Background. The majority of patients with chronic kidney disease (CKD) stages 3-5 are managed within primary care. We describe the effects, on patient outcomes, of the introduction of an algorithm-based, primary care disease management programme (DMP) for patients with CKD based on automated diagnosis using estimated glomerular filtration rate (eGFR) reporting. Results. Four hundred and eighty-three patients with CKD stage 4 or 5 were enrolled in the programme. There were significant improvements in the following parameters, expressed as median values (interquartile range) after 9 months in the programme, compared to baseline and percentage values patients achieving target at 9 months: total cholesterol 4.2 (3.45-5.0) mmol/l versus 4.6 (3.9-5.4) mmol/l (P < 0.01), 75.0% versus 64.5% (P < 0.001); LDL 2.2 (1.6-2.8) mmol/l versus 2.5 (1.9-3.2) mmol/l (P < 0.01), 81.9% versus 69.2% (P < 0.05); systolic blood pressure 130 (125-145) mmHg versus 139 (124-154) mmHg (P < 0.05), 56.2% versus 37.1% (P < 0.05) and diastolic blood pressure 71 (65-79) mmHg versus 76 (69-84) mmHg (P < 0.01), 68.4% versus 90.3% (P < 0.01).The median fall (interquartile range) in eGFR in the 9 months prior to joining the programme was 3.69 (1.49-7.46) ml/min/1.73 m 2 compared to 0.32 (−2.61-3.12) ml/min/1.73 m 2 in the 12 months after enrolment (P < 0.001). One hundred and twenty-two patients experienced a fall in eGFR of ≥5 ml/min/1.73 m 2 , median 9.90 (6.55-12.36) ml/min/1.73 m 2 in the 9 months prior to joining the programme, whilst in the 12 months after enrolment, their median fall in eGFR was −1.70 (−6.41-1.64) ml/min/1.73 m 2 (P < 0.001). In the remaining patients, the median fall in eGFR was 1.92 (0.41-3.23) ml/min/1.73 m 2 prior to joining the programme and 0.86 (−1.03-3.53) ml/min/1.73 m 2 in the 12 months after enrolment (P = 0.082). Conclusions. These data suggest that chronic disease management in this form is an effective method of identifying and managing patients with CKD within the UK. The improvement in cardiovascular risk factors and reduction in the rate of decline of renal function potentially have significant health benefits for the patients and should result in cost savings for the health economy.
T he prevalence of chronic kidney disease (CKD) and its risk factors is increasing worldwide, and there is a rapid rise in global need for the treatment of end-stage kidney disease (ESKD). The global nephrology community recognizes the need for a plan to address the growing incidence of CKD and a cohesive approach for CKD/ESKD integrated care. 1 This provides a major challenge for health systems, particularly
4. Xu D, Kyriakis JM. Phosphatidylinositol 3 0 -kinase-dependent activation of renal mesangial cell Ki-Ras and ERK by advanced glycation end products.
The reporting of the eGFR in association with this DMP effectively identified patients with CKD. A referral assessment programme can effectively ensure appropriate nephrology referral and avoids exceeding the capacity of nephrology services. The vast majority of patients with CKD stages 3-5 are cared for within primary care. There are marked gender differences in the prevalence of CKD stages 3-5 that are not reflected by referral patterns to nephrology services. There are significant differences in referral practices between primary and secondary care. In a steady state the burden of incident patients with CKD stages 4-5 should not exceed the capacity of the local nephrology service.
End-stage renal disease patients should be included in first ranks of the priority list for the influenza A (H1N1)v vaccine, as already advocated by some healthcare authorities.
