These findings are confounded by better prognostic characteristics among people practising extended hours. The aim of this article is to provide an overview of the methods and baseline characteristics for ACTIVE Dialysis Study participants. This multicentre, randomized, open-label, blinded endpoint-assessment trial randomized participants receiving maintenance haemodialysis therapy to either extended (≥24 h) or standard (12-18 h) weekly haemodialysis for 12 months. A web-based randomization system used minimization to ensure balanced allocation across regions, dialysis setting and dialysis vintage. The primary outcome is the change in quality of life over 12 months of study treatment assessed by EQ-5D. Secondary outcomes include change in left ventricular mass index assessed by magnetic resonance imaging and safety outcomes including dialysis access events. A total of 200 participants were recruited between 2009 and 2013 from Australia (29.0%), China (62.0%), Canada (5.5%) and New Zealand (3.5%). Participants had a mean age of 52 (± 12) years and 11.5% were dialysing at home, with a mean duration of 13.9 h per week over a median of three sessions. At baseline, 32.5% had a history of cardiovascular disease and 36.5% had diabetes. The ACTIVE Dialysis Study has met its planned recruitment target. The participant population are drawn from a range of health service settings in a global context. The study will contribute important evidence on the benefits and harms of extending weekly dialysis hours. The trial is registered at clinicaltrials.gov (NCT00649298).
Publisher: Wiley
Date: 27-03-2019
DOI: 10.1111/NEP.13236
Abstract: Poor sleep quality is common in haemodialysis patients and associated with worse outcomes. In this pre-specified analysis, we examined the impact of extended hours haemodialysis on sleep quality. The ACTIVE Dialysis trial randomized 200 participants to extended (≥24 h/week) or standard (target 12-15 h) hours haemodialysis over 12 months. Sleep quality was measured in the Kidney Disease Quality of Life Short Form 1.3 (KDQOL-SF) by overall sleep quality score (0-10, 10 = 'very good') and the sleep subscale (0-100, 100 = 'best possible sleep') every 3 months via blinded telephone interview. The average intervention effect was calculated by mixed linear regression adjusted by time point and baseline score. Factors predicting sleep quality were assessed by multivariate regression analysis. Overall sleep quality score and sleep subscale at baseline were similar in both groups (5.9 [95%CI 5.4-6.4] vs. 6.3 [5.9-6.8] 65.0 [60.9-69.1] vs. 63.2 [59.1-67.3] extended and standard hours, respectively). Extended hours haemodialysis led to a non-significant improvement in overall sleep quality score (average intervention effect 0.44 (-0.01 to 0.89), P = 0.053) and sleep subscale (average intervention effect 3.58 (-0.02 to 7.18), P = 0.051). Poor sleep quality was associated with being female and with current smoking. Sleep quality was positively associated with EuroQol-5D (EQ5D) and the SF-36 Physical Component and Mental Component Summary Scores but not with hospitalizations. Sleep quality was not significantly improved by extended hours dialysis in this study. Sleep quality is positively correlated with quality of life in haemodialysis patients and is poorer in women and current smokers.
Publisher: SAGE Publications
Date: 2022
DOI: 10.1177/20543581221089080
Abstract: Older people with kidney failure often choose conservative kidney care. The experiences and quality of life (QOL) of caregivers who support them are incompletely characterized. To determine the burden, QOL, and understand experiences of caregivers supporting patients managed conservatively. Systematic review of quantitative and qualitative studies. PubMed, Embase, PsycINFO, CINAHL, and MEDLINE electronic databases were systematically searched for quantitative and qualitative studies published between January 2000 and July 2020. Caregivers of adults with kidney failure (estimated glomerular filtration rate 15 mL/min/1.73 m 2 ) managed conservatively. Data were extracted by 2 independent reviewers using a prespecified extraction tool. Study quality was assessed using the Critical Appraisal Skills Program (CASP) tool. Descriptive reports of demographics, measurement scales, and outcomes. Thematic synthesis of qualitative data. Six studies met inclusion criteria, including 3 quantitative and 3 descriptive qualitative studies. Caregivers of patients receiving conservative kidney management (CKM) experienced significant caregiver burden and similar impacts to their QOL as those caring for patients receiving dialysis. Thematic synthesis revealed 5 themes: Understanding the concept of CKM, Need for involvement in the decision for CKM, Identifying available supports, Uncertainty about the future and negotiating deteriorations and dying, and Burden of care impacting on QOL. Low numbers of included studies, data collection and recruitment biases in qualitative studies and small caregiver numbers in quantitative studies, limit transferability of findings. Heterogeneity in study design and outcome measures precluded meta-analysis. Caregivers of patients with conservatively managed kidney failure suffer significant burden and experience QOL comparable with those caring for patients on dialysis. Limited understanding and involvement in conservative management decision making, and a fear of deterioration and dying, result in anxiety in caregivers. Further research into the experiences of caregivers will help support both caregivers and the patients who choose conservative management. PROSPERO registration number CRD42021209811.
