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Patient and Clinician Experiences With the Combination of Virtual and In-Person Chronic Kidney Disease Care Since the COVID-19 Pandemic. 自 COVID-19 大流行以来,患者和临床医生对虚拟和亲临现场相结合的慢性肾病护理的体验。
IF 1.7 Q3 UROLOGY & NEPHROLOGY Pub Date : 2023-12-13 eCollection Date: 2023-01-01 DOI: 10.1177/20543581231217833
Micheli Bevilacqua, Yuriy Melnyk, Helen Chiu, Janet Williams, Paul Watson, Brenda Lee, Palvir Dhariwal, Marlee McGuire, Julie Wei, Robin Chohan, Anne Logie, Michele Fryer, Dominik Stoll, Adeera Levin

Background: Following onset of the COVID-19 pandemic, chronic kidney disease (CKD) clinics in BC shifted from established methods of mostly in-person care delivery to virtual care (VC) and thereafter a hybrid of the two.

Objectives: To determine strengths, weaknesses, quality-of-care delivery, and key considerations associated with VC usage to inform optimal way(s) of integrating virtual and traditional methods of care delivery in multidisciplinary kidney clinics.

Design: Qualitative evaluation.

Setting: British Columbia, Canada.

Participants: Patients and health care providers associated with multidisciplinary kidney care clinics.

Methods: Development and delivery of semi-structured interviews of patients and health care providers.

Results: 11 patients and/or caregivers and 12 health care providers participated in the interviews. Participants reported mixed experiences with VC usage. All participants foresaw a future where both VC and in-person care was offered. A reported benefit of VC was convenience for patients. Challenges identified with VC included difficulty establishing new therapeutic relationships, and variable of abilities of both patients and health care providers to engage and communicate in a virtual format. Participants noted a preference for in-person care for more complex situations. Four themes were identified as considerations when selecting between in-person and VC: person's nonmedical context, support available, clinical parameters and tasks to be completed, and clinic operations. Participants indicated that visit modality selection is an individualized and ongoing process involving the patient and their preferences which may change over time. Health care provider participants noted that new workflow challenges were created when using both VC and in-person care in the same clinic session.

Limitations: Limited sample size in the setting of one-on-one interviews and use of convenience sampling which may result in missing perspectives, including those already facing challenges accessing care who could potentially be most disadvantaged by implementation of VC.

Conclusions: A list of key considerations, aligned with quality care delivery was identified for health care providers and programs to consider as they continue to utilize VC and refine how best to use different visit modalities in different patient and clinical situations. Further work will be needed to validate these findings and evaluate clinical outcomes with the combination of virtual and traditional modes of care delivery.

Trial registration: Not registered.

背景:在 COVID-19 大流行之后,不列颠哥伦比亚省的慢性肾脏病(CKD)诊所从主要由患者亲自提供医疗服务的既定方法转向了虚拟医疗(VC),之后又将两者混合使用:目的:确定与使用虚拟医疗相关的优势、劣势、医疗服务质量和主要考虑因素,为多学科肾脏病诊所整合虚拟医疗和传统医疗服务的最佳方式提供信息:设计:定性评估:环境:加拿大不列颠哥伦比亚省:参与人员:与多学科肾脏治疗诊所相关的患者和医疗服务提供者:方法:对患者和医疗服务提供者进行半结构化访谈:结果:11 名患者和/或护理人员以及 12 名医疗服务提供者参加了访谈。参与者对使用虚拟医疗设备的经历不一。所有参与者都预见到了同时提供视频会议和面对面医疗服务的未来。据报告,视频会议的一个好处是为患者提供了便利。VC 面临的挑战包括难以建立新的治疗关系,以及患者和医疗服务提供者在虚拟形式下参与和交流的能力参差不齐。与会者指出,在较为复杂的情况下,他们更倾向于亲临现场进行治疗。在选择面对面治疗还是虚拟治疗时,有四个主题是需要考虑的:个人的非医疗背景、可用的支持、临床参数和需要完成的任务,以及诊所的运营。与会者指出,就诊方式的选择是一个个性化的持续过程,涉及病人及其偏好,并可能随着时间的推移而改变。医疗服务提供者指出,在同一门诊中同时使用虚拟视像和面对面护理时,会产生新的工作流程挑战:局限性:一对一访谈的样本量有限,而且使用的是方便抽样,这可能会导致观点缺失,包括那些已经面临获得医疗服务挑战的人,他们可能会因实施自愿咨询而处于最不利的地位:我们为医疗服务提供者和项目确定了一系列与提供优质医疗服务相一致的关键注意事项,供他们在继续使用自愿咨询和完善如何在不同患者和临床情况下最好地使用不同的就诊模式时参考。还需要进一步开展工作,以验证这些研究结果,并评估结合虚拟和传统医疗模式的临床结果:未注册。
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引用次数: 0
The Good and the Bad of SHROOM3 in Kidney Development and Disease: A Narrative Review. SHROOM3 在肾脏发育和疾病中的利弊:叙述性综述。
IF 1.7 Q3 UROLOGY & NEPHROLOGY Pub Date : 2023-12-13 eCollection Date: 2023-01-01 DOI: 10.1177/20543581231212038
Amy Paul, Allison Lawlor, Kristina Cunanan, Pukhraj S Gaheer, Aditya Kalra, Melody Napoleone, Matthew B Lanktree, Darren Bridgewater

Purpose of review: Multiple large-scale genome-wide association meta-analyses studies have reliably identified an association between genetic variants within the SHROOM3 gene and chronic kidney disease. This association extends to alterations in known markers of kidney disease including baseline estimated glomerular filtration rate, urinary albumin-to-creatinine ratio, and blood urea nitrogen. Yet, an understanding of the molecular mechanisms behind the association of SHROOM3 and kidney disease remains poorly communicated. We conducted a narrative review to summarize the current state of literature regarding the genetic and molecular relationships between SHROOM3 and kidney development and disease.

