Search

Background: Updates to the Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access emphasize the "right access, in the right patient, at the right time, for the right reasons." Although this implies a collaborative approach, little is known about how patients, their caregivers, and health care providers engage in vascular access (VA) decision-making., Objective: To explore how the perspectives of patients receiving hemodialysis, their caregivers, and hemodialysis care team align and diverge in relation to VA selection., Design: Qualitative descriptive study., Setting: Five outpatient hemodialysis centers in Calgary, Alberta., Participants: Our purposive sample included 19 patients receiving maintenance hemodialysis, 2 caregivers, and 21 health care providers (7 hemodialysis nurses, 6 VA nurses, and 8 nephrologists)., Methods: We conducted semi-structured interviews with consenting participants. Using an inductive thematic analysis approach, we coded transcripts in duplicate and characterized themes addressing our research objective., Results: While participants across roles shared some perspectives related to VA decision-making, we identified areas where views diverged. Areas of alignment included (1) optimizing patient preparedness-acknowledging decisional readiness and timing, and (2) value placed on trusting relationships with the kidney care team-respecting decisional autonomy with guidance. Perspectives diverged in the following aspects: (1) differing VA priorities and preferences-patients' emphasis on minimizing disruptions to normalcy contrasted with providers' preferences for fistulas and optimizing biomedical parameters of dialysis; (2) influence of personal and peer experience-patients preferred pragmatic, experiential knowledge, whereas providers emphasized informational credibility; and (3) endpoints for VA review-reassessment of VA decisions was prompted by access dissatisfaction for patients and a medical imperative to achieve a functioning access for health care providers., Limitations: Participation was limited to individuals comfortable communicating in English and from urban, in-center hemodialysis units. Few informal caregivers of people receiving hemodialysis and younger patients participated in this study., Conclusions: Although patients, caregivers, and healthcare providers share perspectives on important aspects of VA decisions, conflicting priorities and preferences may impact the decisional outcome. Findings highlight opportunities to bridge knowledge and readiness gaps and integrate shared decision-making in the VA selection process., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: S.H. serves on the board of NephJC (www.nephjc.com), which is a 503c organization that supports social media in medical education and has multiple industry and academic supporters. S.H. receives no remuneration for this position. M.J.O. is sole owner of Oliver Medical Management Inc which is a private corporation that licenses the Dialysis Measurement Analysis and Reporting (DMAR) software system; has received honoraria from Baxter Healthcare; and is contracted Medical Lead at Ontario Renal Network, Ontario Health. R.R.Q. is co-inventor of the Dialysis Measurement Analysis and Reporting (DMAR) software system and has received honoraria from Baxter Healthcare. No other authors have disclosures., (© The Author(s) 2023.)

Background: Providing support is important to maintain a patient on peritoneal dialysis (PD), though its impact on outcomes has not been investigated thoroughly. We examined the association between having support and risk of a transfer to hemodialysis., Methods: In this retrospective observational cohort study, we used data captured in the Dialysis Measurement Analysis and Reporting system about patients who started PD in Alberta, Canada, between 1 January 2013 and 30 September 2018. Support was defined as the availability of a support person in the home who was able, willing and available to provide support for PD in the patient's residence. The outcome of interest was a transfer to hemodialysis for at least 90 days. We estimated the cumulative incidence of a transfer over time accounting for competing risks and hazard ratios to summarise the association between support and a transfer. We split follow-up time as hazard ratios varied over time., Results: Six hundred and eighty-three incident PD patients, median age 58 years ( IQR : 47-68) and 35% female, were followed for a median of 15 months. The cumulative incidence of a transfer to hemodialysis at 24 months was 26%. Having support was associated with a reduced risk of a transfer between 3 and 12 months after the start of dialysis (HR 3-12mo : 0.44; 95% CI: 0.25-0.78), but not earlier (hazard ratio (HR) <3mo : 0.96; 95% confidence interval (CI): 0.55-1.69) or later (HR >12mo : 1.19; 95% CI: 0.65-2.17)., Conclusions: A transfer to hemodialysis is common. Having a support person at home is associated with a short-term protective effect after the initiation of PD.

Objectives: Despite advances in medical therapy, reperfusion, and mechanical support, cardiogenic shock remains associated with excess morbidity and mortality. Accurate risk stratification may improve patient management. We compared the accuracy of established risk scores for cardiogenic shock., Methods: Patients admitted to tertiary care center cardiac care units in the province of Alberta in 2015 were assessed for cardiogenic shock. The Acute Physiology and Chronic Health Evaluation-II (APACHE-II), CardShock, intra-aortic balloon pump (IABP) Shock II, and sepsis-related organ failure assessment (SOFA) risk scores were compared. Receiver operating characteristic curves were used to assess discrimination of in-hospital mortality and compared using DeLong's method. Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test., Results: The study included 3021 patients, among whom 510 (16.9%) had cardiogenic shock. Patients with cardiogenic shock had longer median hospital stays (median 11.0 vs 4.1 days, P < .001) and were more likely to die (29.0% vs 2.5%, P < .001). All risk scores were adequately calibrated for predicting hospital morality except for the APACHE-II score (Hosmer-Lemeshow P < .001). Discrimination of in-hospital mortality with the APACHE-II (area under the curve [AUC]: 0.72, 95% confidence interval [CI]: 0.66-0.76) and IABP-Shock II (AUC: 0.73, 95% CI: 0.68-0.77) scores were similar, while the CardShock (AUC: 0.76, 95% CI: 0.72-0.81) and SOFA (AUC: 0.76, 95%CI: 0.72-0.81) scores had better discrimination for predicting in-hospital mortality., Conclusions: In a real-world population of patients with cardiogenic shock, existing risk scores had modest prognostic accuracy, with no clear superior score. Further investigation is required to improve the discriminative abilities of existing models or establish novel methods.

Electronic medical records and clinical information systems are increasingly used in hospitals and can be leveraged to improve recognition and care for acute kidney injury. This Acute Dialysis Quality Initiative (ADQI) workgroup was convened to develop consensus around principles for the design of automated AKI detection systems to produce real-time AKI alerts using electronic systems. AKI alerts were recognized by the workgroup as an opportunity to prompt earlier clinical evaluation, further testing and ultimately intervention, rather than as a diagnostic label. Workgroup members agreed with designing AKI alert systems to align with the existing KDIGO classification system, but recommended future work to further refine the appropriateness of AKI alerts and to link these alerts to actionable recommendations for AKI care. The consensus statements developed in this review can be used as a roadmap for development of future electronic applications for automated detection and reporting of AKI.