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The activity of nephrologists in the hospital is not limited to kidney disease, as they also have a role as advisors for all those disciplines that treat conditions involving kidney function. An analysis based on discharge reports from nephrology wards of Italian hospitals has been conducted for the last biennium available (2005-2006) in the ministerial database of hospital discharge reports that classifies the main diagnoses into diagnosis-related groups (DRGs) according to a national classification system. All discharges from nephrology wards were defined as nephrological. Taking this first sample as the starting point, further analyses were carried out on the 20 most frequent DRGs identified. The aim was to clarify the position of nephrology within the national hospital activity. The nephrological activity proved to be concentrated on the first four DRGs (59%). The first 20 DRGs accounted for 80% of the total activity, while the remaining 400 DRGs were fragmented, each representing less than 1% of the total activity. Analyzing the same data cross-sectionally, we see that the ''nephrology market'' is ''owned'' by nephrology wards for only 18% of the total. Nephrology does not have a precise position in the hospital activities and shows considerable overlap with general medicine and general surgery (kidney transplants in particular). The Italian DRG classification has no specific nephrological diagnosis group; this could partially explain the fragmentation. An improved classification system could help in identifying a more precise outline of the nephrological activity.

For many years Italy has had more active physicians than most Western countries. However, the numerus clausus introduced in 1986 for entry into medical schools together with a sharp decrease in places available in specialty training have changed the situation dramatically and today several specialties suffer actual shortages. In such a situation, professional demography is crucial to outline possible developments for the medical profession and nephrology in particular. Our analysis of the medical profession as a whole was based on data from OECD (international comparative analysis) and the yearly estimate of the General Accounts Office (Italian NHS employees). For calculation of the nephrologists we used the administrative data of the members of the Italian Nephrology Society (SIN) and a survey run among nephrology units in the Lombardy region. Data for the university system (medical and specialty schools) were provided by the University Ministry. We found that Italy is no longer an outlier in terms of physician density compared with other Western countries. This ''normalization'' conceals the high concentration of doctors in the older cohorts and the insufficient number of new doctors to replace those leaving the profession for retirement or other reasons. These patterns are similar - and often more severe - in the case of Italian nephrologists. The aging and increasingly female population of Italian nephrologists calls for a major task shift of many activities to nurses and other healthcare professionals.

To improve chronic kidney disease (CKD) outcomes, board-certified nephrologists of the Japanese Society of Nephrology (certified nephrologists) are anticipated to play an important role in community medicine and establish an effective cooperative relationship with primary care physicians. We analyzed the present status of certified nephrologists in each prefecture of Japan based on national data. As a result, in 2008, the maximum number of certified nephrologists per population among the 47 prefectures was 5.3 times higher than the minimum number. The rate of increase was not high in prefectures with a small number of certified nephrologists per population, which indicates that the disparities among the prefectures will persist in the future. To analyze how certified nephrologists participate in the community medicine of the 47 prefectures of Japan, we performed an ecological regression study. At first, it was shown that the number of certified nephrologists per resident population according to prefectures in 2007 had no significant correlation with the annual amount paid for angiotensin converting enzyme inhibitor (ACEI), angiotensin II receptor blocker (ARB), calcium channel-blocker (CCB), or erythropoiesis stimulating agent (ESA) per resident. Furthermore, to determine what parameters had a significant correlation with the incidence of dialysis in each prefecture, simple linear regression analysis was first performed. As a result, parameters with a significant correlation were the average age of the inhabitants, and the annual amounts paid for ARB, ARB plus ACEI, CCB, and ESA per resident. Furthermore, multiple regression analysis revealed that there were two variables included in the final model which could explain the low incidence of dialysis in each prefecture. One was the annual amount of ESA used for predialysis CKD patients, and the other was the number of certified nephrologists per population. Based on these findings, although our ecological study cannot identify causation, we predict that certified nephrologists can effectively prevent the progression of CKD, and an increase in certified nephrologists will decrease the incidence of dialysis.

Background and Objectives: Acute kidney injury (AKI) is associated with adverse outcomes in critically ill patients. The influence of preexisting chronic kidney disease (CKD) on AKI outcomes is unclear., Design, Setting, Participants, & Measurements: We analyzed data from a prospective observational cohort study of AKI in critically ill patients who received nephrology consultation: the Program to Improve Care in Acute Renal Disease. In-hospital mortality rate, length of stay, and dialysis dependence were compared in patients with and without a prior history of CKD, defined by an elevated serum creatinine, proteinuria, and/or abnormal renal ultrasound within a year before hospitalization. We hypothesized that patients with AKI and prior history of CKD would have lower mortality rates, shorter lengths of stay, and higher rates of dialysis dependence than patients without prior history of CKD., Results: Patients with AKI and a prior history of CKD were older and underwent nephrology consultation earlier in the course of AKI. In-hospital mortality rate was lower (31 versus 40%, P = 0.04), and median intensive care unit length of stay was 4.6 d shorter (14.7 versus 19.3 d, P = 0.001) in patients with a prior history of CKD. Among dialyzed survivors, patients with prior CKD were also more likely to be dialysis dependent at hospital discharge. Differences in outcome were most evident in patients with lower severity of illness., Conclusions: Among critically ill patients with AKI, those with prior CKD experience a lower mortality rate but are more likely to be dialysis dependent at hospital discharge. Future studies should determine optimal strategies for managing AKI with and without a prior history of CKD.

Renal amyloid involvement results, especially, from AL (primary) or AA (secondary) amyloidosis. The extent of amyloid tissue deposits in the kidneys and the clinical course of amyloidosis not only depend on the type of basic process but also reflect the time of diagnosis and the ability to affect the underlying disease. We analyzed laboratory and clinical data from patients with bioptically proven renal amyloidosis. Renal amyloidosis was found in 99 patients (4.65%) from an overall number of 2,128 renal biopsies (RB) performed in our department during a period of 11 years (from 1995 to 2006). AA amyloidosis was diagnosed in 46 patients. Nephrotic syndrome was diagnosed in 27 patients (59%) with AA amyloidosis; all these patients had different degrees of proteinuria. Impaired renal function was discovered in 24 patients (52%); in three of these patients (6.5%) we had to start renal replacement therapy. Patients were treated with corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and biological therapy in various regimens. Nine patients (19.5%) died during the one-year follow-up period; complications such as sepsis and cardiac failure were the leading causes of death. Median survival in the AA group was 54 months. Although for approximately half of patients different treatment regimens can lead to a partial remission or disease stabilization, the prognosis of patients with amyloidosis could be regarded as unsatisfactory.