Sources of information: PubMed, PubMed Central, SCOPUS, and Web of Science databases, as well as review of references from relevant studies and independent Google Scholar searches to fill gaps in knowledge.

Methods: A comprehensive narrative review was conducted to explore the molecular mechanisms underlying SHROOM3 and kidney development, function, and disease.

Key findings: SHROOM3 is a unique protein, as it is the only member of the SHROOM group of proteins that regulates actin dynamics through apical constriction and apicobasal cell elongation. It holds a dichotomous role in the kidney, as subtle alterations in SHROOM3 expression and function can be both pathological and protective toward kidney disease. Genome-wide association studies have identified genetic variants near the transcription start site of the SHROOM3 gene associated with chronic kidney disease. SHROOM3 also appears to protect the glomerular structure and function in conditions such as focal segmental glomerulosclerosis. However, little is known about the exact mechanisms by which this protection occurs, which is why SHROOM3 binding partners remain an opportunity for further investigation.

Limitations: Our search was limited to English articles. No structured assessment of study quality was performed, and selection bias of included articles may have occurred. As we discuss future directions and opportunities, this narrative review reflects the academic views of the authors.

综述目的:多项大规模全基因组关联荟萃分析研究可靠地确定了 SHROOM3 基因内的遗传变异与慢性肾病之间的关联。这种关联还延伸到已知肾脏疾病标志物的改变,包括基线估计肾小球滤过率、尿白蛋白与肌酐比率和血尿素氮。然而,人们对 SHROOM3 与肾脏疾病相关的分子机制的了解仍然很少。我们进行了一项叙述性综述,总结了有关 SHROOM3 与肾脏发育和疾病之间的遗传和分子关系的文献现状:信息来源:PubMed、PubMed Central、SCOPUS 和 Web of Science 数据库,以及相关研究的参考文献和独立的 Google Scholar 搜索,以填补知识空白:对 SHROOM3 与肾脏发育、功能和疾病的分子机制进行了全面的叙述性综述:SHROOM3是一种独特的蛋白质,因为它是SHROOM组蛋白质中唯一通过顶端收缩和顶端基底细胞伸长调节肌动蛋白动力学的成员。它在肾脏中扮演着双重角色,因为 SHROOM3 表达和功能的微妙变化既可能是病理变化,也可能对肾脏疾病具有保护作用。全基因组关联研究发现,SHROOM3 基因转录起始位点附近的遗传变异与慢性肾病有关。在局灶节段性肾小球硬化症等情况下,SHROOM3 似乎还能保护肾小球的结构和功能。然而,人们对这种保护的确切机制知之甚少,这就是为什么SHROOM3的结合伙伴仍是进一步研究的机会:我们的搜索仅限于英文文章。局限性:我们的搜索仅限于英文文章,没有对研究质量进行结构化评估,因此可能存在对纳入文章的选择偏差。当我们讨论未来的方向和机遇时,这篇叙述性综述反映了作者的学术观点。
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引用次数: 0
Case Report of Renal Calculi in a Child Receiving Imatinib for Acute Lymphoblastic Leukemia. 接受伊马替尼治疗的急性淋巴细胞白血病患儿肾结石病例报告。
IF 1.7 Q3 UROLOGY & NEPHROLOGY Pub Date : 2023-12-13 eCollection Date: 2023-01-01 DOI: 10.1177/20543581231215849
Alaa Bamahmud, Mohamed El-Sherbiny, Roman Jednak, Karl Muchantef, Sharon Abish, David Mitchell, Catherine Vezina, Indra R Gupta

Rationale: Imatinib is used in the treatment of Philadelphia chromosome positive (Ph+) leukemias and has been reported to have a direct effect on bone physiology.

Presentation: To report on a child with Ph+ acute lymphoblastic leukemia who presented with bilateral flank pain and gross hematuria.

Diagnosis: She was diagnosed with obstructive kidney stones 101 days after commencing daily oral imatinib. Stone analysis revealed the presence of calcium phosphate.

Interventions and outcome: The patient passed the stones spontaneously with medical therapy that included the use of thiazide, allopurinol, and potassium citrate, but she required temporary insertion of a double-J stent to relieve an obstruction.

Novel findings: Imatinib inhibits receptor tyrosine kinases and stimulates the flux of calcium from the extracellular fluid into bone, resulting in hypocalcemia with a compensatory rise in parathyroid hormone that may result in phosphaturia and the formation of calcium phosphate stones. Given that kidney stones are rare events in children, we believe that monitoring for kidney stone formation needs to be performed in children receiving imatinib.

