Analysis of Cancer Patient Decision-Making and Health Service Utilization after Enforcement of the Life-Sustaining Treatment Decision-Making Act in Korea / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#This study aimed to confirm the decision-making patterns for life-sustaining treatment (LST) and analyze medical service utilization changes after enforcement of the Life-Sustaining Treatment Decision-Making Act. @*Materials and Methods@#Of 1,237 patients who completed legal forms for life-sustaining treatment (hereafter called the LST form) at three academic hospitals and died at the same institutions, 1,018 cancer patients were included. Medical service utilization and costs were analyzed using claims data. @*Results@#The median time to death from completion of the LST form was three days (range, 0 to 248 days). Of these, 517 people died within two days of completing the document, and 36.1% of all patients prepared the LST form themselves. The frequency of use of the intensive care unit, continuous renal replacement therapy, and mechanical ventilation was significantly higher when the families filled out the form without knowing the patient’s intention. In the top 10% of the medical expense groups, the decision-makers for LST were family members rather than patients (28% patients vs. 32% family members who knew and 40% family members who did not know the patient’s intention). @*Conclusion@#The cancer patient’s own decision-making rather than the family’s decision was associated with earlier decision-making, less use of some critical treatments (except chemotherapy) and expensive evaluations, and a trend toward lower medical costs.

Effect of shared decision-making education on physicians’ perceptions and practices of end-of-life care in Korea

Evidence of the ethical appropriateness and clinical benefits of shared decision-making (SDM) are accumulating. This study aimed to not only identify physicians’ perspectives on SDM, and practices related to end-of-life care in particular, but also to gauge the effect of SDM education on physicians in Korea. Methods: A 14-item questionnaire survey using a modified Delphi process was delivered to nephrologists and internal medicine trainees at 17 university hospitals. Results: A total of 309 physicians completed the survey. Although respondents reported that 69.9% of their practical decisions were made using SDM, 59.9% reported that it is not being applied appropriately. Only 12.3% of respondents had received education on SDM as part of their training. The main obstacles to appropriate SDM were identified as lack of time (46.0%), educational materials and tools (29.4%), and education on SDM (24.3%). Although only a few respondents had received training on SDM, the proportion of those who thought they were using SDM appropriately in actual practice was high; the proportion of those who chose lack of time and education as factors that hindered the proper application of SDM was low. Conclusion: The majority of respondents believed that SDM was not being implemented properly in Korea, despite its use in actual practice. To improve the effectiveness of SDM in the Korean medical system, appropriate training programs and supplemental policies that guarantee sufficient application time are required.

Evaluating a shared decision-making intervention regarding dialysis modality: development and validationof self-assessment items for patients with chronic kidney disease

Shared decision-making is a two-way symmetrical communication process in which clinicians and patients work together to achieve the best outcome. This study aimed to develop self-assessment items as a decision aid for choosing a dialysis modality in patients with chronic kidney disease (CKD) and to assess the construct validity of the newly developed items. Methods: Five focus group interviews were performed to extract specific self-assessment items regarding patient values in choosing a dialysis modality. After survey items were refined, a survey of 330 patients, consisting of 152 hemodialysis (HD) and 178 peritoneal dialysis (PD) patients, was performed to validate the self-assessment items. Results: The self-assessment for the decision aid was refined to 35 items. The structure of the final items appeared to have three dimensions of factors; health, lifestyle, and dialysis environment. The health factor consisted of 12 subscales (α = 0.724), the lifestyle factor contained 11 subscales (α = 0.624), and the dialysis environment factor was represented by 12 subscales (α = 0.694). A structural equation model analysis showed that the relationship between the decision aid factors (health, lifestyle, and dialysis environment), patients’ CKD perception, and cognition of shared decision-making differed between HD patients and PD patients. Conclusion: We developed and validated self-assessment items as part of a decision aid to help patients with CKD. This attempt may assist CKD patients in making informed and shared decisions closely aligned with their values when considering dialysis modality.