Background and Objectives: Academic nephrology faces increasing challenges in faculty hiring and development. However, it is unknown how these pressures have affected the number and demographics of academic nephrologists., Design, Setting, Participants, & Measurements: Using the Association of American Medical Colleges Faculty Roster database, changes were analyzed in MD nephrology, as well as other internal medicine subspecialty, faculty from 1998 to 2008., Results: There were 1315 full-time MD nephrology faculty in 2008; this fell by 4.9% over the past decade. There were fewer junior, and more senior, faculty over this period. This was associated with 12.4% fewer tenured, 22.3% fewer tenure track, and an 11.5% increase in nontenure track, academic nephrologists. Academic nephrologists who are U.S. medical school graduates declined by 11.9%, while those who were international medical school graduates increased by 13.2%; nephrology has a greater percentage of international medical school graduates than any other internal medicine subspecialty. Female nephrology faculty increased by 14.3%, while male faculty fell by 9.5%. Asian nephrology faculty increased by 41.3%, while Caucasians declined by 15.2%. Similar changes in all the above parameters were seen for most other internal medicine subspecialties. The nephrology research programs at the top 20 research institutions, as compared with all other nephrology programs, had a greater decline in total MD, male, tenure track, and junior faculty., Conclusions: These data suggest that the future of academic nephrology is at risk. The decline in nephrology faculty provides incentive for leaders in academic nephrology to improve recruiting and retention practices.

Background: The objectives of this pilot study were to evaluate treatment quality for the risk factors of hypertension, diabetes and hyperlipidemia as well as the overall treatment quality for patients on an internal nephrology ward. This evaluation included the collection of data concerning the quality of therapeutic drug monitoring, drug use and potential drug-drug interactions. Establishing such baseline information highlights areas that have a need for further therapeutic intervention and creates a foundation for improving patient care, a subject that could be addressed in future clinical pharmacy research projects., Methods: Medical charts of patients treated on a single internal nephrology ward were retrospectively evaluated using a predefined data collection form. Assessment of further need for therapeutic intervention was performed., Results: For 76.5% (n = 78) of the total study population (n = 102), there was either a possibility (39.2%, n = 40) or a need (37.3%, n = 38) for further intervention based on the overall assessment. For the risk factors of hypertension, diabetes and hyperlipidemia, the proportions of patients that require further intervention were 78.8% (n = 71), 90.6% (n = 58) and 87.9% (n = 58), respectively. Patients with diabetes or hyperlipidemia were less likely to have optimal risk factor control. The number of drugs prescribed and the number of potential drug-drug interactions were significantly higher after in-hospital treatment., Conclusion: Risk factor treatment needs optimisation. Risk factor management, systematic medication reviews, and screening for and management of potential drug-drug interactions deserve great attention. Clinical pharmacy services could help in the achievement of treatment goals.

Serum creatinine alone can be difficult to interpret as a measure of kidney function such that chronic kidney disease might be under-recognized in the general population. In the province of Ontario, Canada, all outpatient laboratories now report estimated glomerular filtration rate (eGFR) in addition to serum creatinine. To determine the impact of this reporting on clinical practice, we linked health administrative data for more than 8 million adults of age 25 years or older over an almost 10-year period and conducted a population-based intervention analysis with seasonal time-series modeling to determine overall trends in the number and type of patients seen by nephrologists. Compared to the period when only serum creatinines were reported, the number of patients seen in consultation by nephrologists increased after eGFR reporting by an average of 24% (an absolute increase of 2.9 consults per 100,000 adults), an increase of about 23 consults per nephrologist per year. The greatest increases were seen in women (39% increase) and those 80 years of age and older (58% increase). Our study found that eGFR reporting was associated with a sudden increase in the number of nephrology consults. However, it remains to be seen whether the routine reporting of eGFR results in improved treatment and outcomes for those with chronic kidney disease.

Aims: Women with chronic kidney disease (CKD) are often at risk for anemia. This study examined variations in anemia care and management among women with CKD in outpatient settings in the United States., Methods: The study utilized National Ambulatory Medical Care Survey (NAMCS) data from 1996 to 2003. Women aged 18 years or older with CKD were included based on ICD-9-CM codes for CKD, anemia, and reason for visit. Anemia-related medications were retrieved using NAMCS drug codes., Results: Approximately 58 million weighted outpatient visits for women with CKD were made. Nearly 14% of these visits were by Hispanic women and 50% visits were by patients aged 65 years or older. Nephrologists accounted for only 15% of CKD patient visits and 51% of these patients had anemia diagnosis. Additionally, 32% of patients were using 5 or more medications. Women with Medicare coverage were 2.6 times more likely (p < .05) to be diagnosed with anemia by a nephrologist and were 2.4 times more likely (p < .05) to receive a prescription to treat anemia than patients seen by non-nephrologists. Hispanic women were 56% less likely (p < or = .05) to use 5 or more medications than non-Hispanic patients. CKD patients with anemia diagnosis were 50% less likely to receive 5 or more medications (p < or = .05)., Conclusion: This study found many risk factors associated with the diagnosis and treatment of anemia in women with CKD being treated in U.S. outpatient settings. Increased awareness of early treatments for anemia and assessments of patients receiving multiple medications is needed in women with CKD.

Data of the European Practice Database (EPD) were used to investigate the use of phosphate binders in the European HD population. A cross-sectional observation among five participating countries of the cycle 2 study revealed that most patients used phosphate binders and many of them used more than one agent. Calcium-based products were most frequently used (55% of HD patients) followed by sevelamer (37%). There was a wide variation between different countries in the kind of phosphates that were used. Renal dietitians advised regularly on therapy adjustment for calcium/phosphorus metabolism in one third of European centres and their involvement is increasing.