理由:伊马替尼用于治疗费城染色体阳性(Ph+)白血病,据报道对骨生理有直接影响:报告一名患有Ph+急性淋巴细胞白血病的儿童,该患儿出现双侧侧腹疼痛和毛细血尿:在开始每日口服伊马替尼101天后,她被诊断为梗阻性肾结石。结石分析显示存在磷酸钙:患者通过使用噻嗪类药物、别嘌呤醇和枸橼酸钾等药物治疗自行排出结石,但需要临时植入双J支架以缓解梗阻:新发现:伊马替尼抑制受体酪氨酸激酶,刺激钙从细胞外液流入骨骼,导致低钙血症,甲状旁腺激素代偿性升高,可能导致磷酸盐尿和磷酸钙结石的形成。鉴于肾结石在儿童中较为罕见,我们认为需要对接受伊马替尼治疗的儿童进行肾结石形成监测。
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引用次数: 0
Implementing a Formalized Risk-Based Approach to Determine Candidacy for Multidisciplinary CKD Care: A Descriptive Cohort Study. 实施一种正式的基于风险的方法来确定多学科CKD治疗的候选资格:一项描述性队列研究。
IF 1.7 Q3 UROLOGY & NEPHROLOGY Pub Date : 2023-12-01 eCollection Date: 2023-01-01 DOI: 10.1177/20543581231215865
Maoliosa Donald, Robert G Weaver, Michelle Smekal, Chandra Thomas, Robert R Quinn, Braden J Manns, Marcello Tonelli, Aminu Bello, Tyrone G Harrison, Navdeep Tangri, Brenda R Hemmelgarn
<p><strong>Background: </strong>The kidney failure risk equation (KFRE) can be used to predict progression to end-stage kidney disease in a clinical setting.</p><p><strong>Objective: </strong>Evaluate implementation of a formalized risk-based approach in nephrologists' outpatient clinics and multidisciplinary chronic kidney disease (CKD) clinics to determine candidacy for multidisciplinary care, and the impact of CKD care selection on clinical outcomes.</p><p><strong>Design: </strong>Population-based descriptive cohort study.</p><p><strong>Setting: </strong>Alberta Kidney Care South.</p><p><strong>Patients: </strong>Adults attending or considered for a multidisciplinary CKD clinic between April 1, 2017, and March 31, 2019.</p><p><strong>Measurements: </strong><i>Exposure</i>-The course of CKD care assigned by the nephrologist: management at multidisciplinary CKD clinic; management by a nephrologist or primary care physician. <i>Primary Outcome</i>-CKD progression, defined as commencement of kidney replacement therapy (KRT). <i>Secondary Outcomes</i>-Death, emergency department visits, and hospitalizations.</p><p><strong>Methods: </strong>We linked operational data from the clinics (available until March 31, 2019) with administrative health and laboratory data (available until March 31, 2020). Comparisons among patient groups, courses of care, and clinical settings with negative binomial regression count models and calculated unadjusted and fully adjusted incidence rate ratios. For the all-cause death outcome, we used Cox survival models to calculate unadjusted and fully adjusted hazard ratios.</p><p><strong>Results: </strong>Of the 1748 patients for whom a KFRE was completed, 1347 (77%) remained in or were admitted to a multidisciplinary CKD clinic, 310 (18%) were managed by a nephrologist only, and 91 (5%) were referred back for management by their primary care physician. There was a much higher kidney failure risk among patients who remained at or were admitted to a multidisciplinary CKD clinic (median 2-year risk of 34.7% compared with 3.6% and 0.8% who remained with a nephrologist or primary care physician, respectively). None of the people managed by their primary care physician alone commenced KRT, while only 2 (0.6%) managed by a nephrologist without multidisciplinary CKD care commenced KRT. The rates of emergency department visits, hospitalizations, and death were lower in those assigned to management outside the multidisciplinary CKD clinics when compared with those managed in the multidisciplinary care setting.</p><p><strong>Limitations: </strong>The follow-up period may not have been long enough to determine outcomes, and potentially limited generalizability given variability of care in multidisciplinary clinics.</p><p><strong>Conclusions: </strong>Our findings indicate that a portion of patients can be directed to less resource-intensive care without a higher risk of adverse events.</p><p><strong>Trial registration: </strong>Not appli
背景:肾衰竭风险方程(KFRE)可用于临床预测终末期肾脏疾病的进展。目的:评估在肾病科门诊和多学科慢性肾脏疾病(CKD)诊所实施的基于风险的正式方法,以确定多学科治疗的候选资格,以及CKD治疗选择对临床结果的影响。设计:基于人群的描述性队列研究。工作地点:艾伯塔省南部肾脏护理中心。患者:2017年4月1日至2019年3月31日期间参加或考虑参加多学科CKD诊所的成年人。测量:暴露——肾病专家指定的CKD治疗过程:多学科CKD诊所的管理;由肾病专家或初级保健医生管理。主要结局:ckd进展,定义为肾替代治疗(KRT)的开始。次要结果:死亡、急诊科就诊和住院。方法:我们将诊所的操作数据(截至2019年3月31日)与行政卫生和实验室数据(截至2020年3月31日)联系起来。采用负二项回归计数模型比较患者组、治疗过程和临床环境,并计算未调整和完全调整的发病率比。对于全因死亡结局,我们使用Cox生存模型来计算未调整和完全调整的风险比。结果:在完成KFRE的1748例患者中,1347例(77%)留在或入住多学科CKD诊所,310例(18%)仅由肾病专家管理,91例(5%)由其初级保健医生转回管理。留在多学科CKD诊所或被收住的患者的肾衰竭风险要高得多(2年风险中位数为34.7%,而留在肾病科医生或初级保健医生那里的患者分别为3.6%和0.8%)。由初级保健医生单独管理的患者中没有一人开始KRT,而由没有多学科CKD护理的肾病专家管理的患者中只有2人(0.6%)开始KRT。与在多学科护理环境中管理的患者相比,在多学科CKD诊所外管理的患者急诊科就诊率、住院率和死亡率都较低。局限性:随访时间可能不够长,无法确定结果,并且考虑到多学科诊所护理的可变性,可能限制了通用性。结论:我们的研究结果表明,一部分患者可以直接接受资源密集程度较低的护理,而不会出现较高的不良事件风险。试验注册:不适用。