Publisher: Wiley
Date: 25-04-2018
DOI: 10.1111/NEP.13037
Abstract: Commencement of haemodialysis with an arteriovenous fistula (AVF) or arteriovenous graft (AVG) is associated with improved survival compared with commencement with a central venous catheter. In 2011-2012, Queensland Health made incentive payments to renal units for early referred patients who commenced peritoneal dialysis (PD), or haemodialysis with an AVF/AVG. The aim of this study was to determine if pay for performance improved clinical care. All patients who commenced dialysis in Australia between 2009 and 2014 and were registered with the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) were included. A multivariable regression model was used to compare rates of commencing dialysis with a PD catheter or permanent AVF/AVG during the pay-for-performance period (2011-2012) with periods prior (2009-2010) and after (2013-2014). A total of 10 858 early referred patients commenced dialysis during the study period, including 2058 in Queensland. In Queensland, PD as first modality increased with time (P < 0.001) but there was no change in AVF/AVG rate at first haemodialysis (P = 0.5). In a multivariate model using the pay-for-performance period as reference, the odds ratio for commencement with PD or haemodialysis with an AVF/AVG in Queensland was 1.02 (95% CI 0.81-1.29) in 2009-2010 and 1.28 (95% CI 1.01-1.61) in 2013-2014. There was no change for the rest of Australia (0.97 95% CI 0.87-1.09 in 2009-2010 and 1.00 95% CI 0.90-1.11 in 2013-14). Pay for performance did not improve rates of commencement of dialysis with PD or an AVF/AVG during the payment period. A lag effect on clinical care may explain the improvement in later years.
Publisher: Wiley
Date: 19-01-2012
Publisher: Wiley
Date: 04-2012
DOI: 10.1111/J.1440-1797.2012.01579.X
Abstract: Bone disease is a major cause of morbidity post renal transplantation. The authors present a case of adynamic bone disease and atypical fractures associated with the use of bisphosphonates following renal transplantation. The uncertain role of parathyroidectomy and bone mineral density scans is also reviewed.
Publisher: Wiley
Date: 31-01-2003
DOI: 10.1046/J.1440-1797.2003.00119.X
Abstract: Culture-negative peritoneal inflammation accounts for between 5 and 20% of cases of peritonitis in peritoneal dialysis patients. Diagnostic yields may be enhanced considerably by reculturing dialysate effluents using appropriate collection methods and optimal laboratory techniques (including prolonged low-temperature and anaerobic incubations). In patients with persistent culture-negative peritonitis, consideration should be given to the possibilities of unusual or fastidious microorganisms (especially fungi and mycobacteria) and non-infective causes (especially drug reactions, malignancy, visceral inflammation and retroperitoneal inflammation). In this paper, an illustrative case of persistent culture-negative peritonitis is presented followed by a discussion of the investigative approach to such patients, with particular emphasis on differential diagnosis and the limitations of currently available tests.
Publisher: Elsevier BV
Date: 06-2011
DOI: 10.1053/J.AJKD.2010.12.020
Abstract: Current clinical practice guidelines recommend a native arteriovenous fistula (AVF) as the vascular access of first choice. Despite this, most patients in western countries start hemodialysis therapy using a catheter. Little is known regarding specific physician and system characteristics that may be responsible for delays in permanent access creation. Multicenter cohort study using mixed methods qualitative and quantitative analysis. 9 nephrology centers in Australia and New Zealand, including 319 adult incident hemodialysis patients. Identification of barriers and enablers to AVF placement. Type of vascular access used at the start of hemodialysis therapy. Prospective data collection included data concerning predialysis education, interviews of center staff, referral times, and estimated glomerular filtration rate (eGFR) at AVF creation and dialysis therapy start. 319 patients started hemodialysis therapy during the 6-month period, 39% with an AVF and 59% with a catheter. Perceived barriers to access creation included lack of formal policies for patient referral, long wait times for surgical review and access placement, and lack of a patient database for management purposes. eGFR thresholds at referral for and creation of vascular accesses were considerably lower than appreciated (in both cases, median eGFR of 7 mL/min/1.73 m(2)), with median wait times for access creation of only 3.7 weeks. First assessment by a nephrologist less than 12 months before dialysis therapy start was an independent predictor of catheter use (OR, 8.71 P < 0.001). Characteristics of the best performing centers included the presence of a formalized predialysis pathway with a centralized patient database and low nephrologist and surgeon to patient ratios. A limited number of patient-based barriers was assessed. Cross-sectional data only. A formalized predialysis pathway including patient education and eGFR thresholds for access placement is associated with improved permanent vascular access placement.