Background and Objectives: Many patients with chronic kidney disease (CKD) are seen by primary care physicians who may not be aware of indications or benefits of timely nephrologist referral. Late referral to a nephrologist may lead to suboptimal pre-end stage renal disease care and greater mortality. It is not known whether current postgraduate training adequately prepares a future internist in this aspect of CKD management., Design, Setting, Participants, and Measurements: The authors performed an online questionnaire survey of internal medicine residents in the United States to determine their perceptions of indications for nephrology referral in CKD management., Results: Four hundred seventy-nine residents completed the survey with postgraduate year (PGY) distribution of 166 PGY 1,187 PGY 2 and 126 PGY 3. Few residents chose nephrology referral for proteinuria (45%), uncontrolled hypertension (64%), or hyperkalemia (26%). Twenty-eight percent of the residents considered consulting a nephrologist for anemia of CKD, whereas 45% would do so for bone disorder of CKD. Most of the residents would involve a nephrologist at glomerular filtration rate (GFR) <30 ml/min/1.73 m(2) (90%) and for rapid decline in GFR (79%). Many residents would refer a patient for dialysis setup at GFR 15 to 30 ml/min/1.73 m(2) (59%); however, 18% would do so at GFR <15 ml/min/1.73 m(2). Presence of CKD clinic experience or an in-house nephrology fellowship program did not considerably change these perceptions., Conclusions: Results show that internal medicine residents have widely differing perceptions of indications for nephrology referral. Educational efforts during residency training to raise awareness and benefits of early referral may improve CKD management by facilitating better collaboration between internist and nephrologist.

Background/aims: Despite implications for long-term care, little is known about outpatient care for kidney transplant patients., Methods: In this retrospective observational cohort study, outpatient claims were examined for 42,078 Medicare kidney transplant patients using United States Renal Data System data to ascertain location and timing of outpatient visits and type of physician seen. Logistic regression with generalized estimating equations was used to determine the odds and clinical correlates of visits in 4 post-transplant time periods., Results: In months 1-3, 88% of patients visited their transplant centers, but this declined to 69% in months 25-36. In the adjusted analysis, Native Americans (odds ratio 0.56, 95% confidence interval 0.48-0.65) and Hispanics (OR 0.86, 95% CI 0.80-0.92) were less likely than whites to visit their transplant centers. Centers performing 18-34 (OR 1.44, 95% CI 1.30-1.59) and 35-61 transplants per year (OR 1.30, 95% CI 1.18-1.43) were more likely to see patients than centers performing <18 or >61. Almost 80% of patients saw nephrologists in months 1-3 after transplant. African-Americans (OR 0.85, 95% CI 0.80-0.90), Asians (OR 0.87, 95% CI 0.77-0.97), and Native Americans (OR 0.63, 95% CI 0.53-0.75) were less likely than whites to see nephrologists, as were Hispanics (OR 0.78, 95% CI 0.72-0.84) compared with non-Hispanics., Conclusion: Frequency of visits to transplant centers varied by center and region; most visits were to nephrologists. Patients from minority groups were less likely to visit transplant centers and nephrologists, with possibly significant public health implications., (Copyright 2009 S. Karger AG, Basel.)

What is this patient's prognosis regarding graft rejection? Do patients using a particular drug live longer than those not using it? How does this co-morbidity affect access to transplantation? To answer this type of questions one needs to perform survival analysis. This paper focuses on the Kaplan-Meier method, the most popular method used for survival analysis. It makes it possible to calculate the incidence rate of events like recovery of renal function, myocardial infarction or death by using information from all subjects at risk for these events. It explains how the method works, how survival probabilities are calculated, survival data can be summarized and survival in groups can be compared using the logrank test for hypothesis testing. In addition, it provides some guidance regarding the presentation of survival plots. Finally, it discusses the limitations of the Kaplan-Meier method and refers to other methods that better serve additional purposes.

In recent years, there has been a resurgence of home hemodialysis (HHD) therapies. Given the small percentage of prevalent patients in the United States currently on home dialysis, an appropriate question is: What is the role of peritoneal dialysis (PD) in this era? Data suggest that in centers that are promoting the growth of HHD, their PD programs also tend to be very active. Furthermore, our experience and other data suggest that one should not worry about cannibalizing PD in order to grow HHD. Most HHD patients come from in-center hemodialysis or those patients transitioning from PD to another therapy. In fact, data suggest that in order to promote the growth of HHD, a certain minimal infrastructure is needed in terms of staff. An active PD program not only supports a robust infrastructure that allows for HHD growth but also fosters profitability of a home program.

A survey conducted by Bonucchi et al. underlined the different types of doctors placing arteriovenous fistula (AVF) for hemodialysis in the United States and Europe (in particular Italy). In fact, nephrologists definitely prevail in Italy, where almost 48.8% of nephrologists place an AVF themselves or with the help of a vascular surgeon (26.4%). In Europe, only 35% do so, whereas 89% of AVF are performed by surgeons in the United States. In 98% of the cases occurring at our center, the AVF was placed and reviewed by the nephrologists. This paper reports surgery cases related to the period between January 1983 and September 2006. Over this time, 1386 operations for placing and reviewing vascular access were conducted. Among these, 47 (3.3%) were related to a cuffed central venous catheter (CVC); 1138 (80.2%) related to a distal AVF; 201 (10.6%) related to a proximal AVF; and 51 (3.6%) related to an arteriovenous graft (AVG). In addition, 33 (2.3%) operations performed before January 1983 relating to AV Scribner shunts were included. Arteriovenous fistulas or AVGs were provided to our patients (only 2.6% of them have a CVC), and AVF rescue operations were performed in the shortest possible time with advantages for the patient and his vascular access.

Background: To identify patient and health system characteristics associated with late referral of patients with chronic kidney disease to nephrologists., Methods: MEDLINE, CENTRAL, and CINAHL were searched using the appropriate MESH terms in March 2007. Two reviewers individually and in duplicate reviewed the abstracts of 256 articles and selected 18 observational studies for inclusion. The reasons for late referral were categorized into patient or health system characteristics. Data extraction and content appraisal were done using a prespecified protocol., Results: Older age, the existence of multiple comorbidities, race other than Caucasian, lack of insurance, lower socioeconomic status and educational levels were patient characteristics associated with late referral of patients with chronic kidney disease. Lack of referring physician knowledge about the appropriate timing of referral, absence of communication between referring physicians and nephrologists, and dialysis care delivered at tertiary medical centers were health system characteristics associated with late referral of patients with chronic kidney disease. Most studies identified multiple factors associated with late referral, although the relative importance and the combined effect of these factors were not systematically evaluated., Conclusion: A combination of patient and health system characteristics is associated with late referral of patients with chronic kidney disease. Overall, being older, belonging to a minority group, being less educated, being uninsured, suffering from multiple comorbidities, and the lack of communication between primary care physicians and nephrologists contribute to late referral of patients with chronic kidney disease. Both primary care physicians and nephrologists need to engage in multisectoral collaborative efforts that ensure patient education and enhance physician awareness to improve the care of patients with chronic kidney disease.