{"title":"Implementing a Formalized Risk-Based Approach to Determine Candidacy for Multidisciplinary CKD Care: A Descriptive Cohort Study.","authors":"Maoliosa Donald, Robert G Weaver, Michelle Smekal, Chandra Thomas, Robert R Quinn, Braden J Manns, Marcello Tonelli, Aminu Bello, Tyrone G Harrison, Navdeep Tangri, Brenda R Hemmelgarn","doi":"10.1177/20543581231215865","DOIUrl":"10.1177/20543581231215865","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;The kidney failure risk equation (KFRE) can be used to predict progression to end-stage kidney disease in a clinical setting.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;Evaluate implementation of a formalized risk-based approach in nephrologists' outpatient clinics and multidisciplinary chronic kidney disease (CKD) clinics to determine candidacy for multidisciplinary care, and the impact of CKD care selection on clinical outcomes.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Design: &lt;/strong&gt;Population-based descriptive cohort study.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Setting: &lt;/strong&gt;Alberta Kidney Care South.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Patients: &lt;/strong&gt;Adults attending or considered for a multidisciplinary CKD clinic between April 1, 2017, and March 31, 2019.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Measurements: &lt;/strong&gt;&lt;i&gt;Exposure&lt;/i&gt;-The course of CKD care assigned by the nephrologist: management at multidisciplinary CKD clinic; management by a nephrologist or primary care physician. &lt;i&gt;Primary Outcome&lt;/i&gt;-CKD progression, defined as commencement of kidney replacement therapy (KRT). &lt;i&gt;Secondary Outcomes&lt;/i&gt;-Death, emergency department visits, and hospitalizations.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;We linked operational data from the clinics (available until March 31, 2019) with administrative health and laboratory data (available until March 31, 2020). Comparisons among patient groups, courses of care, and clinical settings with negative binomial regression count models and calculated unadjusted and fully adjusted incidence rate ratios. For the all-cause death outcome, we used Cox survival models to calculate unadjusted and fully adjusted hazard ratios.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Of the 1748 patients for whom a KFRE was completed, 1347 (77%) remained in or were admitted to a multidisciplinary CKD clinic, 310 (18%) were managed by a nephrologist only, and 91 (5%) were referred back for management by their primary care physician. There was a much higher kidney failure risk among patients who remained at or were admitted to a multidisciplinary CKD clinic (median 2-year risk of 34.7% compared with 3.6% and 0.8% who remained with a nephrologist or primary care physician, respectively). None of the people managed by their primary care physician alone commenced KRT, while only 2 (0.6%) managed by a nephrologist without multidisciplinary CKD care commenced KRT. The rates of emergency department visits, hospitalizations, and death were lower in those assigned to management outside the multidisciplinary CKD clinics when compared with those managed in the multidisciplinary care setting.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Limitations: &lt;/strong&gt;The follow-up period may not have been long enough to determine outcomes, and potentially limited generalizability given variability of care in multidisciplinary clinics.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Our findings indicate that a portion of patients can be directed to less resource-intensive care without a higher risk of adverse events.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Trial registration: &lt;/strong&gt;Not appli","PeriodicalId":9426,"journal":{"name":"Canadian Journal of Kidney Health and Disease","volume":"10 ","pages":"20543581231215865"},"PeriodicalIF":1.7,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10693221/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138476754","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Alignment Among Patient, Caregiver, and Health Care Provider Perspectives on Hemodialysis Vascular Access Decision-Making: A Qualitative Study. 患者、护理人员和卫生保健提供者对血液透析血管通路决策的看法:一项定性研究。
IF 1.7 Q3 UROLOGY & NEPHROLOGY Pub Date : 2023-11-29 eCollection Date: 2023-01-01 DOI: 10.1177/20543581231215858
Angela R Schneider, Pietro Ravani, Kathryn M King-Shier, Robert R Quinn, Jennifer M MacRae, Shannan Love, Matthew J Oliver, Swapnil Hiremath, Matthew T James, Mia Ortiz, Braden R Manns, Meghan J Elliott

