Clinical journal of the American Society of Nephrology : CJASN
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Clin J Am Soc Nephrol · Jan 2007
Nephrologists' changing practices in reported end-of-life decision-making.
Because the dialysis patient population is increasingly composed of older patients with high symptom burden, shortened life expectancy, and multiple comorbid conditions, nephrologists often engage in end-of-life decision-making with their patients. In the 1990s, reported practices of nephrologists' end-of-life decision-making showed much variability. In part as a reaction to that variability, the Renal Physicians Association (RPA) and the American Society of Nephrology (ASN) developed a clinical practice guideline on end-of-life decision-making. ⋯ In 2005, less variability was noted in reported practices to withhold dialysis from a permanently unconscious patient (90% would withhold in 2005 versus 83% who would withhold in 1990, P < 0.001) and to stop dialysis in a severely demented patient (53% in 2005 would stop versus 39% in 1990, P < 0.00001). In 2005, significantly more dialysis units were reported to have written policies on cardiopulmonary resuscitation (86% in 2005 versus 31% in 1990, P < 0.0001) and withdrawal of dialysis (30% in 2005 versus 15% in 1990, P < 0.0002); nephrologists were also more likely to honor a dialysis patient's do-not-resuscitate order (83% in 2005 versus 66%, P < 0.0002) and to consider consulting a Network ethics committee (52% in 2005 versus 39%, P < 0.001). Nephrologists' reported practices in end-of-life care have changed significantly over the 15 years separating the two surveys, suggesting that the development of the clinical practice guideline was worthwhile.
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Clin J Am Soc Nephrol · Nov 2006
Multicenter StudyNephrologists' reported preparedness for end-of-life decision-making.
Nephrologists commonly engage in end-of-life decision-making with patients with ESRD and their families. The purpose of this study was to determine the perceived preparedness of nephrologists to make end-of-life decisions and to determine factors that are associated with the highest level of perceived preparedness. The nephrologist members of the Renal Physicians Association (RPA) and the Canadian Society of Nephrology were invited to participate in an online survey of their end-of-life decision-making practices. ⋯ Compared with Americans, Canadian nephrologists reported being equally prepared to make end-of-life decisions, stopped dialysis of a higher number of patients, referred fewer to hospice, and were more likely to stop dialysis of a patient with severe dementia. Nephrologists who have been in practice longer and are knowledgeable of the RPA/ASN guideline report greater preparedness to make end-of-life decisions and report doing so more often in accordance with guideline recommendations. To improve nephrologists' comfort with end-of-life decision-making, fellowship programs should teach the recommendations in the RPA/ASN guideline and position statement.
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Clin J Am Soc Nephrol · Sep 2006
ReviewAssessing iron status: beyond serum ferritin and transferrin saturation.
The increasing prevalence of multiple comorbidities among anemic patients with chronic kidney disease has made the use of serum ferritin and transferrin saturation more challenging in diagnosing iron deficiency. Because serum ferritin is an acute-phase reactant and because the inflammatory state may inhibit the mobilization of iron from reticuloendothelial stores, the scenario of patients with serum ferritin >800 ng/ml, suggesting iron overload, and transferrin saturation <20%, suggesting iron deficiency, has become more common. ⋯ These newer tests include reticulocyte hemoglobin content, percentage of hypochromic red cells, and soluble transferrin receptor, all of which have shown some promise in limited studies. Finally, the role of hepcidin, a hepatic polypeptide, in the pathophysiology of iron mobilization is reviewed briefly.
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Clin J Am Soc Nephrol · Sep 2006
Comparative Study Clinical TrialPro- and anti-inflammatory cytokines in chronic pediatric dialysis patients: effect of aspirin.
Dialysis provides effective and safe treatment of ESRD in children, but patients who are maintained on chronic dialysis are at risk for cardiovascular disease. One major risk factor for cardiovascular disease in adult patients with ESRD is chronic inflammation. The effect of anti-inflammatory therapy with aspirin on serum cytokine concentration was studied in seven children who were receiving hemodialysis (HD) and seven who were receiving continuous cycling peritoneal dialysis (CCPD or PD). ⋯ The effect of aspirin treatment on serum cytokine concentrations was similar for HD and PD patients. In HD patients, IL-6, IL-8, and TNF-alpha remained suppressed 1 mo after discontinuation of aspirin. It is concluded that proinflammatory cytokines are elevated in pediatric HD and PD patients without counterbalance from anti-inflammatory cytokines, and aspirin therapy attenuates inflammation.
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Clin J Am Soc Nephrol · Sep 2006
Multicenter Study Comparative StudyTiming of initiation of dialysis in critically ill patients with acute kidney injury.
Among critically ill patients, acute kidney injury (AKI) is a relatively common complication that is associated with an increased risk for death and other complications. To date, no treatment has been developed to prevent or attenuate established AKI. Dialysis often is required, but the optimal timing of initiation of dialysis is unknown. ⋯ Further adjustment for the propensity score did not materially alter the association (relative risk 1.97; 95% confidence interval 1.21 to 3.20). Among critically ill patients with AKI, initiation of dialysis at higher BUN concentrations was associated with an increased risk for death. Although the results could reflect residual confounding by severity of illness, they provide a rationale for prospective testing of alternative dialysis initiation strategies in critically ill patients with severe AKI.