Awareness of Doctors’ Shared Decision-Making in Life-Sustaining Care Decisions / 한국호스피스완화의료학회지

Purpose@#At the end of life, communication is a key factor for good care. However, in clinical practice, it is difficult to adequately discuss end-of-life care. In order to understand and analyze how decision-making related to life-sustaining treatment (LST) is performed, the shared decision-making (SDM) behaviors of physicians were investigated. @*Methods@#A questionnaire was designed after reviewing the literature on attitudes toward SDM or decision-making related to LST. A final item was added after consulting experts. The survey was completed by internal medicine residents and hematologists/medical oncologists who treat terminal cancer patients. @*Results@#In total, 202 respondents completed the questionnaire, and 88.6% said that the decision to continue or end LST is usually a result of SDM since they believed that sufficient explanation is provided to patients and caregivers, patients and caregivers make their own decisions according to their values, and there is sufficient time for patients and caregivers to make a decision. Expected satisfaction with the decisionmaking process was the highest for caregivers (57.4%), followed by physicians (49.5%) and patients (41.1%). In total, 38.1% of respondents said that SDM was adequately practiced when making decisions related to LST. The most common reason for inadequate SDM was time pressure (89.6%). @*Conclusion@#Although most physicians answered that they practiced SDM when making decisions regarding LST, satisfactory SDM is rarely practiced in the clinical field. A model for the proper implementation of SDM is needed, and additional studies must be conducted to develop an SDM model in collaboration with other academic organizations.

Disaster preparedness for earthquakes in hemodialysis units in Gyeongju and Pohang, South Korea

In 2016 and 2017, there were earthquakes greater than 5.0 in magnitude on the Korean Peninsula, which has previously been considered an earthquake-free zone. Patients with chronic kidney disease are particularly vulnerable to earthquakes, as the term “renal disaster” suggests. In the event of a major earthquake, patients on hemodialysis face the risk of losing maintenance dialysis due to infrastructure disruption. In this review, we share the experience of an earthquake in Pohang that posed a serious risk to patients on hemodialysis. We review the disaster response system in Japan and propose a disaster preparedness plan with respect to hemodialysis. Korean nephrologists and staff in dialysis facilities should be trained in emergency response to mitigate risk from natural disasters. Dialysis staff should be familiar with the action plan for natural disaster events that disrupt hemodialysis, such as outages and water treatment system failures caused by earthquakes. Patients on hemodialysis also need to be educated about disaster preparedness. In the event of a disaster situation that results in dialysis failure, patients need to know what to do. At the local and national government level, long-term preparations should be made to handle renal disaster and patient safety logistics. Moreover, Korean nephrologists should also be prepared to manage cardiovascular disease and diabetes in disaster situations. Further evaluation and management of social and national disaster preparedness of hemodialysis units to earthquakes in Korea are needed.

Do Korean Medical Schools Provide Adequate End-of-Life Care Education? A Nationwide Survey of the Republic of Korea's End-of-Life Care Curricula / 한국호스피스완화의료학회지

PURPOSE: Physician competency in end-of-life (EOL) care is becoming increasingly important. This study investigated the EOL care curricula in Korean medical schools.METHODS: Questionnaires were issued to the faculty members responsible for the EOL care curricula at each of the medical schools. These included questions on the structure and content of the curricula, teaching methods, and faculty members' attitudes to the curricula.RESULTS: Characteristics of the EOL care curricula were compiled from 27 (66%) of the 41 medical schools. All of the medical schools taught essential aspects of the EOL care curriculum either as a separate course or embedded within other medical education courses. The mean time spent on EOL care teaching was 10 hrs (range, 2~32 hrs). The most frequently taught topics were delivering bad news (100%) and symptom management (74%). When the palliative care education assessment tool (PEAT) was used to evaluate the curricula, a median of 11 PEAT objectives was met (range, 2~26; maximum, 83). More than two teaching methods were used in most of the curricula. However, lectures were the only teaching method used by three medical schools. 78% of faculty members who were responsible for curriculum reported dissatisfaction with it, whereas 18% believed that the time allotted to it was adequate. Only 7% of these faculty members believed that their students were adequately prepared to practice EOL care.CONCLUSION: There is a need to improve EOL care education in basic medical curricula and to take a more systematic approach to achieving learning outcomes.