Vascular calcification is highly prevalent and often severe in patients with chronic kidney disease. Arterial calcification in patients with chronic kidney disease can result from the deposition of mineral along the intimal layer of arteries in conjunction with atheromatous plaques or from calcium deposition in the medial wall of arteries, also known as Monckeberg's sclerosis. Whether coronary artery calcium scores as measured by electron beam computed tomography correlate with occlusive atherosclerotic disease in the dialysis population is uncertain. Here we report a case of an asymptomatic patient with diabetes mellitus and end-stage renal disease undergoing maintenance hemodialysis, who was found to have extremely elevated coronary artery calcium scores on electron beam computed tomography, but varied degrees of atherosclerotic plaque in her coronary arteries on coronary angiography. This suggests that in addition to the calcification anticipated in a remodeled intima, a proportion of the calcification is also likely to be in the arterial media. Thus, this case demonstrates that even an extremely high coronary calcium score may not be a satisfactory surrogate marker for obstructive atherosclerosis in elderly diabetic dialysis patients.

Purpose: The study purpose was to compare differences in mortality and the duration of hospitalization in patients with chronic kidney disease who are referred early versus late to nephrologists., Methods: We searched English-language literature from 1980 through December 2005, along with national conference proceedings, the Web of Science Citation Index, and reference lists of all included studies. Twenty-two studies with a total sample size of 12,749 met inclusion criteria., Results: There was significantly increased overall mortality in the late referral group as compared with the early referral group (relative risk 1.99; 95% confidence interval [CI], 1.66 to 2.39, P <.0001). The duration of hospital stay, at the time of initiation of renal replacement therapy, was greater in the late referred group by an average of 12 days (95% CI, 8.0 to 16.1, P=.0007). Significant heterogeneity was detected for both outcomes., Conclusion: Timing of referral emerged to be a significant factor impacting homogeneity in the mortality outcome. Our results suggest significantly higher mortality and increased early hospitalization of chronic kidney disease subjects referred late to nephrologists as compared with earlier referred subjects.

Unlabelled: Opioids are commonly used in both cancer and noncancer pain. Many patients who require opioids have renal impairment. This can adversely influence the safety of opioids in these patients., Objectives: The objectives of this study were to (1) determine which opioids are most commonly prescribed in patients with renal impairment, (2) to identify differences in prescribing practices between two groups of physicians, and (3) to determine how renal impairment was recognized in this setting., Design and Participants: A questionnaire postal survey was sent out to renal and palliative medicine consultants in U.K. and Ireland. One hundred and seventy-eight (30.5 percent) questionnaires were completed., Results: A larger proportion of renal than palliative medicine physicians prescribed morphine in patients with renal impairment. A significant number of physicians did not adjust doses of morphine or codeine. Palliative medicine physicians were more likely to prescribe opioids other than morphine, with the exception offentanyl which was widely used by both groups. Renal physicians were more likely to base their choice of opioid on glomerular filtration rate while palliative medicine physicians were more likely to be influenced by serum creatinine., Conclusions: Consensus guidelines drawing on expertise from both palliative and renal physicians are needed to promote safer use of opioids in this vulnerable patient group.

Background: The aim of this study is to evaluate the association between acute serum creatinine changes in acute renal failure (ARF), before specialized treatment begins, and in-hospital mortality, recovery of renal function, and overall mortality at 6 months, on an equal degree of ARF severity, using the RIFLE criteria, and comorbid illnesses., Methods: Prospective cohort study of 1008 consecutive patients who had been diagnosed as having ARF, and had been admitted in an university-affiliated hospital over 10 years. Demographic, clinical information and outcomes were measured. After that, 646 patients who had presented enough increment in serum creatinine to qualify for the RIFLE criteria were included for subsequent analysis. The population was divided into two groups using the median serum creatinine change (101%) as the cut-off value. Multivariate non-conditional logistic and linear regression models were used., Results: A >or= 101% increment of creatinine respect to its baseline before nephrology consultation was associated with significant increase of in-hospital mortality (35.6% vs. 22.6%, p < 0.001), with an adjusted odds ratio of 1.81 (95% CI: 1.08-3.03). Patients who required continuous renal replacement therapy in the >or= 101% increment group presented a higher increase of in-hospital mortality (62.7% vs 46.4%, p = 0.048), with an adjusted odds ratio of 2.66 (95% CI: 1.00-7.21). Patients in the >or= 101% increment group had a higher mean serum creatinine level with respect to their baseline level (114.72% vs. 37.96%) at hospital discharge. This was an adjusted 48.92% (95% CI: 13.05-84.79) more serum creatinine than in the < 101% increment group., Conclusion: In this cohort, patients who had presented an increment in serum level of creatinine of >or= 101% with respect to basal values, at the time of nephrology consultation, had increased mortality rates and were discharged from hospital with a more deteriorated renal function than those with similar Liano scoring and the same RIFLE classes, but with a < 101% increment. This finding may provide more information about the factors involved in the prognosis of ARF. Furthermore, the calculation of relative serum creatinine increase could be used as a practical tool to identify those patients at risk, and that would benefit from an intensive therapy.