Publisher: Oxford University Press (OUP)
Date: 16-05-2013
DOI: 10.1093/HMG/DDT215
Abstract: Focal segmental glomerulosclerosis (FSGS) is the consequence of a disease process that attacks the kidney's filtering system, causing serious scarring. More than half of FSGS patients develop chronic kidney failure within 10 years, ultimately requiring dialysis or renal transplantation. There are currently several genes known to cause the hereditary forms of FSGS (ACTN4, TRPC6, CD2AP, INF2, MYO1E and NPHS2). This study involves a large, unique, multigenerational Australian pedigree in which FSGS co-segregates with progressive heart block with apparent X-linked recessive inheritance. Through a classical combined approach of linkage and haplotype analysis, we identified a 21.19 cM interval implicated on the X chromosome. We then used a whole exome sequencing approach to identify two mutated genes, NXF5 and ALG13, which are located within this linkage interval. The two mutations NXF5-R113W and ALG13-T141L segregated perfectly with the disease phenotype in the pedigree and were not found in a large healthy control cohort. Analysis using bioinformatics tools predicted the R113W mutation in the NXF5 gene to be deleterious and cellular studies support a role in the stability and localization of the protein suggesting a causative role of this mutation in these co-morbid disorders. Further studies are now required to determine the functional consequence of these novel mutations to development of FSGS and heart block in this pedigree and to determine whether these mutations have implications for more common forms of these diseases in the general population.
Publisher: Wiley
Date: 22-07-2019
DOI: 10.1111/NEP.13626
Abstract: To explore the current practices related to the insertion, management and removal of dialysis central venous catheters (CVCs) used in patients with chronic kidney disease requiring haemodialysis. This qualitative descriptive study involved semi-structured interviews with surgeons, interventional radiologists, renal physicians, dialysis nurses, renal access nurses and renal researchers involved in the care of patients with chronic kidney disease requiring haemodialysis. Data were collected from staff at eight hospitals in six states and territories of Australia. Thirty-eight face-to-face interviews were conducted. A modified five-step qualitative content analysis approach was used to analyse the data. Improved visualization technology and its use by interventional radiologists has steered insertions to specialist teams in specialist locations. This is thought to have decreased risk and improved patient outcomes. Nurses were identified as the professional group responsible for maintaining catheter access integrity, preventing access failure and reducing access-related complications. While best practice was considered important, justifications for variations in practice related to local patient and environment challenges were identified. The interdisciplinary team is central in the insertion, maintenance, removal and education of patients regarding dialysis CVCs. Clinicians temper research-based decision-making about central dialysis access catheter management with knowledge of in idual, environmental and patient factors. Strategies to ensure guidelines are appropriately translated for use in a wide variety of settings are necessary for patient safety.
Publisher: Springer Science and Business Media LLC
Date: 12-07-2019
Publisher: Oxford University Press (OUP)
Date: 10-01-2017
Publisher: BMJ
Date: 18-04-2012
DOI: 10.1136/BMJ.E2727
Publisher: Wiley
Date: 29-04-2019
DOI: 10.1111/NEP.13507
Abstract: Dialysis catheter-associated infections (CAI) are a serious and costly burden on patients and the health-care system. Many approaches to minimizing catheter use and infection prophylaxis are available and the practice patterns in Australia and New Zealand are not known. We aimed to describe dialysis catheter management practices in dialysis units in Australia and New Zealand. Online survey comprising 52 questions, completed by representatives from dialysis units from both countries. Of 64 contacted units, 48 (75%) responded (Australia 43, New Zealand 5), representing 79% of the dialysis population in both countries. Nephrologists (including trainees) inserted non-tunnelled catheters at 60% and tunnelled catheters at 31% of units. Prophylactic antibiotics were given with catheter insertion at 21% of units. Heparin was the most common locking solution for both non-tunnelled (77%) and tunnelled catheters (69%), with antimicrobial locks being predominant only in New Zealand (80%). Eight different combinations of exit site dressing were in use, with an antibiotic patch being most common (35%). All units in New Zealand and 84% of those in Australia undertook CAI surveillance. However, only 51% of those units were able to provide a figure for their most recent rate of catheter-associated bacteraemia per 1000 catheter days. There is wide variation in current dialysis catheter management practice and CAI surveillance is suboptimal. Increased attention to the scope and quality of CAI surveillance is warranted and further evidence to guide infection prevention is required.