Estimating the urinary sodium excretion in patients with chronic kidney disease is not useful in monitoring the effects of a low-salt diet

BACKGROUND: Several epidemiologic studies have suggested that the urine sodium excretion (USE) can be estimated in lieu of performing 24-hour urine collection. However, this method has not been verified in patients with chronic kidney disease (CKD) or in an interventional study. The purpose of this study was to evaluate the usefulness of estimating USE in a prospective low-salt diet education cohort (ESPECIAL). METHODS: A new formula was developed on the basis of morning fasting urine samples from 228 CKD patients in the ESPECIAL cohort. This formula was compared to the previous four formulas in the prediction of 24-hour USE after treatment with olmesartan and low-salt diet education. RESULTS: Most previously reported formulas had low predictability of the measured USE based on the ESPECIAL cohort. Only the Tanaka formula showed a small but significant bias (9.8 mEq/day, P < 0.05) with a low correlation (r = 0.34). In contrast, a new formula showed improved bias (−0.1 mEq/day) and correlation (r = 0.569) at baseline. This formula demonstrated no significant bias (−1.2 mEq/day) with the same correlation (r = 0.571) after 8 weeks of treatment with olmesartan. Intensive low-salt diet education elicited a significant decrease in the measured USE. However, none of the formulas predicted this change in the measured urine sodium after diet adjustment. CONCLUSION: We developed a more reliable formula for estimating the USE in CKD patients. Although estimating USE is applicable in an interventional study, it may be unsuitable for estimating the change of individual sodium intake in a low-salt intervention study.

Hemodialysis as a life-sustaining treatment at the end of life

The Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life came into effect on February 4th, 2018, in South Korea. Based on the Act, all Koreans over the age of 19 years can decide whether to refuse life-sustaining treatments at the end of life via advance directive or physician orders. Hemodialysis is one of the options designated in the Act as a life-sustaining treatment that can be withheld or withdrawn near death. However, hemodialysis has unique features. So, it is not easy to determine the best candidates for withholding/withdrawing hemodialysis at the end of life. Thus, it is necessary to investigate the meaning and implications of hemodialysis at the end of life with ethical consideration of futility and withholding or withdrawal of intervention.

Weight loss has an additive effect on the proteinuria reduction of angiotensin II receptor blockers in hypertensive patients with chronic kidney disease

BACKGROUND: Weight reduction is a lifestyle intervention that has been introduced for prevention and management of chronic kidney disease (CKD). We investigate the additive anti-proteinuric effect of weight reduction on the usage of angiotensin II receptor blockers (ARBs) and its potential mechanisms in hypertensive CKD patients. METHODS: This study is a subanalysis of data from an open-label, randomized, controlled clinical trial. Among the 235 participants, 227 were assigned to subgroups according to changes in body weight. RESULTS: Fifty-eight participants (25.6%) were assigned to group 1 (≥1.5% decrease in body weight after 16 weeks), 32 participants (14.1%) were assigned to group 2 (1.5–0.1% decrease in body weight), and 136 participants (59.9%) were assigned to group 3 (≥ 0.0% increase in body weight). Characteristics at enrollment were not different among the three groups, but mean differences in weight and percent changes in urinary sodium excretion over the period were statistically different (P < 0.001 and P = 0.017). Over the study period, unintentional weight loss independently increased the probability of reduced albuminuria (group 1, relative risk 6.234, 95% confidence interval 1.913–20.315, P = 0.002). Among urinary cytokines, only podocalyxin level decreased significantly in participants who lost weight (P = 0.013). CONCLUSION: We observed that weight loss had an additive effect on the anti-proteinuric effects of ARBs in nondiabetic hypertensive CKD patients, although it was minimal. An additive effect was shown in both obese and non-obese participants, and its possible mechanism is related to reduction of podocyte damage.