Predialysis nephrologist care is associated with morbidity and mortality in incident dialysis patients, but the relationship with access to kidney transplantation (KT) is unclear. From a national study of incident US dialysis patients, we identified 2253 patients with detailed information about predialysis care, sociodemographic characteristics and comorbidities. We used multivariate Cox proportional hazards models to study associations between predialysis nephrology care and two outcomes: time from first dialysis to the first day on the KT wait-list, and time to first KT. Two-thirds of patients first encountered a nephrologist >3 months prior to dialysis and one-third

Background: Late referral to nephrologists is common and associated with increased morbidity and mortality. We aimed to analyze the prevalence rates, predictors and consequences of late referral to nephrologists by primary care physicians for chronic kidney disease (CKD) care., Methods: A retrospective analysis of 204 patients started on dialysis for CKD in two community hospitals between March 2003 and March 2005 was conducted. Relevant clinical and laboratory data were obtained from the patient records of the nephrology clinics and dialysis units. Patients referred in CKD stage 5 (estimated glomerular filtration rate <15 ml/min) were defined as late referral and patients in CKD stage 1-4 (estimated glomerular filtration rate >15 ml/min) as early referral., Results: Forty-five (22%) of the 204 patients were referred late. In the multivariate analysis, non-diabetic kidney disease (odds ratio = 2.46, p = 0.02) and Charlson comorbidity index (odds ratio = 1.17, p = 0.009) were significantly associated with late referral. The late referral group had lower hematocrit and serum calcium levels, and higher serum phosphorus and parathyroid hormone levels than the early referral group (p < or =0.05) at the time of referral. Late referral resulted in less permanent vascular access for initiation of dialysis (p = 0.03). Even though there was twice the number of deaths in the late referral group in 1 year (18 vs. 9%), this was not statistically significant (p = 0.07)., Conclusion: Referring physicians should pay special attention to patients with non-diabetic kidney disease and patients with multiple comorbidities since delayed referral to nephrologists may result in poorer patient-related outcomes. Larger and long-term prospective studies analyzing the long-term consequences of late referral to nephrologists are needed., (Copyright 2007 S. Karger AG, Basel.)

Background: It is unclear whether primary care physicians (PCPs) and nephrologists differ in their recognition of progressive chronic kidney disease (CKD), agree on diagnostic and referral strategies, and identify similar barriers to caring for patients., Methods: We conducted a national study of PCPs and nephrologists in the United States through a questionnaire describing a PCP caring for a patient with progressing CKD and questions to assess recognition of kidney dysfunction and approaches to diagnostic evaluation and referral. We identified participant and patient characteristics independently associated with CKD recognition and referral., Results: We randomly identified a national sample of 304 physicians (126 nephrologists [39% response rate], 89 family physicians [28% response rate], and 89 general internists [28% response rate]). PCPs recognized CKD less (adjusted percentage, 59%; 95% confidence interval [CI], 47 to 69, family physicians; adjusted percentage, 78%; 95% CI, 67 to 86, general internists; adjusted percentage, 97%; 95% CI, 93 to 99, nephrologists; P < 0.01), differed from nephrologists in their recommendations for diagnostic testing, and recommended referral less (adjusted percentage, 76%; 95% CI, 65 to 84, family physicians; adjusted percentage, 81%; 95% CI, 70 to 89, general internists; adjusted percentage, 99%; 95% CI, 95 to 100, nephrologists; P < 0.01). PCPs differed from nephrologists in their expected intensity of specialists' involvement in care (16%, family physicians; 20%, general internists; 6%, nephrologists recommending nephrologist input monthly to every 6 months; P = 0.01). Lack of awareness of clinical practice guidelines and lack of clinical and administrative resources were identified as important barriers to care., Conclusion: PCPs recognize and recommend specialist care for progressive CKD less than nephrologists and differ in their clinical evaluations and expectations for referral. Improved dissemination of existing guidelines and targeted education in conjunction with efforts to build consensus among PCPs and nephrologists regarding their roles in the care of patients with CKD, including the collaborative development of clinical practice guidelines, could enhance patient care.

Objectives: A bibliometric investigation was done to identify characteristics of the literature that nephrology nurses utilize. It is one component of a broader study, "Mapping the Literature of Nursing," by the Medical Library Association's Nursing and Allied Health Resources Section Task Force to Map the Literature of Nursing., Methods: Following a standard protocol, this project utilized Bradford's Law of Scattering to analyze the literature of nephrology nursing. Citation analysis was done on articles that were published from 1996 to 1998 in a source journal. Cited journal titles were divided into three zones, and coverage in major article databases were scored for Zones 1 and 2., Results: During the three-year period, journals were the most frequently cited format type. Eighty-one journals were cited in Zones 1 and 2. As Bradford's Law of Scattering predicted, a small number of the cited journals accounted for the most use. Coverage is most comprehensive for cited journals in Science Citation Index, PubMed/ MEDLINE, and EMBASE. When looking just at cited nursing journals, CINAHL and PubMed/MEDLINE provide the best indexing coverage., Conclusion: This study offers understanding of and insights into the types of information that nephrology nurses use for research. It is a valuable tool for anyone involved with providing nephrology nursing literature.

Background: It is estimated that 20-50% of adult patients start chronic dialysis therapy without prior contact with a nephrologist. The aim of this nationwide study was to assess clinical and metabolic status of children at the start of chronic dialysis in Poland with regard to the timing of the referral to a nephrologist., Methods: We studied data of 180 children (mean age 14+/-6 years) undergoing chronic dialysis in 13 (out of 14) dialysis pediatric centres in Poland. Patients were classified as early referrals (ERs) when they entered the dialysis programme at least 1 month after the first referral to a nephrologist or late referrals (LRs) when the dialysis was introduced within 1 month from the first visit., Results: Seventy-nine percent of pediatric patients were referred early (ER) to the dialysis centre and 21% were referred late (LR) and had to start dialysis within a month. When starting dialysis, LR patients had significantly higher levels of urea and phosphate as well as lower calcium and haemoglobin in comparison with ERs. Hypertension, pulmonary oedema, fluid overload, treatment in the intensive care unit (ICU) and body mass index (BMI) below 10th percentile turned out to be more frequent in the LR group. Peritoneal dialysis (PD) was used as the first method of dialysis in 59% of ERs and 46% of LRs. The majority of ER patients was treated in the predialysis period with calcitriol, phosphate binders and low protein diet (84%, 89%, 92% of all children, respectively), and 20% of them received epoetin. In the up to 3 years observation of our initial cohort, we also found that the patients who were referred late were less likely to receive kidney transplant (P = 0.02)., Conclusion: The results of the study indicate that the LR to a pediatric nephrologist was associated with poorer clinical and metabolic status of children entering chronic dialysis programmes.

