Clinical journal of the American Society of Nephrology : CJASN
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Clin J Am Soc Nephrol · Jul 2008
Identifying best practices in dialysis care: results of cognitive interviews and a national survey of dialysis providers.
Because there is wide variation in case-mix adjusted outcomes across dialysis facilities, it is possible that top-performing facilities use practices not shared by others. We sought to catalogue "best practices" that may account for interfacility variations in outcomes. ⋯ This study provides a "conceptual map" of candidate dialysis best practices and highlights areas of general agreement and disagreement. These findings can help the dialysis community think critically about what may define "best practice" and provide targets for future research in quality improvement.
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Alterations in intracellular calcium homeostasis and cyclic adenosine 3',5'-phosphate likely underlie the increased cell proliferation and fluid secretion in polycystic kidney disease. Hormone receptors that affect cyclic adenosine 3',5'-phosphate and are preferentially expressed in affected tissues are logical treatment targets. There is a sound rationale for considering the arginine vasopressin V2 receptor as a target. ⋯ A number of clinical studies in polycystic kidney disease have been performed or are currently active. The results of phase 2 and 2-3 studies indicate that tolvaptan seems to be safe and well tolerated in autosomal dominant polycystic kidney disease. A phase 3,placebo-controlled, double-blind study in 18- to 50-yr-old patients with autosomal dominant polycystic kidney disease and preserved renal function but relatively rapid progression, as indicated by a total kidney volume >750 ml, has been initiated.
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Clin J Am Soc Nephrol · Jul 2008
Multicenter StudyPerformance of procedures by nephrologists and nephrology fellows at U.S. nephrology training programs.
Some procedures (e.g., placement of temporary hemodialysis catheters and kidney biopsies) are required in nephrology fellowship training. Others (e.g., placement of tunneled hemodialysis catheters, ultrasonography, and hemodialysis access interventions) are not required but are performed at some centers. To assess the procedures performed by nephrologists and nephrology fellows at U.S. adult nephrology training programs and the number of procedures required for fellow competency, a survey was conducted of all such training programs. ⋯ Core procedures are performed at almost all programs. Experience and training in other procedures are variable. Many programs have limited requirements for the number of procedures trainees need to perform to demonstrate competence.
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Clin J Am Soc Nephrol · Jul 2008
B-type natriuretic peptides strongly predict mortality in patients who are treated with long-term dialysis.
Left ventricular abnormalities contribute to cardiovascular disease in patients with chronic kidney disease and may be detected by measurement of B-type natriuretic peptide in serum. ⋯ Levels of B-type natriuretic peptide are greatest in patients who are on dialysis and have cardiovascular comorbidities and are strong predictors of death.
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Clin J Am Soc Nephrol · Jul 2008
Coronary flow velocity reserve and carotid intima media thickness in patients with autosomal dominant polycystic kidney disease: from impaired tubules to impaired carotid and coronary arteries.
Cardiovascular problems are a major cause of morbidity and mortality in patients with autosomal dominant polycystic kidney disease. Endothelial dysfunction, an early and reversible feature in the pathogenesis of atherosclerosis, is associated with increased vascular smooth muscle tone, arterial stiffening, and increased intima-media thickness. Coronary flow velocity reserve is a noninvasive test showing endothelial function of epicardial coronary arteries and coronary microcirculatory function. The aim of the study was to investigate the carotid intima-media thickness and coronary flow velocity reserve in patients with autosomal dominant polycystic kidney disease. ⋯ Normotensive patients with autosomal dominant polycystic kidney disease with well-preserved renal function have significantly increased carotid intima-media thickness and significantly decreased coronary flow velocity reserve compared with healthy subjects. These findings suggest that atherosclerosis starts at an early stage in the course of their disease in patients with autosomal dominant polycystic kidney disease.