The Necessity for End-of-Life Care Education: A Preliminary Analysis with Interns at Two University Hospitals / 한국호스피스완화의료학회지

PURPOSE: This study was performed to explore the current state of end-of-life (EoL) care education provided to new interns at two university hospitals. METHODS: A questionnaire was given to incoming interns (N=64). The levels of acquired knowledge and experience of clinical observation were measured. Seven areas for self-assessment questions were identified and used to analyze the interns' attitudes towards EoL-related education and practice. RESULTS: On average, participants learned five elements (nine in total) from EoL-related classes and two (seven in total) from clinical observation. The most frequently educated element was how to deliver bad news (96.9%) in the classroom setting and how to control physical symptoms (56.5%) in clinical observation. Less than 20% received training on EoL care communication, including discussion of advanced directives. Compared with participants who had no EoL training, those who had EoL training showed positive attitudes in all seven categories regarding overall satisfaction, interest and preparedness in relation to EoL-care classes and practice. CONCLUSION: Although interns are responsible for caring of dying patients, their EoL training in classroom and clinical settings was very insufficient. Further research should be conducted to establish an education system that provides sufficient knowledge and training on EoL care.

Delayed Vertebral Collapse in Osteoporotic Vertebral Compression Fractures: Risk Factors and Treatment Strategies

STUDY DESIGN: Literature review. OBJECTIVES: To review the complications of osteoporotic vertebral compression fractures (OCFs) with regard to risk factors and treatment strategies. SUMMARY OF LITERATURE REVIEW: Understanding the complications and treatment methods of OCFs is important given their increasing prevalence. MATERIALS AND METHODS: Review of the literature. RESULTS: The complications of OCFs include kyphotic deformity due to a delayed collapse of the vertebral body and neurologic deficits. The pathophysiologic mechanism of these complications has not been established; however, the most accepted theory is posttraumatic avascular necrosis of the vertebral body. The risk factors for these complications include fracture at the thoracolumbar junction, systemic usage of steroids, severe osteoporosis, and radiological intravertebral vacuum cleft. Most of these complications require surgical treatment, the indications for which include progressing axial back pain, pseudarthrosis, kyphotic deformity, and neurologic deficits. Surgical approaches for treating the complications of OCFs include anterior, posterior, and combined anterior-posterior approaches. Osteotomies should be done when deformity correction is needed. The decision among these various surgical methods should be made considering patient factors and the surgeon's ability to achieve the best outcomes with solid fusion. CONCLUSIONS: complications of OCFs include kyphotic deformity due to delayed collapse of the vertebral body and neurologic deficits. Most of these complications require surgical treatment, in which achieving solid fusion at the fracture site is the ultimate goal. Patient-related factors and the surgeon's ability should be considered prior to making decisions regarding surgery.

Prevalence of Masked Hypertension: a Population-Based Survey in a Large City by Using 24-Hour Ambulatory Blood Pressure Monitoring

BACKGROUND AND OBJECTIVES: We estimated the prevalence of hypertension and hypertension subtypes in a large semi-urban city in Korea, using 24-hour ambulatory blood pressure monitoring (ABPM) in a randomly selected sample population. SUBJECTS AND METHODS: A random sample (aged 20-65 years) from a city with an adult population of approximately 600000 was selected by using a list-assisted random digit dialing method. The 24-hour ABPM and conventional blood pressure measurement (CBPM) of these individuals were obtained. RESULTS: Among the 496 participants, valid 24-hour ABPM and CBPM were obtained from 462 (93%) individuals. The estimated prevalence of hypertension in Goyang was 17.54% by CBPM and 32.70% by 24-hour ABPM (p<0.01). In the age stratified analysis, both CBPM and 24-hour ABPM showed increased prevalence of hypertension with age. The estimated prevalence of masked hypertension was 16.22% and that of white-coat hypertension was 1.08%. Men had a higher prevalence of masked hypertension than women (20.79% vs. 11.86%, p=0.0295). The estimated prevalence of masked hypertension was 17.5%, 20.58%, 24.34%, and 13.29% in the age categories of 30s, 40s, 50s, and 60s, respectively. The estimated prevalence of masked uncontrolled hypertension was 26.79% in patients with hypertension who were taking antihypertensive medications. CONCLUSION: The estimated prevalence of hypertension by 24-hour ABPM was higher than that by CBPM, revealing high prevalence of masked hypertension. The high prevalence of masked hypertension supports the adoption of ABPM in the national population survey and clinical practice to improve public health and reduce health care costs.