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.

背景:更新的肾脏疾病结局质量倡议临床实践指南血管通路强调“正确的通路,在正确的病人,在正确的时间,出于正确的原因。”虽然这意味着一种合作的方法,但很少有人知道患者,他们的护理人员和卫生保健提供者如何参与血管通路(VA)决策。目的:探讨接受血液透析的患者、他们的护理人员和血液透析护理团队在VA选择方面的观点是如何一致和分歧的。设计:定性描述性研究。环境:阿尔伯塔省卡尔加里的五个门诊血液透析中心。参与者:我们的目的样本包括19名接受维持性血液透析的患者,2名护理人员和21名卫生保健提供者(7名血液透析护士,6名VA护士和8名肾病学家)。方法:我们对同意的参与者进行了半结构化访谈。使用归纳主题分析方法,我们对副本进行编码,并描述了解决我们研究目标的主题。结果:虽然不同角色的参与者分享了与VA决策相关的一些观点,但我们确定了观点分歧的领域。一致的领域包括(1)优化患者准备-承认决策准备和时机,以及(2)重视与肾脏护理团队的信任关系-尊重有指导的决策自主权。观点在以下方面存在分歧:(1)不同的VA优先级和偏好-患者强调尽量减少对正常的破坏,与提供者对瘘和优化透析生物医学参数的偏好形成对比;(2)个人经验和同伴经验的影响——患者更倾向于实用的经验知识,而提供者则强调信息的可信度;(3)退伍军人服务审查的终点——退伍军人服务决策的重新评估是由患者对服务渠道的不满和医疗保健提供者实现有效服务渠道的迫切需要引起的。局限性:参与仅限于能自如地用英语交流的个体,以及来自城市中心血液透析单位的个体。很少有接受血液透析的人和年轻患者的非正式护理人员参与了这项研究。结论:尽管患者、护理人员和医疗保健提供者在VA决策的重要方面有共同的观点,但冲突的优先级和偏好可能会影响决策结果。调查结果强调了在退伍军人选择过程中弥合知识和准备差距并整合共同决策的机会。
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引用次数: 0
Are There Any Pleiotropic Benefits of Vitamin D in Patients With Diabetic Kidney Disease? A Systematic Review of Randomized Controlled Trials. 维生素D对糖尿病肾病患者有多效性益处吗?随机对照试验的系统回顾。
IF 1.7 Q3 UROLOGY & NEPHROLOGY Pub Date : 2023-11-28 eCollection Date: 2023-01-01 DOI: 10.1177/20543581231212039
Jaya K Sharma, Sono Khan, Tristin Wilson, Nathan Pilkey, Sanjana Kapuria, Angélique Roy, Michael A Adams, Rachel M Holden
<p><strong>Background: </strong>Type 2 diabetes (T2D) and kidney disease are risk factors for vitamin D deficiency. Native forms of vitamin D have a lower risk of hypercalcemia than calcitriol, the active hormone. The enzyme responsible for activating native vitamin D is now known to be expressed throughout the body; therefore, native vitamin D may have clinically relevant effects in many body systems.</p><p><strong>Objective: </strong>The objective of this systematic review was to examine the effect of native vitamin D supplementation on clinical outcomes and surrogate laboratory measures in patients with T2D and diabetic kidney disease (DKD).</p><p><strong>Design: </strong>Systematic review.</p><p><strong>Setting: </strong>Randomized controlled trials (RCTs) conducted in any country.</p><p><strong>Patients: </strong>Adults with T2D and DKD receiving supplementation with any form of native vitamin D (eg, ergocalciferol, cholecalciferol, calcifediol).</p><p><strong>Measurements: </strong>Clinical outcomes and surrogate clinical and laboratory measures reported in each of the trials were included in this review.</p><p><strong>Methods: </strong>The following databases were searched from inception to January 31, 2023: Embase, MEDLINE, Cochrane CENTRAL, Web of Science, ProQuest Dissertations and Theses, and medRxiv. Only RCTs examining supplementation with a native vitamin D form with a control or placebo comparison group were included. We excluded studies reporting only vitamin D status or mineral metabolism parameters, without any other outcomes of clinical relevance or surrogate laboratory measures. Study quality was evaluated using the Cochrane risk-of-bias tool (RoB2). Results were synthesized in summary tables for each type of outcome with the <i>P</i> values from the original studies displayed.</p><p><strong>Results: </strong>Nine publications were included, corresponding to 5 separate RCTs (377 participants total). Mean age ranged from 40 to 63. All trials administered vitamin D<sub>3</sub>. Intervention groups experienced improvements in vitamin D status and a reduction in proteinuria in 4 of the 5 included RCTs. There was a decrease in low-density lipoprotein and total cholesterol in the 2 trials in which they were measured. Improvements in bone mass, flow-mediated dilation, and inflammation were also reported, but each was only measured in 1 RCT. Effects on glucose metabolism, high-density lipoprotein, triglycerides, blood pressure, oxidative stress, and kidney function were mixed. No serious adverse effects were reported.</p><p><strong>Limitations: </strong>Limitations include the small number of RCTs and lack of information on the use of drugs that affect measured outcomes (eg, proteinuria-lowering renin-angiotensin-aldosterone system inhibitors and lipid-lowering medication) in most studies. Our study is also limited by the absence of a prestudy protocol and registration.</p><p><strong>Conclusions: </strong>Native vitamin D is a safe tr
背景:2型糖尿病(T2D)和肾脏疾病是维生素D缺乏的危险因素。天然形式的维生素D比骨化三醇(一种活性激素)患高钙血症的风险要低。负责激活天然维生素D的酶现在已知在全身表达;因此,天然维生素D可能在许多身体系统中具有临床相关作用。目的:本系统综述的目的是研究补充天然维生素D对T2D和糖尿病肾病(DKD)患者的临床结局和替代实验室测量的影响。设计:系统回顾。环境:随机对照试验(rct)在任何国家进行。患者:接受补充任何形式的天然维生素D(如麦角钙化醇、胆钙化醇、钙化二醇)的T2D和DKD成人患者。测量:本综述包括了每个试验报告的临床结果和替代临床和实验室测量。方法:检索自建校至2023年1月31日的数据库:Embase、MEDLINE、Cochrane CENTRAL、Web of Science、ProQuest dissertation and Theses、medRxiv。仅纳入了对照组或安慰剂对照组补充天然维生素D形式的随机对照试验。我们排除了仅报告维生素D状态或矿物质代谢参数,而没有任何其他临床相关结果或替代实验室测量的研究。使用Cochrane风险偏倚工具(RoB2)评估研究质量。结果在汇总表中对每种类型的结果进行综合,并显示原始研究的P值。结果:纳入9篇出版物,对应5个独立的rct(共377名受试者)。平均年龄为40至63岁。所有试验均给予维生素D3。干预组在5个纳入的随机对照试验中有4个改善了维生素D状态,减少了蛋白尿。在两项试验中,低密度脂蛋白和总胆固醇都有所下降。骨量、血流介导的扩张和炎症的改善也有报道,但仅在1项RCT中进行了测量。对葡萄糖代谢、高密度脂蛋白、甘油三酯、血压、氧化应激和肾功能的影响是混合的。没有严重的不良反应报告。局限性:在大多数研究中,局限性包括随机对照试验数量少,以及缺乏影响测量结果的药物使用信息(例如,降蛋白尿肾素-血管紧张素-醛固酮系统抑制剂和降脂药物)。我们的研究也受到缺乏研究前方案和登记的限制。结论:天然维生素D是一种安全的治疗方法,可改善DKD患者的维生素D状态。维生素D可能会改变DKD患者的蛋白尿和脂质代谢,但需要进一步设计良好的试验,包括完善的治疗方法。总的来说,维生素D对DKD患者有益的多效性作用的证据有限。
