[Show abstract][Hide abstract] ABSTRACT: CKD patients referred to a renal management clinic are looked after by a multidisciplinary team whose care may improve outcome and delay the progression of kidney disease. This paper describes our experience and the results obtained in 940 patients with CKD stage 4 and 5 patients from two renal management clinics (RMC).
We collected and analyzed the data from 940 patients with CKD stage 4 and 5 at the RMCs of the Toronto General Hospital (TGH), University Health Network and The Scarborough General Hospital (TSH) from January 2000 to November 2007. Inclusion criteria for the study required at least three measurements of serum creatinine over a minimum follow-up of 6 months. We calculated the change of slope of the estimated GFR by linear regression analysis. The slopes were further subdivided into five groups: improved eGFR (eGFR slope >or=+5 ml/min/year); mild improvement (slope >+1 to <+5 ml/min/year); stable (slope <+1 to >-1 ml/min/year); slow progression (i.e., deterioration; slope <-1 to >-5 ml/min/year) and rapid progression (slope >-5 ml/min/year).
During a median follow-up of 1.57 year (range 0.5-8.7 year) of stage 4 patients, eGFR improved in 10.6%, showed mild improvement in 24.2%, was stable in 27.5%, showed slow progression in 28.8% and rapid progression in 8.9% of patients. During a median follow-up of 1.4 year (range 0.5-8 year) of CKD stage 5 patients, eGFR improved in only 1.3%, showed mild improvement in 4.3%, remained stable in 35.6%; showed slow progression in 19.7% and rapid progression in 39.1%. Between the two hospitals (TGH and TSH) there was a statistically significant difference in the number of visits per year for CKD stage 4 patients during the first, second and third year. However, the number of visits per year had no effect on the rate of decline. On univariate analysis, factors predicting non-progression in eGFR slope were eGFR at referral, the use of ACE inhibitors-ARBs and absence of cardiovascular disease. However, in logistic multivariate regression analysis, after adjusting for confounding factors only the eGFR at referral and ACE inhibitors-ARBs were independent factors for non-progression in eGFR. A significant percentage of CKD stage 4 patients attending a renal management clinic (RMC) showed non-progression or improvement in their kidney function. Although only few stage 5 CKD patients had improvement in their eGFR, 32% of them maintained their eGFR on conservative treatment for over 2 years delaying the initiation of dialysis.
International Urology and Nephrology 08/2009; 41(4):977-82. · 1.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BackgroundIncreasing numbers of patients on dialysis are undergoing coronary artery bypass grafting (CABG). We undertook this retrospective
study to identify risk factors of operative mortality in dialysis patients who underwent CABG.
Patients and methodsWe performed retrospective analysis of 105 patients who were on dialysis for at least two months before surgery and who underwent
CABG in Toronto General Hospital from 1997 to 2006. Using prospectively collected data from the Division of Cardiovascular
Surgery Database of Toronto General Hospital, we collected data on comorbidities, procedures, modality change during hospitalization,
and operative outcomes. Logistic regression was used to assess risk factors of operative mortality.
ResultsOne hundred and five maintenance dialysis patients (40 PD and 65 HD) who met the inclusion criteria were studied. Overall
in-hospital mortality was 7.6%. Atrial fibrillation and pneumonia occurred in 16.2 and 9.5%, respectively, of all dialysis
patients. Among PD patients, rates of post-operative dialysate leak and peritonitis were 10 and 12.5%, respectively. Among
HD patients, 4.6% experienced post-operative AV access thrombosis. Logistic regression showed older age (≥70years) and peritoneal
dialysis are independent risk factors of operative mortality.
ConclusionIn this retrospective study, older patients on PD had higher operative mortality than HD patients. These findings suggest
extra care should be taken when CABG is considered for PD patients over 70years old. In this study we could not identify
the reason(s) for the high mortality of elderly peritoneal dialysis patients undergoing CABG.
International Urology and Nephrology 01/2009; 41(3):653-662. · 1.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Chronic kidney disease (CKD) has been identified as a growing global burden and traditional health care systems are inadequate for the management of CKD patients. This paper describes an initiative to establish a renal management clinic (RMC) in China and discusses the challenges and opportunities in the management of CKD patients.
We collected and analyzed the data for the first 1,000 CKD patients treated since the establishment of the RMC (from April 2006 to April 2007). They had CKD stages 1-4 and stage 5 (before dialysis), as described by the Kidney Outcome Quality Initiatives (KDOQI). They were managed at the RMC established at the Peking University Third Hospital, by a multidisciplinary team (nephrologists, nurses, and dietitians) who developed care plans, clinical pathways, and a multidimensional patient-education program.
The most frequent causes of CKD among these 1,000 patient were glomerulonephritis (35%), hypertensive nephrosclerosis (19%), chronic interstitial nephritis (13%), and diabetic nephropathy (11%). Six percent of the patients had stage 1 CKD, 27% stage 2, 33% stage 3, 20% stage 4, and 13% had stage 5. Five hundred and fifty-four were male and 446 were female; mean age was 55 +/- 18.9 years (range 18-92 years). Seven hundred and seventy patients (77%) had hypertension; 400 patients (40%) had body mass index (BMI) equal to or higher than 25 kg/m(2); 180 (18%) had overt cardiovascular disease; 726 (72.6%) had low-density lipoprotein (LDL)-cholesterol higher than 2.6 mmol/l; 440 patients (44%) had hyperuriemia; and 274 patients (27.4%) had anemia (hemoglobin <110 g/l). Although the team is multidisciplinary, management of the patients in the RMC is undertaken mainly by nephrologists, whereas nurses and dietitians still do not play an important role. There are no family doctors in China and nephrologists are responsible for management of these patients' kidney disease and related complications.
Our findings show that the prevalence of hypertension, diabetes mellitus, overweight. and hyperuricemia is high among Chinese CKD population. Nurses and dietitians do not yet play an important role in the present pattern of RMC. We believe that the present medical care model should be revised because it does not address the concerns of CKD patients and their need for lifestyle changes that would help them to cope with their chronic condition.
International Urology and Nephrology 09/2008; 40(4):1053-8. · 1.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A preliminary report from our unit previously suggested that diabetic patients on continuous cyclic peritoneal dialysis (CCPD) have higher ultrafiltration (UF) with icodextrin than non-diabetic patients. To confirm this observation, we did a retrospective analysis of our patients (17 diabetic and 23 non-diabetic) who were on stable CCPD prescription using a long-day dwell with icodextrin. We collected daily UF data from these patients' records for 30 days. The two groups showed no significant difference with respect to age, gender, hemoglobin, serum albumin, peritoneal dialysis and icodextrin vintage, peritoneal membrane characteristics, CCPD prescription, and peritoneal and residual renal clearance. The overnight net UF achieved with the cycler with standard glucose dialysate was similar in the two groups (850+/-379 in diabetic vs 713+/-484 ml/day in non-diabetic, P=0.34). However, UF with icodextrin during the day dwell (14.8+/-0.8 h) was significantly higher in diabetics than non-diabetics (348+/-198 vs 137+/-311 ml/day, P=0.02). Our results show that icodextrin produces significantly higher UF in long-day dwell in diabetic ESRD patients on CCPD than in non-diabetic patients. The reason for this difference is not clear.
International Urology and Nephrology 02/2008; 40(1):219-23. · 1.29 Impact Factor