Dabigatran Toxicity Secondary to Acute Kidney Injury

Dabigatran is the first oral direct thrombin inhibitor approved by the US Food and Drug Administration (FDA) for prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Because dabigatran is excreted mainly by the kidneys, serum levels of dabigatran can be elevated to a supratherapeutic range in patients with renal failure, predisposing to emergent bleeding. We describe the case of a 66-year-old man taking dabigatran 150 mg twice daily for atrial fibrillation and cerebral infarction who presented with hematochezia and disseminated intravascular coagulation. Laboratory evaluation showed a hemoglobin level of 6.3 g/dL, platelets of 138,000/mm3, activated partial thromboplastin time (aPTT) of 10?s, and an international normalized ratio (INR) of 8.17. Colonoscopy showed a bleeding anal fissure. Hemostasis was provided by hemoclips and packed red blood cells and fresh frozen plasma were transfused. Since then, there was no further hematochezia, however, bleeding including oral mucosal bleeding, hematuria, and intravenous site bleeding persisted. At presentation, his serum creatinine was 4.96 mg/dL (baseline creatinine, 0.9 mg/dL). Dabigatran toxicity secondary to acute kidney injury was presumed. Because acute kidney injury of unknown cause was progressing after admission, he was treated with hemodialysis. Fresh frozen plasma transfusion was provided with hemodialysis. At 15 days from admission, there was no further bleeding, and laboratory values, including hemoglobin, partial thromboplastin time, and prothrombin time were normalized. He was discharged without bleeding. After 2 months, he undergoes dialysis three times per week and no recurrence of bleeding has been observed.

Urinary Sodium Excretion Has Positive Correlation with Activation of Urinary Renin Angiotensin System and Reactive Oxygen Species in Hypertensive Chronic Kidney Disease

It is not well described the pathophysiology of renal injuries caused by a high salt intake in humans. The authors analyzed the relationship between the 24-hr urine sodium-to-creatinine ratio (24HUna/cr) and renal injury parameters such as urine angiotensinogen (uAGT/cr), monocyte chemoattractant peptide-1 (uMCP1/cr), and malondialdehyde-to-creatinine ratio (uMDA/cr) by using the data derived from 226 hypertensive chronic kidney disease patients. At baseline, the 24HUna/cr group or levels had a positive correlation with uAGT/cr and uMDA/cr adjusted for related factors (P or =200 mEq/g cr was higher than in patients with or =200 mEq/g cr (P=0.016). During the 16-week follow-up period, an increase in urinary sodium excretion predicted an increase in urinary angiotensinogen excretion. In conclusion, high salt intake increases renal renin-angiotensin-system (RAS) activation, primarily, and directly or indirectly affects the production of reactive oxygen species through renal RAS activation.

Beta-Thalassemia Minor Is Associated with IgA Nephropathy

No abstract available.

Elevation of Morning Blood Pressure in Sodium Resistant Subjects by High Sodium Diet

The present study evaluated the response of blood pressure (BP) by dietary sodium in sodium resistant (SR) subjects. One hundred one subjects (mean age, 46.0 yr; 31 hypertensives) were admitted and given low sodium-dietary approaches to stop hypertension (DASH) diet (LSD, 100 mM NaCl/day) for 7 days and high sodium-DASH diet (HSD, 300 mM NaCl/day) for the following 7 days. On the last day of each diet, 24 hr ambulatory BP was measured. Morning systolic BP (SBP) and diastolic BP (DBP) were elevated after HSD in all subjects (P 0.05). In hypertensive subjects, morning DBP elevation was greater than daytime DBP elevation (P = 0.036), although both DBPs were significantly elevated after HSD. The augmented elevation of morning DBP in hypertensive subjects was contributed by the absolute elevation of morning DBP (P = 0.032) and relative elevation to daytime DBP (P = 0.005) in sodium resistant (SR) subjects, but not by sodium sensitive subjects. Although there was no absolute elevation, SR subjects with normotension showed a relative elevation of morning SBP compared to daytime SBP change after HSD (P = 0.009). The present study demonstrates an absolute and relative elevation of morning BP in SR subjects by HSD.

