Clinical journal of the American Society of Nephrology : CJASN
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Clin J Am Soc Nephrol · Oct 2012
Randomized Controlled TrialVascular disease, ESRD, and death: interpreting competing risk analyses.
Vascular disease, a common condition in CKD, is a risk factor for mortality and ESRD. Optimal patient care requires accurate estimation and ordering of these competing risks. ⋯ When competing events exist, absolute risk is better estimated using competing risk regression, but etiologic associations by this method must be carefully interpreted. The presence of vascular disease in CKD decreases the likelihood of survival to ESRD, independent of age and other risk factors.
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Clin J Am Soc Nephrol · Oct 2012
Review Practice GuidelineExtracorporeal treatment for thallium poisoning: recommendations from the EXTRIP Workgroup.
The EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup was formed to provide recommendations on the use of extracorporeal treatment (ECTR) in poisoning. To test and validate its methods, the workgroup reviewed data for thallium (Tl). ⋯ Despite Tl's low dialyzability and the limited evidence, the workgroup strongly recommended extracorporeal removal in the case of severe Tl poisoning.
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Clin J Am Soc Nephrol · Oct 2012
ReviewOnco-nephrology: renal toxicities of chemotherapeutic agents.
Despite dramatic improvements in patient survival and drug tolerability, nephrotoxicity remains an important complication of chemotherapy. Adverse renal effects occur because of innate drug toxicity and a number of patient- and drug-related factors. ⋯ Unfortunately, some patients who develop nephrotoxicity will be left with long-term complications such as chronic tubulopathies and CKD. Onco-Nephrology is a new area that is rapidly expanding and requires a close working relationship between oncologists and nephrologists.
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Clin J Am Soc Nephrol · Oct 2012
Critical and honest conversations: the evidence behind the "Choosing Wisely" campaign recommendations by the American Society of Nephrology.
Estimates suggest that one third of United States health care spending results from overuse or misuse of tests, procedures, and therapies. The American Board of Internal Medicine Foundation, in partnership with Consumer Reports, initiated the "Choosing Wisely" campaign to identify areas in patient care and resource use most open to improvement. Nine subspecialty organizations joined the campaign; each organization identified five tests, procedures, or therapies that are overused, are misused, or could potentially lead to harm or unnecessary health care spending. ⋯ The ASN Quality and Patient Safety Task Force selected five recommendations based on relevance and importance to individuals with kidney disease. Recommendations selected were: (1) Do not perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms; (2) do not administer erythropoiesis-stimulating agents to CKD patients with hemoglobin levels ≥10 g/dl without symptoms of anemia; (3) avoid nonsteroidal anti-inflammatory drugs in individuals with hypertension, heart failure, or CKD of all causes, including diabetes; (4) do not place peripherally inserted central catheters in stage 3-5 CKD patients without consulting nephrology; (5) do not initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians. These five recommendations and supporting evidence give providers information to facilitate prudent care decisions and empower patients to actively participate in critical, honest conversations about their care, potentially reducing unnecessary health care spending and preventing harm.
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Clin J Am Soc Nephrol · Oct 2012
Monitoring quality of care at dialysis facilities: a case for regulatory parsimony--and beyond.
With the issuance of the new Conditions for Coverage in 2008 and the implementation of the Prospective Payment System in 2011, the Centers for Medicare & Medicaid Services has fundamentally altered the regulatory landscape of quality in the ESRD program. Although these changes-largely through use of tools comparing individual facility performance to regional and national quality expectations-have increased facility accountability for the quality of patient care in many quarters, they have also complicated both substance and process of facility adherence to quality rules in that component of the program. This editorial critically assesses the main quality tools now in use for dialysis facilities and reviews the issues arising from their conjoint use. A scheme for improving the effectiveness of each quality tool is proposed, and an assessment of their future value and effectiveness in quality improvement is offered.