Survival was 29% after a mean and median follow up of 4.6 and 4.2 years, respectively. Factors associated with worse survival included the following: age; for each decade of life the relative risk (RR) of death was 1.52 (95% confidence intervals 1.41-1.65, p < 0.0001); comorbidity, one or two comorbid conditions, RR = 1.56 (95% CI 1.24-1.95, p < 0.001) and three or more comorbid conditions, RR = 2.34 (1.68-3.27, p < 0.001). Factors associated with better survival included the following: south-Asian ethnicity, RR = 0.6 (0.46-0.80, p < 0.001); renal transplantation, RR = 0.20 (95% CI 0.11-0.59, p < 0.0001) and glomerulonephritis as the primary renal disease, RR = 0.70 (0.50-0.97, p = 0.04). Factors associated with likelihood of transplantion were having a functioning fistula/peritoneal dialysis catheter at start of dialysis (RR 1.91, 95% CI 1.24-2.94, p = 0.003) and glomerulonephritis (RR 9.54, 95% CI 2.43-37.64, p = 0.001). Patients were less likely to receive if they were black (RR 0.10, 95% CI 0.02-0.34, p < 0.001), South Asian (RR 0.64, 95% CI 0.42-0.97, p = 0.037), diabetic (RR 0.06, 95% CI 0.01-0.23, p < 0.001) and had one or two comorbid conditions (RR 0.51, 95% CI 0.32-0.82, p = 0.06). Every decade increase in age was also associated with a lesser likelihood of transplantation (RR 0.55, 95% CI 0.49-0.61, p < 0.001). Discussion. Risk stratification at commencement of chronic dialysis may predict long-term survival in different patient groups. As expected ethnic minorities are less likely to receive a transplant and this should be addressed by the new waiting list prioritization. The better survival on dialysis in this population of patients with south-Asian ethnicity is unexplained and this requires further investigation.
Summary To better understand outcomes in postpartum patients who receive peripartum anaesthetic interventions, we aimed to assess quality of recovery metrics following childbirth in a UK‐based multicentre cohort study. This study was performed during a 2‐week period in October 2021 to assess in‐ and outpatient post‐delivery recovery at 1 and 30 days postpartum. The following outcomes were reported: obstetric quality of recovery 10‐item measure (ObsQoR‐10); EuroQoL (EQ‐5D‐5L) survey; global health visual analogue scale; postpartum pain scores at rest and movement; length of hospital stay; readmission rates; and self‐reported complications. In total, 1638 patients were recruited and responses analysed from 1631 (99.6%) and 1282 patients (80%) at one and 30 days postpartum, respectively. Median (IQR [range]) length of stay postpartum was 39.3 (28.5–61.0 [17.7–513.4]), 40.3 (28.5–59.1 [17.8–220.9]), and 35.9 (27.1–54.1 [17.9–188.4]) h following caesarean, instrumental and vaginal deliveries, respectively. Median (IQR [range]) ObsQoR‐10 score was 75 ([62–86] 4–100) on day 1, with the lowest ObsQoR‐10 scores (worst recovery) reported by patients undergoing caesarean delivery. Of the 1282 patients, complications within the first 30 days postpartum were reported by 252 (19.7%) of all patients. Readmission to hospital within 30 days of discharge occurred in 69 patients (5.4%), with 49 (3%) for maternal reasons. These data can be used to inform patients regarding expected recovery trajectories; facilitate optimal discharge planning; and identify populations that may benefit most from targeted interventions to improve postpartum recovery experience.
According to estimates, the dialysis prevalence in Abu Dhabi is around 370 per million population. The annual growth is 12-15% and the dialysis population is likely to double in the next five years. Most patients present to dialysis as an emergency and only 2.7% have an arteriovenous fistula at the first dialysis. The prevalence of chronic kidney disease (CKD) in the Emirate is undefined. A study of the epidemiology of CKD and referral patterns was undertaken. SEHA, the Abu Dhabi Health Service delivery company, has a unified computer system containing all measurements made in its laboratories. This study considered all serum creatinine measurements performed between 1 September 2011 and 31 October 2012 from outpatient departments or emergency rooms. The estimated glomerular filtration rate (eGRF) was calculated using the Modification of Diet in Renal Disease formula (the Schwartz formula was used for children). We identified 331,360 samples from 212,314 individuals. The mean serum creatinine was 61 ± 48 μmol/L in females (59 ± 43 μmol/L in Emiratis, 63 ± 54 μmol/L in expatriates) and 87 ± 69 μmol/L in males (80 ± 59 μmol/L in Emiratis, 92 ± 74 μmol/L in expatriates). Among Emiratis, 4.6% of males and 2.8% of females had an eGFR between CKD 3 and 5. Among expatriates, 4.2% of males and 3.2% of females had an eGFR between CKD 3 and 5. On average, eight months elapsed before a patient with CKD 3, and three months for a patient in CKD 5, to attend the nephrology clinic. This study has defined the prevalence of CKD within Abu Dhabi and demonstrated the need to improve identification and referral of CKD patients. Possible solutions include campaigns to increase public and physician awareness of CKD.
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