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引用次数: 0
Identification and Prioritization of Canadian Society of Nephrology Clinical Practice Guideline Topics With Multidisciplinary Stakeholders and People Living With Kidney Disease: A Clinical Research Protocol. 加拿大肾脏病学会临床实践指南主题与多学科利益相关者和肾病患者的确定和优先顺序:临床研究方案。
IF 1.7 Q3 UROLOGY & NEPHROLOGY Pub Date : 2023-11-24 eCollection Date: 2023-01-01 DOI: 10.1177/20543581231207142
Brigitte H Baragar, Melissa Schorr, Nancy Verdin, Tania Woodlock, David A Clark, Gregory L Hundemer, Anna Mathew, Reem A Mustafa, Krista S Ryz, Tyrone G Harrison
Background: Despite efforts to provide evidence-based care for people living with kidney disease, health care provider goals and priorities are often misaligned with those of individuals with lived experience of disease. Coupled with competing interests of time, resources, and an abundance of suitable guideline topics, identifying and prioritizing areas of focus for the Canadian nephrology community with a patient-oriented perspective is necessary and important. Similar priority-setting exercises have been undertaken to establish research priorities for kidney disease and to standardize outcomes for kidney disease research and clinical care; however, research priorities are distinct from priorities for guideline development. Inclusion of people living with health conditions in the selection and prioritization of guideline topics is suggested by patient engagement frameworks, though the process to operationalizing this is variable. We propose that the Canadian Society of Nephrology Clinical Practice Guideline Committee (CSN CPGC) takes the opportunity at this juncture to incorporate evidence-based prioritization exercises with involvement of people living with kidney disease and their caregivers to inform future guideline activities. In this protocol, we describe our planned research methods to address this. Objective: To establish consensus-based guideline topic priorities for the CSN CPGC using a modified Delphi survey with involvement of multidisciplinary stakeholders, including people living with kidney disease and their caregivers. Study design: Protocol for a Modified Delphi Survey. Setting: Pilot-tested surveys will be distributed via email and conducted using the online platform SurveyMonkey, in both French and English. Participants: We will establish a group of multidisciplinary clinical and research stakeholders (both within and outside CSN membership) from Canada, in addition to people living with kidney disease and/or their caregivers. Methods: A comprehensive literature search will be conducted to generate an initial list of guideline topics, which will be organized into three main categories: (1) International nephrology-focused guidelines that may require Canadian commentary, (2) Non-nephrology specific guidelines from Canada that may require CSN commentary, and (3) Novel topics for guideline development. Participants will engage in a multi-round Modified Delphi Survey to prioritize a set of “important guideline topics.” Measures: Consensus will be reached for an item based on both median score on the Likert-type scale (≥ 7) and the percentage agreement (≥ 75%); the Delphi process will be complete when consensus is reached on each item. Guideline topics will then be given a priority score calculated from the total Likert ratings across participants, adjusted for the number of participants. Limitations: Potential limitations include participant response rates and compliance to survey completion. Conclusions: We propose to incorporate
背景:尽管努力为肾脏疾病患者提供循证护理,但卫生保健提供者的目标和优先事项往往与有疾病生活经历的个体不一致。再加上时间、资源和大量合适的指南主题的竞争利益,以患者为导向的角度确定和优先考虑加拿大肾脏病学界的重点领域是必要和重要的。已经开展了类似的确定优先事项的工作,以确定肾脏疾病的研究重点,并使肾脏疾病研究和临床护理的结果标准化;然而,研究重点与指南制定的重点是不同的。患者参与框架建议将有健康问题的人纳入指南主题的选择和优先顺序,尽管实施这一框架的过程是可变的。我们建议加拿大肾脏病学会临床实践指南委员会(CSN CPGC)抓住这个机会,在肾脏疾病患者及其护理人员的参与下,将循证优先练习纳入未来的指南活动中。在本协议中,我们描述了我们计划的研究方法来解决这个问题。目的:利用多学科利益相关者(包括肾脏疾病患者及其护理者)参与的改进德尔菲调查,为CSN CPGC建立基于共识的指南主题优先级。研究设计:修改德尔菲调查方案。设置:试点测试的调查将通过电子邮件分发,并使用在线平台SurveyMonkey进行,使用法语和英语。参与者:除了肾脏疾病患者和/或其护理者外,我们将建立一个由加拿大的多学科临床和研究利益相关者(包括CSN成员内部和外部)组成的小组。方法:将进行全面的文献检索,以生成指南主题的初始列表,该列表将分为三大类:(1)可能需要加拿大评论的国际肾脏病学指南,(2)可能需要CSN评论的加拿大非肾脏病学指南,以及(3)指南开发的新主题。参与者将参与多轮修改德尔菲调查,以确定一组“重要指导主题”的优先级。措施:将根据李克特量表的中位数得分(≥7)和同意百分比(≥75%)就一个项目达成共识;德尔菲程序将在每个项目达成共识时完成。然后,根据参与者的总李克特评分计算出指南主题的优先级分数,并根据参与者的数量进行调整。局限性:潜在的局限性包括参与者的回复率和调查完成的依从性。结论:我们建议将循证优先排序练习与肾脏疾病患者及其护理人员的参与结合起来,以建立基于共识的指南主题,并为CSN CPGC的未来指南活动提供信息。
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引用次数: 0
Association Between Arterial Stiffness and Measures of Autonomic Dysfunction in People With Chronic Kidney Disease. 慢性肾病患者动脉僵硬度与自主神经功能障碍之间的关系
IF 1.7 Q3 UROLOGY & NEPHROLOGY Pub Date : 2023-11-21 eCollection Date: 2023-01-01 DOI: 10.1177/20543581231213798
Rachelle Davies, Natasha Wiebe, Andrew Brotto, Michael K Stickland, Branko Braam, Stephanie Thompson