Acalculous Gallbladder Perforation and Coronary Artery Aneurysm after Kidney Transplantation / 대한이식학회지

Although gallbladder (GB) perforation due to acalculous cholecystitis after kidney transplantation is rarely observed, it can be life threatening and result in cholecystectomy. Coronary artery aneurysm (CAA) is also rare and may require invasive therapy depending on its diameter. We report herein the case of a 69-year-old female who developed GB perforation due to acalculous cholecystitis after kidney transplantation and underwent cholecystectomy. The patient was later invasively treated when CCA was detected by coronary angiography.

The Efficacy of Urinary Albumin-to-Osmolality Ratio in Predicting 24-hour Urine Albumin Excretion in Type 2 DM Patients / 대한신장학회지

PURPOSE: Microalbuminuria is a predictive marker for early diabetic nephropathy and an independent risk factor for cardiovascular disease. Screening for the presence of microalbuminuria is one of the best ways to detect early kidney damage in patients with diabetes or other disease, and also is of great significance in prevention of cardiovascular disease. Recently spot urine albumin-to-creatinine ratio (ACR) has been proposed as a screening test for microalbuminuria. However, the creatinine level is affected by diet, drugs, age, muscle mass and race, etc. The cutoff value for ACR has generated some controversy. In this report, we evaluated the efficacy of spot urine albumin-to-osmolality ratio (AOR) in order to predict 24-hour urine albumin excretion (AER). METHODS: Seventy-three patients diagnosed as type 2 DM in DUIH were recruited. Urine was collected for 24 hours for the measurement of microalbumin and first morning urine was obatined for the measurement of ACR and AOR. We evaluated the correlation of AER and ACR or AOR. RESULTS: Correlation between spot urine AOR and 24 hour urine AER (Spearmans' rho=0.804, p<0.01) was similar to that between ACR and AER (Spearman's rho=0.872, p<0.01). Also correlation analysis revealed that AOR is closely correlated with ACR (Spearman's rho=0.939, p<0.01). We evaluate accuracy of spot urine ACR and AOR using receiver operating characteristics (ROC) curve, AUC were 0.97, 0.94, respectively. CONCLUSION: AOR correlates closely with AER. Both AOR and ACR are effective predictors of microalbuminuria. Therefore AOR is an alternative to ACR in the detection and follow-up of microalbuminuria in patients with DM.

A Case of Lateral Femoral Cutaneous Neuropathy after Renal Transplantation / 대한신장학회지

A few cases of Lateral femoral cutaneous neuropathy that developed after renal transplantation have been reported in western literature but there is no reported case in Korea. It may develop from one to nine days after surgery; the clinical course is favorable but the incidence is not low. According to the reported cases of western literature, the major causes of lateral femoral cutaneous neuropathy after renal transplantation included steal phenomenon, clamping the internal iliac artery during surgery, direct surgical damage to the vessels supplying the femoral nerve, and direct compression of the femoral nerve. We experienced one case of lateral femoral cutaneous nerve neuropathy after renal transplantation that developed at postoperative day (POD) 7. It was partially improved symptomatically after POD 60, so we reported this case with a brief review of literatures.

Characteristics of Sodium Sensitivity in Korean Populations

Sodium sensitivity (SS) is a variable response of blood pressure (BP) to changes in sodium intake. The present study evaluated the existence and the characteristics of subjects with SS in Koreans. One hundred one subjects with (n = 31, 57.7 +/- 9.8 yr) or without hypertension (n = 70, 40.8 +/- 16.5 yr) were given a low-sodium dietary approache to stop hypertension (DASH) diet (LSD) for 7 days and a high-sodium DASH diet (HSD) for the following 7 days. The prevalence of SS in the present study population was 27.7% (17.6% in the non-hypertensive subjects and 51.6% in the hypertensive subjects). Analysis of the non-hypertensive subjects showed that systolic BP, diastolic BP, and mean arterial pressure at baseline and after HSD were higher in the subjects with SS than the subjects without SS, and there were no differences after LSD. In the hypertensive subjects, there was no difference in the BP at baseline and after HSD whether or not the subjects had SS. However, the systolic BP of hypertensive subjects with SS was lower than hypertensive subjects without SS after LSD. In the present study population, subjects with SS have distinctive BP features unlike to subjects without SS.