Background: Early referral of patients with end-stage renal disease to a nephrologist is associated with lower morbidity and mortality after initiating dialysis therapy; earlier referral may have better results. The aim of the study is to prospectively determine the impact of earlier referral to a nephrologist on renal damage progression of patients with type 2 diabetes mellitus (DM2) with early nephropathy., Methods: Fifty-two patients (27 patients, early nephropathy [EN]; 25 patients, overt nephropathy [ON]) from a primary health care unit were referred to a nephrologist (study cohort); 65 patients (34 patients, EN; 31 patients, ON) from another health care unit remained treated by only family doctors (control cohort). Both cohorts were followed up for 1 year., Results: Delta (final-baseline) in serum creatinine levels was maintained better by the nephrologist in the EN (study, 0.02 mg/dL versus control, 0.13 mg/dL [2 versus 11 micromol/L]; P = 0.02) than ON group (study, 0.15 mg/dL versus control, 0.25 mg/dL [13 versus 22 micromol/L]). In concordance, glomerular filtration rate was maintained better by the nephrologist in EN (study, 3.2 mL/min/1.73 m2 versus control, -13.3 mL/min/1.73 m2 [0.05 versus -0.22 mL/s/1.73 m2]; P = 0.01) than ON patients (study, -9.8 mL/min/1.73 m2 versus control, -10.9 mL/min/1.73 m2 [-0.16 versus -0.18 mL/s/1.73 m2]). Albuminuria increased more in patients treated by family doctors in the EN (study, 30 mg/d versus control, 116 mg/d; P < 0.05) and ON groups (study, 160 mg/d versus control, 623 mg/d). The nephrologist controlled systolic blood pressure better in both the EN (study, -3 mm Hg versus control, 2 mm Hg; P < 0.05) and ON groups (study, -19 mm Hg versus control, 5 mm Hg; P < 0.05); diastolic blood pressure had a similar pattern. The nephrologist significantly increased (P < 0.05) the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and statins and discontinued nonsteroidal anti-inflammatory drugs more than family doctors (study, 42%, 43%, 39%, and -11% versus control, 17%, 4%, -7%, and 27%, respectively). Glycemic and lipid control and stopping smoking were not attained by either the nephrologist or family doctors., Conclusion: Earlier referral of patients with DM2 to a nephrologist was associated with better renal function preservation, which was significantly more evident in the EN than ON group. The nephrologist obtained better blood pressure control, more frequently used angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and statins; and discontinued nonsteroidal anti-inflammatory drugs more than family doctors. However, metabolic control and stopping smoking were not attained by either the nephrologist or family doctors.

The European Practice Database (EPD) project, developed by the EDTNA/ERCA Research Board, collects data on renal practice at centre level in different European countries. Results presented in this paper focus on the European Practice in Haemodialysis centres from 8 European countries or regions following data collection from 2002 to 2004. These results will enable international comparison in practice and will stimulate further research and the development of new practice recommendations.

After the successful pilot EPD Project in 2002-2003, we decided to perform the EPD project in four additional countries: Belgium, Greece, Norway and Scotland. Before starting the EPD Project in Belgium, we installed a Belgium National EPD Board in order to support the practical organisation of this project. National coordinators were Luc Picavet (Chair) and Sylviane Boullé (Wallonia). The members of the Belgium National EPD Board were Jean-Yves De Vos (President of National Association, ORPADT Flanders), Hichem Marzougui (Link member, Association of Dialysis Technicians) and Luc Vonckx (President of Association of Dialysis Technicians).

Aim: To review the outcomes of elderly patients referred to a nephrology clinic and to develop referral guidelines., Methods: A retrospective audit of patients aged 65 years or older referred over a 24-month period to a nephrology clinic. Outcomes assessed were whether a renal diagnosis was made and if there was any change in management., Results: Sixty-one patients were referred with an average age of 74 years (range 65-88 years). The commonest reason for referral was renal impairment (69%); mean estimated creatinine clearance 32 ml/min. Diagnoses included hypertensive renal disease (30%), chronic renal failure - cause unknown (18%) and diabetic nephropathy (8%). In the majority of cases, the diagnosis was clinical. Renal biopsy was performed on four patients and declined by a further two. Management usually consisted of advice regarding clinical monitoring and drug treatment (80%). The clinic visit resulted in a change of management in 50% of cases., Conclusions: Most elderly patients with renal disease have chronic pathology for which intensive investigation is not warranted. The majority of nephrology clinic referrals resulted in advice on clinical management being given to the general practitioner. Patients with severe or acute renal impairment are more likely to be investigated and offered treatment. Referral guidelines for general practitioners may aid appropriate referral.

Background: Medicare's reimbursement system was changed in January 2004 to encourage more frequent visits between dialysis patients and nephrologists. We sought to determine the impact of this policy change on patient-nephrologist visits, quality of care, and health-related quality of life., Methods: We examined visits and outcomes for 2,043 patients at 12 hemodialysis facilities in northeast Ohio for 12 months before and 7 months after the reimbursement change. For comparison of outcomes, we used linear, logistic, or negative binomial regression models (for continuous, binary, and rate outcomes, respectively) to assess the significance of changes across the 2 periods., Results: For patients seen before and after the reimbursement change for at least 6 months, the number of visits per patient-month increased from 1.52 before to 3.14 after (P < 0.001). The percentage of patients with no nephrologist visits per patient-month decreased from 16.6% before to 4.6% after (P < 0.001). However, there were no clinically important changes in Kt/V, albumin level, hemoglobin level, phosphorus level, calcium level, hemodialysis catheter use, ultrafiltration volume, shortened or skipped treatments, hospital admissions, hospitalization days, or health-related quality of life, including patient satisfaction., Conclusion: Despite a marked increase in visits between patients and nephrologists, there was no clinically important impact on parameters related to quality of care or health-related quality of life. Additional work is needed to determine effective payment strategies to improve dialysis patient outcomes.