Publisher: Oxford University Press (OUP)
Date: 10-12-2020
DOI: 10.1093/CID/CIAA1839
Abstract: Cutibacterium species are common pathogens in periprosthetic joint infections (PJI). These infections are often treated with β-lactams or clindamycin as monotherapy, or in combination with rif in. Clinical evidence supporting the value of adding rif in for treatment of Cutibacterium PJI is lacking. In this multicenter retrospective study, we evaluated patients with Cutibacterium PJI and a minimal follow-up of 12 months. The primary endpoint was clinical success, defined by the absence of infection relapse or new infection. We used Fisher’s exact tests and Cox proportional hazards models to analyze the effect of rif in and other factors on clinical success after PJI. We included 187 patients (72.2% male, median age 67 years) with a median follow-up of 36 months. The surgical intervention was a 2-stage exchange in 95 (50.8%), 1-stage exchange in 51 (27.3%), debridement and implant retention (DAIR) in 34 (18.2%), and explantation without reimplantation in 7 (3.7%) patients. Rif in was included in the antibiotic regimen in 81 (43.3%) cases. Infection relapse occurred in 28 (15.0%), and new infection in 13 (7.0%) cases. In the time-to-event analysis, DAIR (adjusted hazard ratio [HR] = 2.15, P = .03) and antibiotic treatment over 6 weeks (adjusted HR = 0.29, P = .0002) significantly influenced treatment failure. We observed a tentative evidence for a beneficial effect of adding rif in to the antibiotic treatment—though not statistically significant for treatment failure (adjusted HR = 0.5, P = .07) and not for relapses (adjusted HR = 0.5, P = .10). We conclude that a rif in combination is not markedly superior in Cutibacterium PJI, but a dedicated prospective multicenter study is needed.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-02-2023
DOI: 10.34067/KID.0000000000000076
Abstract: Health professionals resisted practice change in environments of low infection where the perception of a need to change is small. Standardizing care of central venous catheters for hemodialysis requires breaking down silos of practice to benefit all patients. Knowledge of and adherence to guidelines, formal change management, and ongoing facilitation are required to implement standardized care. Implementation of a care bundle standardizing insertion, management, and removal practices to reduce infection related to central venous catheters (CVCs) used for hemodialysis was evaluated in a stepped wedge, cluster randomized controlled trial conducted at 37 Australian hospitals providing kidney services, with no reduction in catheter-related blood stream infection detected. This process evaluation explored the barriers, enablers, and unintended consequences of the implementation to explain the trial outcomes. Qualitative process evaluation using pre-post semistructured interviews with 38 (19 nursing and 19 medical) and 44 (25 nursing and 19 medical) Australian health professionals involved in hemodialysis CVC management. Analysis was guided by the process implementation domain of the Consolidated Framework for Implementation Research. Key influences on bundle uptake were that clinicians were open to change that was evidence-based and driven by guidelines and had a desire to improve practice and patient outcomes. However, resistance to change in environments of low infection, working in silos of practice, and a need for in idualized delivery of patient education created barriers to uptake. Unintended effects of increased costs and lack of interoperability of systems for data collection were reported. Because the trial was in progress at the time of qualitative data collection, perceptions of the bundle may have been influenced by the fact that practices of participants were being observed as a part of the trial. This national process evaluation revealed that health professionals who reported experiencing a benefit viewed the bundle positively. Those who already provided most of the recommended care or perceived that their patient population was not included in the research evidence that underpinned the interventions, resisted the implementation of the bundle. Potentially, formal change management processes using facilitation may improve implementation of evidence-based practice. Australian New Zealand Clinical Trials Registry, ACTRN12616000830493.