Background: Autonomic nervous system (ANS) dysfunction and vascular stiffness increase cardiovascular risk in people with chronic kidney disease (CKD). Chronic elevations in sympathetic activity can lead to increased arterial stiffness; however, the relationship between these variables is unknown in CKD.

Objective: To explore the association between measures of autonomic function and arterial stiffness in patients with moderate-to-severe CKD.

Methods: This study was a prespecified secondary analysis of a randomized controlled trial. This included the following measures: 24-hour ambulatory blood pressure (BP), carotid-femoral and carotid-radial pulse wave velocity (PWV), and postexercise heart rate recovery (HRR). We used mixed effect linear regression models with Bayesian information criteria (BIC) to assess the contribution of ANS measurements.

Results: Forty-four patients were included in the analysis. Mean carotid-femoral and carotid-radial PWV were 7.12 m/s (95% CI 6.13, 8.12) and 8.51 m/s (7.90, 9.11), respectively. Mean systolic dipping, calculated as percentage change in mean systolic readings from day to night, was 10.0% (95% CI 7.79, 12.18). Systolic dipping was independently associated with carotid-radial PWV, MD -0.09 m/s (95% CI -0.15, -0.02) and had the lowest BIC.

Conclusions: Systolic dipping was associated with carotid-radial PWV in people with moderate-to-severe CKD; however, there was no association with carotid-femoral PWV. Systolic dipping may be a feasible surrogate of ANS function, as the association with carotid-radial PWV was consistent with the minimal clinically important difference (MCID). Future studies are needed to define the relationship between ANS function, arterial stiffness, and CV events over time in people with CKD.

背景:自主神经系统(ANS)功能障碍和血管僵硬增加慢性肾脏疾病(CKD)患者的心血管风险。交感神经活动的慢性升高可导致动脉僵硬度增加;然而,CKD中这些变量之间的关系尚不清楚。目的:探讨中重度CKD患者自主神经功能与动脉僵硬度的关系。方法:本研究是一项预先指定的随机对照试验的二次分析。这包括以下测量:24小时动态血压(BP),颈动脉-股动脉和颈动脉-桡动脉脉搏波速度(PWV),以及运动后心率恢复(HRR)。我们使用带有贝叶斯信息准则(BIC)的混合效应线性回归模型来评估ANS测量的贡献。结果:44例患者纳入分析。颈动脉-股动脉和颈动脉-桡动脉的平均PWV分别为7.12 m/s (95% CI 6.13, 8.12)和8.51 m/s(7.90, 9.11)。平均收缩压下降,以昼夜平均收缩压读数变化百分比计算,为10.0% (95% CI 7.79, 12.18)。收缩期倾斜与颈动脉-桡动脉PWV独立相关,MD -0.09 m/s (95% CI -0.15, -0.02), BIC最低。结论:收缩期倾斜与中重度CKD患者颈动脉-桡动脉PWV相关;然而,与颈-股动脉PWV无关。收缩期倾斜可能是ANS功能的可行替代指标,因为与颈动脉-桡动脉PWV的相关性与最小临床重要差异(MCID)一致。未来的研究需要明确慢性肾病患者ANS功能、动脉僵硬度和CV事件之间的关系。
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引用次数: 0
Use of Wearable and Wireless Technology in Real-World Clinical Settings to Improve Patient Outcomes in Chronic Kidney Disease: A Mixed Methods Pilot Prospective Trial. 在现实世界的临床环境中使用可穿戴和无线技术来改善慢性肾脏疾病患者的预后:一项混合方法的前瞻性试验
IF 1.7 Q3 UROLOGY & NEPHROLOGY Pub Date : 2023-11-21 eCollection Date: 2023-01-01 DOI: 10.1177/20543581231212125
Domenic Pieroni, Silvia J Leon, Amanda L Krueger, Lauren Burton, Olivier Tremblay-Savard, Navdeep Tangri, Paul Komenda, Clara Bohm, Claudio Rigatto

Background: During the 30-day period prior to initiating dialysis, there is a 10-fold rise in emergency department visits and hospitalizations related to kidney failure.

Objective: The Virtual Ward Incorporating Electronic Wearables (VIEWER) trial implemented a home telemonitoring system to track changes in patients' vitals and assess their adherence and the acceptability of telemonitoring in a chronic kidney disease (CKD) population.

Design: A pilot prospective clinical trial using a mixed methods approach was performed.

Setting: The research was conducted in Winnipeg, Manitoba.

Participants: There were 2 phases: Phase 1 was a 2-week-long pilot trial consisting of 10 participants. Phase 2 was a 3-month-long trial with a total of 26 participants. Patients with an estimated glomerular filtration rate <15 and a >40% risk of beginning dialysis in the next 2 years according to the kidney failure risk equation were eligible to participate in the study.

Methods: The primary quantitative outcome was adherence, defined as the proportion of daily self-assessments completed using VIEWER over the follow-up period. The usability and acceptability of VIEWER was assessed qualitatively at the end of the trial through structured questionnaires and focus groups.

Results: Phase 1 participants (n = 10) had a median adherence of 77.17% for the 2-week observation period. Phase 2 participants (n = 26) showed a lower median adherence of 36% for the 3-month period. Focus group participants (n = 11) identified many positive aspects of VIEWER, including increased awareness and empowerment over health, simplicity of the data platform, and the ability to show clinical staff their health trends. Some challenges identified with VIEWER were connectivity issues with the Bluetooth, perceived inconvenience, and negative thoughts toward their health.

Limitations: Limitations of the study include a small sample size, which limited our ability to measure quantitative outcomes. In addition, patients agreeing to participate in any trial are generally more highly motivated and engaged in their care than those declining participation. Therefore, our results may not be generalizable to individuals who are not interested in self-management of their health.

Conclusion: Our results suggest that home telemonitoring in patients with advanced CKD is feasible using a CKD-specific platform like VIEWER. We anticipate that improved functionality with incorporation of feedback from this study will result in greater long-term adherence. A future randomized clinical trial is planned.

