Clinical journal of the American Society of Nephrology : CJASN
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Clin J Am Soc Nephrol · Dec 2016
Prevalence and Contents of Advance Directives of Patients with ESRD Receiving Dialysis.
ESRD requiring dialysis is associated with increased morbidity and mortality rates, including increased rates of cognitive impairment, compared with the general population. About one quarter of patients receiving dialysis choose to discontinue dialysis at the end of life. Advance directives are intended to give providers and surrogates instruction on managing medical decision making, including end of life situations. The prevalence of advance directives is low among patients receiving dialysis. Little is known about the contents of advance directives among these patients with advance directives. ⋯ Although one-half of the patients receiving dialysis in our study had advance directives, end of life management of dialysis was rarely addressed. Future research should focus on improving discernment and documentation of end of life values, goals, and preferences, such as dialysis-specific advance directives, among these patients.
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Clin J Am Soc Nephrol · Dec 2016
Comparative Effectiveness of Second-Line Agents for the Treatment of Diabetes Type 2 in Preventing Kidney Function Decline.
Diabetes is the leading cause of ESRD. Glucose control improves kidney outcomes. Most patients eventually require treatment intensification with second-line medications; however, the differential effects of those therapies on kidney function are unknown. ⋯ Among patients who intensified metformin monotherapy, the addition of insulin compared with a sulfonylurea was not associated with a higher rate of kidney outcomes but was associated with a higher rate of the composite outcome that included death. These risks were not modified by baseline eGFR.
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Clin J Am Soc Nephrol · Dec 2016
Achieving Procedural Competence during Nephrology Fellowship Training: Current Requirements and Educational Research.
Concerns have previously been raised as to whether training programs are ensuring that nephrology fellows achieve competence in the procedural skills required for independent practice. We sought to review the current requirements for procedural training as well as educational research pertaining to achieving competence in the core nephrology procedures of nontunneled (temporary) hemodialysis catheter insertion and percutaneous kidney biopsy. ⋯ For percutaneous kidney biopsy, the development and evaluation of inexpensive simulators are a promising starting point for future study. Current practice with respect to procedural training during nephrology fellowship remains imperfect; however, the ongoing shift toward competency-based evaluation provides opportunities to refocus on improvement.
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Clin J Am Soc Nephrol · Nov 2016
Multicenter StudyDevelopment of a Multicenter Ward-Based AKI Prediction Model.
Identification of patients at risk for AKI on the general wards before increases in serum creatinine would enable preemptive evaluation and intervention to minimize risk and AKI severity. We developed an AKI risk prediction algorithm using electronic health record data on ward patients (Electronic Signal to Prevent AKI). ⋯ Readily available electronic health record data can be used to improve AKI risk stratification with good to excellent accuracy. Real time use of Electronic Signal to Prevent AKI would allow early interventions before changes in serum creatinine and may improve costs and outcomes.
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Clin J Am Soc Nephrol · Nov 2016
Albuminuria Changes and Cardiovascular and Renal Outcomes in Type 1 Diabetes: The DCCT/EDIC Study.
In trials of people with type 2 diabetes, albuminuria reduction with renin-angiotensin system inhibitors is associated with lower risks of cardiovascular events and CKD progression. We tested whether progression or remission of microalbuminuria is associated with cardiovascular and renal risk in a well characterized cohort of type 1 diabetes. ⋯ In type 1 diabetes, microalbuminuria and macroalbuminuria are associated with higher risks of cardiovascular disease and reduced eGFR, but achieving a remission of established microalbuminuria to normoalbuminuria does not appear to improve outcomes.