Publisher: Oxford University Press (OUP)
Date: 16-07-2008
DOI: 10.1093/NDT/GFN385
Publisher: Elsevier BV
Date: 06-2020
Publisher: BMJ
Date: 09-2017
DOI: 10.1136/BMJOPEN-2016-014615
Abstract: The cytokine midkine (MK) is pathologically implicated in progressive chronic kidney disease (CKD) and its systemic consequences and has potential as both a biomarker and therapeutic target. To date, there are no published data on MK levels in patients with different stages of CKD. This study aims to quantify MK levels in patients with CKD and to identify any correlation with CKD stage, cause, progression, comorbid disease or prescribed medication. In this observational, single-centre study, demographic data were collected, and serum and urine assayed from 197 patients with CKD and 19 healthy volunteers in an outpatient setting. The median serum and urine MK level in volunteers was 754 pg/mL (IQR: 554–1025) and 239 pg/mL (IQR: 154–568), respectively. Compared with serum MK in stage 1 CKD (660 pg/mL, IQR: 417–893), serum MK increased in stage 3 (1878 pg/mL, IQR: 1188–2756 p .001), 4 (2768 pg/mL, IQR: 2065–4735 p .001) and 5 (4816 pg/mL, IQ: 37477807 p .001). Urine MK levels increased from stage 1 CKD (343 pg/mL, IQR: 147–437) to stage 3 (1007 pg/mL, IQR: 465–2766 p=0.07), 4 (2961 pg/mL, IQR: 1368–5686 p=0.005) and 5 (6722 pg/mL, IQR: 3796–10 060 p=0.001). Fractional MK excretion (FeMK) increased from stage 1 CKD (0.159, IQR: 0.145–0.299) to stage 3 (1.024, IQR: 0.451–1.886, p=0.047), 4 (3.39, IQR: 2.10–5.82, p=0.004) and 5 (11.95, IQR: 5.36–24.41, p .001). When adjusted for estimated glomerular filtration rate, neither serum nor urine MK correlated with primary CKD diagnosis or CKD progression (small s le). There was a positive correlation between protein:creatinine ratio and FeMK (p=0.003). Angiotensin blockade (adjusted for proteinuria) was associated with lower urine MK (p=0.018) and FeMK (p=0.025). MK levels sequentially rise with CKD stage beyond stage 2, and our data support existing animal evidence for an MK/renin angiotensin-system roteinuria relationship. To what extent this is related to renal clearance versus pathology, or the consequences of chronically elevated MK levels requires further exploration.
Publisher: Cambridge University Press (CUP)
Date: 2021
DOI: 10.1017/JNS.2021.33
Abstract: Adherence to a Mediterranean lifestyle may be a useful primary and secondary prevention strategy for chronic kidney disease (CKD). This cross-sectional study aimed to explore adherence to a Mediterranean lifestyle and its association with cardiometabolic markers and kidney function in 99 people aged 73⋅2 ± 10⋅5 years with non-dialysis dependant CKD (stages 3–5) at a single Australian centre. Adherence was assessed using an a priori index, the Mediterranean Lifestyle (MEDLIFE) index. Cardiometabolic markers (total cholesterol, LDL-cholesterol, HbA1c and random blood glucose) and kidney function (estimated GFR) were sourced from medical records and blood pressure measured upon recruitment. Overall, adherence to a Mediterranean lifestyle was moderate to low with an average MEDLIFE index score of 11⋅33 ± 3⋅31. Adherence to a Mediterranean lifestyle was associated with employment ( r 0⋅30, P = 0⋅004). Mediterranean dietary habits were associated with cardiometabolic markers, such as limiting sugar in beverages was associated with lower diastolic blood pressure ( r 0⋅32, P = 0⋅002), eating in moderation with favourable random blood glucose ( r 0⋅21, P = 0⋅043), having more than two snack foods per week with HbA1c ( r 0⋅29, P = 0⋅037) and LDL-cholesterol ( r 0⋅41, P = 0⋅002). Interestingly, eating in company was associated with a lower frequency of depression ( χ 2 5⋅975, P = 0⋅015). To conclude, Mediterranean dietary habits were favourably associated with cardiometabolic markers and management of some comorbidities in this group of people with non-dialysis dependent CKD.