背景:在开始透析前的30天内,与肾衰竭相关的急诊就诊和住院率上升了10倍。目的:结合电子可穿戴设备(VIEWER)的虚拟病房试验实施了一种家庭远程监测系统,以跟踪慢性肾脏疾病(CKD)人群中患者生命体征的变化,并评估他们的依从性和远程监测的可接受性。设计:采用混合方法进行前瞻性临床试验。环境:研究在马尼托巴省温尼伯进行。参与者:有两个阶段:第一阶段是为期两周的试点试验,包括10名参与者。第二阶段是为期3个月的试验,共有26名参与者。根据肾衰竭风险方程,估计肾小球滤过率在未来2年内开始透析的风险为40%的患者有资格参加这项研究。方法:主要定量结果是依从性,定义为在随访期间使用VIEWER完成每日自我评估的比例。在试验结束时,通过结构化问卷和焦点小组对VIEWER的可用性和可接受性进行定性评估。结果:1期参与者(n = 10)在2周的观察期内的中位依从性为77.17%。2期参与者(n = 26)在3个月期间的中位依从性较低,为36%。焦点小组参与者(n = 11)确定了VIEWER的许多积极方面,包括提高对健康的认识和赋权、数据平台的简便性以及向临床工作人员展示其健康趋势的能力。VIEWER面临的一些挑战是蓝牙连接问题、感知到的不便以及对健康的负面想法。局限性:本研究的局限性包括样本量小,这限制了我们测量定量结果的能力。此外,同意参加任何试验的患者通常比那些拒绝参与的患者更有积极性,更投入到他们的护理中。因此,我们的结果可能不能推广到那些对自我管理健康不感兴趣的人。结论:我们的研究结果表明,使用VIEWER等CKD专用平台对晚期CKD患者进行家庭远程监测是可行的。我们预计,结合本研究反馈的功能改进将导致更大的长期依从性。计划在未来进行随机临床试验。
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引用次数: 0
Patient Care Gaps Prior to Maintenance Dialysis Initiation: A Population-Based Retrospective Study. 维持性透析开始前的患者护理缺口:一项基于人群的回顾性研究。
IF 1.7 Q3 UROLOGY & NEPHROLOGY Pub Date : 2023-11-17 eCollection Date: 2023-01-01 DOI: 10.1177/20543581231212134
Amber O Molnar, Danielle M Nash, Jennifer Emblem, Sarah Bota, Eric McArthur, Bin Luo, Yaqing Liu, Amit X Garg, Peter G Blake, K Scott Brimble

Background: Guidelines in Ontario, Canada, recommend timely referral for multidisciplinary kidney care to facilitate planned dialysis initiation. Many patients do not receive recommended multidisciplinary kidney care prior to dialysis.

Objective: To better understand why this gap in pre-dialysis care exists, we conducted a study to describe the pathways by which patients initiate maintenance dialysis.

Design: A retrospective cohort study.

Setting: Population-based, using health care administrative databases from Ontario, Canada.

Patients: Adults initiating maintenance dialysis from April 2016 to March 2019.

Measurements and methods: Patients were grouped based on whether they received recommended multidisciplinary kidney care prior to dialysis initiation (at least 1 year of care with at least 2 visits). For those who did not receive recommended care, we grouped patients as having no identified care gap or into the following groups: (1) lack of timely chronic kidney disease (CKD) screening, (2) late nephrology referral (<1 year), or (3) late or no referral for multidisciplinary kidney care among patients followed by a nephrologist for at least 1 year.

Results: A total of 9216 patients were included with a mean (standard deviation) age of 66 (15) years, and 61.5% were male. Of the total, 896 (9.7%) patients died, 7671 (83.2%) remained on dialysis at 90 days, and 649 (7.0%) had stopped dialysis due to kidney function recovery within 90 days. Of the 9216 patients, 5434 (59%) had not received recommended multidisciplinary kidney care. Among those without recommended care, there were 2251 (41.4%) patients with no identified care gaps, 1351 (24.9%) patients with a lack of timely CKD screening, 359 (6.6%) patients with late nephrology referral, and 1473 (27.1%) patients with late or no referral for multidisciplinary kidney care.

Limitations: We could not determine if patients were referred but declined multidisciplinary kidney care.

Conclusions: More than half of patients had not received recommended multidisciplinary kidney care. Many patients experienced an acute decline in kidney function, which may not be preventable, but in others, there were missed opportunities for CKD screening or early referral to nephrology, or at the level of nephrology practice for early referral for multidisciplinary care. This work could be used to inform policies aimed at improving increased uptake of multidisciplinary kidney care prior to dialysis.

背景:加拿大安大略省的指南建议及时转诊多学科肾脏护理,以促进计划透析的开始。许多患者在透析前没有接受推荐的多学科肾脏护理。目的:为了更好地理解为什么透析前护理存在这种差距,我们进行了一项研究来描述患者开始维持性透析的途径。设计:回顾性队列研究。环境:基于人群,使用来自加拿大安大略省的卫生保健管理数据库。患者:2016年4月至2019年3月开始维持性透析的成人。测量和方法:根据患者在透析开始前是否接受推荐的多学科肾脏护理(至少1年的护理,至少2次就诊)对患者进行分组。对于那些没有接受推荐治疗的患者,我们将患者分组为没有确定的护理差距或分为以下组:(1)缺乏及时的慢性肾脏疾病(CKD)筛查,(2)晚期肾脏病转诊(结果:共纳入9216例患者,平均(标准差)年龄为66(15)岁,其中61.5%为男性。其中死亡896例(9.7%),90天仍在透析的7671例(83.2%),90天内因肾功能恢复停止透析的649例(7.0%)。在9216例患者中,5434例(59%)未接受推荐的多学科肾脏护理。在没有推荐治疗的患者中,有2251例(41.4%)患者没有明确的护理缺口,1351例(24.9%)患者缺乏及时的CKD筛查,359例(6.6%)患者有肾脏病晚期转诊,1473例(27.1%)患者有晚期或未转诊的多学科肾脏治疗。局限性:我们不能确定患者是否转诊,但拒绝多学科肾脏护理。结论:超过一半的患者没有接受推荐的多学科肾脏护理。许多患者经历了肾功能的急性下降,这可能是不可预防的,但在其他患者中,他们错过了CKD筛查或早期转诊到肾病学的机会,或者在肾病学实践水平上早期转诊到多学科治疗的机会。这项工作可以用来为政策提供信息,旨在提高透析前多学科肾脏护理的吸收。
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引用次数: 0
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Canadian Journal of Kidney Health and Disease
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