Background: We lack information about the role of late diagnosis of end-stage renal disease (ESRD), late nephrological referral and its impact on biochemical variables and first hospitalization in East Anatolia, Turkey., Methods and Results: For a total of 101 ESRD patients, dialysis was initiated between January 1998 and December 2002 at the Yuzuncu Yil University Hospital. Early referral (ER) and late referral (LR) were defined as the time of first referral or admission to a nephrologist greater or less than 12 weeks, respectively, before initiation of haemodialysis (HD)., Results: The need for urgent dialysis was less among the early referral cases compared with the late referral cases (P = 0.03). Patients with LR started dialysis with lower levels of haemoglobin (8.6 vs 9.5 g/dL, P < 0.05) bicarbonate (16 vs 12 mEq/lt, P < 0.03) and albumin (2.9 vs 3.29 mg/dL, P < 0.02) and with higher serum levels of blood urea nitrogen (173 vs 95 mg/dL, P < 0.001), creatinine (10 vs 7.9 mg/dL, P < 0.001) and potassium (5.3 vs 4.8, P < 0.04). Hospitalization duration beginning at dialysis was significantly longer in the LR group (27.3 +/- 24) compared with the ER group (13.4 +/- 7.5, P < 0.001). When the groups were compared in terms of distance between the patients home and hospital, there were significantly more patients living far away from hospital (i.e. >100 km) in the LR group compared with the ER (P < 0.0001) group., Conclusion: Early referral to a nephrology unit and/or early diagnosis of ESRD results in better biochemical variables, shorter first hospitalization length and a higher percentage of elective construction of AVF and the availability to start with an alternative dialysis modality (i.e. CAPD).

The Italian Society of Nephrology (SIN) promoted a national survey in order to obtain detailed information from all Renal and/or Dialysis Units using the on-line questionnaire (158 items) regarding structural and technological resources, medical workforce organisation and activity features. The purposes of this initiative were to obtain regional benchmarks as references for renal units and to describe the current Italian renal network in order to plan further interventions for the next 5 years. In this paper data of the first three Italian Regions (Piemonte, Liguria and Valle d'Aosta) which completed the survey (100% of the units) are reported. Main findings in the 3 Regions. A) Epidemiology: prevalence of dialysis patients = 709, 720, 787 pmp (per million population); prevalence of transplanted patients = 325, 387, 279 pmp; incidence of dialysis patients = 166, 191, 156 pmp; gross mortality of dialysis patients = 13.7, 15.0, 13.0%; distribution of vascular access in prevalent dialysis patients: arteriovenous fistula = 74, 83, 76%, central venous catheter = 18, 12, 15%, vascular graft = 8, 5, 9%. B) Structural resources: hospital's number of beds = 49, 72, 49 pmp, dialysis places = 166, 158, 164 pmp. C) Personnel resources: renal physicians = 44, 47, 41 pmp, renal nurses = 186, 194, 205 pmp; each renal physician takes care of 16, 15, 19 dialysis patients and each renal nurse cares for 3.8, 3.7, 3.8 dialysis patients. D) Activity: admission to hospital = 1507, 2392, 1606 pmp, renal biopsies = 109, 133, 57 pmp. Despite discrepancies in population density in the three Regions, most indexes are surprisingly similar and show the satisfactory level of renal care attained in the Northwestern Italian area. Further improvements in health care management can be predicted as a consequence of a direct comparison between needs and results in the various Regions of the Country.

Background: Nephrologists report that patients' choice should play an important role in the selection of renal replacement therapy (RRT) for end-stage renal disease (ESRD). In the United States, kidney transplant rates remain low and <10% of patients utilize home dialysis therapies. This study examined the effect of pre-ESRD processes on the selection of RRT among incident ESRD patients., Methods: Using surveys, data were collected for all patients admitted to 229 dialysis units in ESRD Network 18 between April 1, 2002 and May 31, 2002. A total of 1365 patients began chronic dialysis and 1193 facility (87%) and 428 patient (31%) surveys were returned., Results: Substantial proportions of patients were unaware of their kidney disease (36%) or were not seeing a nephrologist (36%) until <4 months before first dialysis. The presentation of treatment options was delayed (48% either after or < 1 month before the first dialysis). The majority of ESRD patients were not presented with chronic peritoneal dialysis, home hemodialysis, or renal transplantation as options (66%, 88%, and 74%, respectively). Using multivariate analyses, variables significantly associated with selection of chronic peritoneal dialysis as dialysis modality were the probability of chronic peritoneal dialysis being presented as a treatment option and the time spent on patient education., Conclusion: An incomplete presentation of treatment options is an important reason for under-utilization of home dialysis therapies and probably delays access to transplantation. Improvements in and reimbursement for pre-ESRD education could provide an equal and timely access for all medically suitable patients to various RRTs.

Background: Although most patients with moderate chronic kidney disease (CKD) are managed exclusively in primary care (PC), no data on blood pressure (BP) control in this setting are available. We compared hypertension management in patients with CKD followed up in PC and nephrology tertiary care (TC)., Methods: We studied hypertensive patients with estimated glomerular filtration rates (eGFRs) of 15 to 60 mL/min/1.73 m2 (0.25 to 1.00 mL/s) exclusively followed up for at least 1 year in PC (n = 259) or TC (n = 186)., Results: PC compared with TC patients were characterized by older age (73 +/- 10 versus 65 +/- 14 years; P < 0.0001), greater prevalences of previous cardiovascular events (59% versus 32%; P < 0.0001) and diabetes (36% versus 23%; P = 0.005), and slightly greater eGFRs (37 +/- 10 versus 34 +/- 11 mL/min/1.73 m2 ; P = 0.005). They showed higher BP levels (143 +/- 15/82 +/- 7 versus 136 +/- 18/78 +/- 11 mm Hg; P < 0.0001), with a lower prevalence of BP target (5.8% [95% confidence interval (CI), 2.9 to 8.6] versus 21.5% [95% CI, 15.6 to 27.4]; P < 0.0001). The risk for not achieving BP target in PC was 2.6 times greater, independently from age, sex, diabetes, and eGFR. Fewer antihypertensive drugs were prescribed in PC (1.9 +/- 1.1 versus 2.5 +/- 1.1; P < 0.0001). In both groups, inhibitors of the renin-angiotensin system were the most frequently prescribed drugs (>84%), followed by diuretics (50%). However, family physicians almost exclusively prescribed hydrochlorothiazide, whereas nephrologists preferentially prescribed furosemide, administered at a higher dose than in PC (47 +/- 41 versus 28 +/- 21 mg/d; P = 0.004)., Conclusion: Control of CKD-related hypertension is significantly worse in PC despite a greater cardiovascular risk. Barriers to optimal BP control likely are represented by a low number of drugs and inadequate diuretic therapy.