Publisher: Oxford University Press (OUP)
Date: 09-10-2012
DOI: 10.1093/NDT/GFR584
Abstract: Australians living in rural regions have poorer health outcomes than city residents. This study compares rural and city patient access to and outcomes of renal replacement therapy (RRT) in Australia. Non-indigenous Australians aged ≥16 years who commenced dialysis or underwent renal transplantation between 1996 and 2009 and were registered with the Australia and New Zealand Dialysis and Transplant Registry were included. Each patient's location was classified according to a remote area index as major city (MC), inner regional (IR), outer regional (OR) or remote/very remote (REM). A total of 24 068 commenced dialysis and 5399 received a renal transplant during the study period. Patient distribution by remote area index was 71.3 and 70.8% MC, 19.1 and 18.6% IR, 8.4 and 9.1% OR and 1.1 and 1.5% REM for dialysis and transplant patients, respectively. RRT incidence per million population after adjusting for age and gender was 124 [95% confidence interval (CI): 122-126] MC, 106 (95% CI: 103-110) IR, 100 (95% CI: 96-105) OR and 96 (95% CI: 84-109) REM. After controlling for demographic variables, comorbidities and other covariates, hazard ratios for dialysis survival compared to MC were 1.08 (95% CI: 1.03-1.14) IR, 1.19 (95% CI: 1.11-1.28) OR and 1.03 (95% CI: 0.84-1.25) REM. Transplant patient survival was not statistically different by remoteness. Rural Australians have lower incidence of RRT. Whether the causes of the lower RRT reflect lower disease rates or differential treatment access is not known. Differences in outcomes were seen for dialysis but not transplantation.
Publisher: Springer Science and Business Media LLC
Date: 20-07-2016
Publisher: Wiley
Date: 04-2005
DOI: 10.1111/J.1440-1797.2005.00386.X
Abstract: Studies have consistently shown the superior dosing efficiency of subcutaneous (s.c.) compared to intravenous (i.v.) erythropoietin (r-HuEPO). Unlike r-HuEPO, data from pivotal darbepoetin trials support s.c. and i.v. dosing equivalence, however, no blinded cross-over randomized studies of s.c. and i.v. dose efficiency or intra-patient variability in response have been published. During this 12-month study, 53 haemodialysis patients were randomized to s.c. or i.v. darbepoetin for a 6-month period and then switched to the alternative route for a second 6-month period. Darbepoetin dose was titrated during the first 4-months of each period to achieve a stable haemoglobin during the final 2-month observation period of each arm. Twenty-four patients were included in analysis. No significant difference between s.c. and i.v. administration was observed for any measured parameter. Patients achieved a non-significantly higher haemoglobin (123.6 +/- 3.76 vs 120.9 +/- 4.42 g/L, P = 0.11) from a non-significantly lower darbepoetin dose (40.8 +/- 10.7 vs 42.5 +/- 11.0 mcg/week, P = 0.23) with i.v. administration. The population-based weight normalized s.c./i.v. dose ratio was 1.04 (0.97-1.11). Despite no significant overall difference, some patients experienced changes in in idual dose efficiency response. Three of 24 patients recorded a greater than 30% change, four of 24 recorded between a 20 and 30% change, and five of 24 patients recorded between a 10 and 20% change relative to i.v. dose efficiency. This study further supports s.c. and i.v. dosing equality and that overall the more convenient i.v. route can be used with equal dosing efficiency. However, patients switching routes of administration should be monitored due to the wide range in in idual response.
Publisher: Wiley
Date: 22-12-2020
DOI: 10.1111/JORC.12311
Abstract: To evaluate dietary sodium intake in people with chronic kidney disease (CKD) and identify contributing factors to low sodium intake by applying the Theory of Planned Behaviour (TPB) framework. Non-dialysed people with CKD completed a 24-hour urinary sodium excretion test and Scored Salt Questionnaire (SSQ). A survey including socio-demographic information, Brief Illness Perception Questionnaire, Short Sodium Knowledge Survey and Dietary Sodium Restriction Questionnaire based on TPB measured the factors contributing to dietary adherence. Sixty-three people [age: 71 (IQR: 64-77) 27% female] participated with 80% having high urinary sodium excretion [median: 134 mmol/day (111 183)] but only 40% reported high sodium intake [SSQ score = 53 (39 75)]. Overall sodium knowledge was high in 57% of participants although only 33% had seen a dietitian. There was a positive correlation between attitude towards a low-sodium diet and subjective norm (social expectations), r = 0.44, p < 0.01 urinary sodium and the extent of perceived consequences of CKD (r = 0.26, p < 0.05) and the extent to which willpower was perceived as a barrier to adherence to dietary sodium restriction (r = 0.27, p < 0.05). Multiple regression analysis revealed taste of low-salt foods (β = 8.9, p < 0.01) explained 26.4% of variance in dietary sodium intake (R TPB successfully identified barriers to follow a low-sodium diet in non-dialysed people with CKD. Taste preferences, willpower, meeting social expectations and disease concern were identified as key contributing factors to adherence.
No related grants have been discovered for Nicholas Gray.