This study investigates the changing referral patterns of young patients to a tertiary pediatric nephrology center with a well-defined catchment area over two consecutive 8.5-year periods. We paid special attention to the known increase of obesity and diabetes mellitus in childhood. Demographic data (site of residence, height, weight, gender and renal diagnosis) were collected on 6,154 children aged 0-19 years, referred as in- and outpatients to the Children's Hospital of Eastern Ontario for nephrological work-up. Body mass index (BMI) Z-scores were calculated on the basis of data from the National (USA) Center for Health Statistics (2000). In 6,124 (99.5%) patients a final renal diagnosis could be made, allowing calculation of the incidence of a variety of renal diseases in pediatric patients, data that are not readily available. BMI increased significantly over the years, with a Z-score that rose from a median of +0.20 to +0.32 in the two 8.5-year study periods (p<0.0001). The increase in obesity coincided with a significant increase in the incidence of chronic renal insufficiency (CRI). The combined incidence of CRI and end stage renal disease rose from 0.994 to 2.334 per 100,000 children per year (p=0.0014). This study provides new information on the (changing) pattern of pediatric renal disease over almost two decades. Pediatric renal patients became progressively overweight and showed an increase in the incidence of CRI. This is the first time that this phenomenon, well known in adults, has been observed in the pediatric age group.

Background: Late referral to specialist nephrological care is associated with increased morbidity, mortality, and cost. Consequently, nephrologists' associations recommend early referral. The recommendations' effectiveness remains questionable: 22-51% of referrals need renal replacement therapy (RRT) within 3-4 months. This may be due to these recommendations addressing the specialist, rather than the primary care providers (PCP). The potential of specialist intervention aiming at slowing progression of chronic renal failure was introduced individually to some 250 local PCPs, and referral strategies were discussed. To overcome the PCPs' most often expressed fears, every referred patient was asked to report back to his PCP immediately after the initial specialist examination, and new medications were prescribed directly, and thus allotted to the nephrologist's budget., Methods: In retrospective analysis, the stage of renal disease in patients referred within three months before the introductory round (group A, n = 18), was compared to referrals two years later (group B, n = 50)., Results: Relative number of patients remained stable (28%) for mild/ moderate chronic kidney disease (MMCKD), while there was a noticeable shift from patients referred severe chronic kidney disease (SCKD) (group A: 44%, group B: 20%) to patients referred in moderate chronic kidney disease (MCKD) (group A: 28%, group B: 52%)., Conclusion: Individually addressing PCPs' ignorance and concerns noticeably decreased late referral. This stresses the importance of enhancing the PCPs' problem awareness and knowledge of available resources in order to ensure timely specialist referral.

This qualitative study was designed to explore the perception of stress of nephrology nurses within a major nephrology center in Northern Ireland. The information was collated from a sample of 10 nurses through semi- structured taped interviews. The findings indicate that stress was derived from the following categories: job content, resource issues, professional concerns, professional working relationships, and extrinsic factors. The coping mechanisms adopted by these nurses are also discussed. The actual dialogue of the nurses is included to provide depth and substance to the categories and themes, and a discussion is presented of the relationship of these findings to theory. These findings have relevant implications for nursing practice, nursing education, and nursing administration.

Background: In 1997 the National Kidney Foundation put forth guidelines for hemoaccess through its Dialysis Outcomes Quality Initiative (DOQI). Some centers have been able to meet these standards; most have not., Methods: A retrospective review was made of our database of more than 3,500 hemoaccess procedures from 1986 to 2003., Results: Our approach, increased use of transposed fistulas and preoperative duplex mapping, has led to a fistula incidence (84%) and prevalence (54%) exceeding DOQI criteria. Meeting the DOQI guideline for thrombectomy rate (0.5 per year) is mostly achieved by increased use of fistulas. Additionally, access monitoring, as well as intraoperative angiography, angioplasty, stenting, and surgical revision, can aid in decreasing the frequency of occlusions (0.45 per year). This operative approach has led to a 98% success rate for surgical thrombectomy, exceeding the DOQI guideline of 85%. Earlier referrals from nephrologists have lowered the catheter use prevalence to 9%., Conclusions: An aggressive approach to placing fistulas, maintaining the access, and receiving prompt referrals can lead to success in meeting DOQI criteria.

Background: Most studies looking at how the outcome of end-stage renal disease (ESRD) is affected by the timing and quality of the care received before initiation of renal replacement therapy (RRT) are inconclusive., Methods: Five hundred and two adult French patients (age, 62.8 +/- 16 years) receiving their first RRT were enrolled in a 2-year, community-based, prospective study. Subjects were assigned to 1 of 5 groups depending on the time between their first serum creatinine reading above 2 mg/dL (177 micromol/L): chronic renal failure (CRF) and nephrology referral (NR) and RRT. Multivariate logistic regression was used to analyze 90-day survival data, and data concerning long-term survival and inclusion on the waiting list for renal transplantation were analyzed using Cox proportional hazards regression., Results: Overall survival rates were 88% at 90 days, 77.2% at 1 year, 65.2% at 2 years, and 54.2% at 3 years. The nephrology referral pattern was associated with age and systolic blood pressure, and independently predicted early death. Compared with group 1 (NR > 12 months), odds ratios (confidence interval 95%) were 2.7 (1.2 to 6.3) for group 2 (NR < or = 12 months or >4 months), 2.8 (1.0 to 8.0) for group 3 (NR < or = 4 months or >1 month), 4.9 (2.2 to 11.0) for group 4 (NR < or = 1 month; CRF > 1 month), and 5.2 (2.2 to 12.3) for group 5 (NR < or = 1 month; CRF < or = 1 month). Independent predictors of death in 90-day survivors were age, cardiac disease with previous episodes of heart failure, vascular disease, low diastolic blood pressure, and group 3 referral pattern. Not being entered on the waiting list for renal transplantation was predicted by age, diabetes, vascular disease, and nonelective first dialysis., Conclusion: Late nephrology referral is strongly associated with early death. Emergency first dialysis is an independent risk factor for not being placed on the waiting list for transplantation. Among 90-day survivors, referral pattern has little influence on mortality, which is mainly determined by cardiovascular complications at initiation of RRT.