Identifying high-risk hospitalised chronic kidney disease patient using electronic health records for serious illness conversation.

INTRODUCTION: This study aimed to identify risk factors that are associated with increased mortality that could prompt a serious illness conversation (SIC) among patients with chronic kidney disease (CKD). METHODS: The electronic health records of adult CKD patients admitted between August 2018 and February 2020 were retrospectively reviewed to identify CKD patients with >1 hospitalisation and length of hospital stay ≥4 days. Outcome measures were mortality and the duration of hospitalisation. We also assessed the utility of the Cohen's model to predict 6-month mortality among CKD patients. RESULTS: A total of 442 patients (mean age 68.6 years) with median follow-up of 15.3 months were identified. The mean (standard deviation) Charlson Comorbidity Index [CCI] was 6.8±2.0 with 48.4% on chronic dialysis. The overall mortality rate until August 2020 was 36.7%. Mortality was associated with age (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.29-1.77), CCI≥7 (1.58, 1.08-2.30), lower serum albumin (1.09, 1.06-1.11), readmission within 30-day (1.96, 1.43-2.68) and CKD non-dialysis (1.52, 1.04-2.17). Subgroup analysis of the patients within first 6-month from index admission revealed longer hospitalisation stay for those who died (CKD-non dialysis: 5.5; CKD-dialysis: 8.0 versus 4 days for those survived, P<0.001). The Cohen's model demonstrated reasonable predictive ability to discriminate 6-month mortality (area under the curve 0.81, 95% CI 0.75-0.87). Only 24 (5.4%) CKD patients completed advanced care planning. CONCLUSION: CCI, serum albumin and recent hospital readmission could identify CKD patients at higher risk of mortality who could benefit from a serious illness conversation.

Simple citrate anticoagulation protocol for low flux haemodialysis.

BACKGROUND: For patients unable to receive heparin anticoagulation during haemodialysis, saline flushes to reduce circuit clotting are often the norm. Regional citrate anticoagulation (RCA) although effective is not used by many centres including in Singapore. We wanted to demonstrate the superiority and safety of a simple regional citrate anticoagulation regime, compared to saline flushes, for heparin-free low flux haemodialysis. METHODS: This is a prospective, open label, cross over study on 25 sequential haemodialysis sessions for inpatients receiving heparin-free haemodialysis. Patients were allocated either to regional citrate anticoagulation or standard heparin free haemodialysis and subsequently cross over to the alternate method. RCA was carried out using a protocol derived from previous studies. Assessment of anticoagulation was performed using visual inspection of clot formation in dialysis circuits and post-filter ionized calcium (iCa2+) using point-of-care Ionized calcium device at stipulated intervals. Intravenous Calcium gluconate replacement was given to patients receiving citrate adjusting the rate according to pre-filter iCa2+. Laboratory analyses of electrolytes were also assessed at the start and end of the RCA sessions. RESULTS: There were no clots in the RCA arm, with 79% (n = 19) in the saline flush arm having some clot, including 1 clotted circuit. Post-filter iCa2+ at various time points were within acceptable range. Electrolyte readings in the RCA group were all within normal limits except for 4 cases of total Calcium:iCa2+ ratio > 2.5. CONCLUSION: RCA is confirmed to be superior to saline flushes for circuit patency. We have a simple and safe protocol that can be followed for low flux haemodialysis. The study was approved by Singapore National Health Group domain-specific ethnical committee. NHG DSRB reference number 2014/01037. TRIAL REGISTRATION: Trial registration number: ISRCTN69952745 (registration date 8/11/17).

Outcomes of a nephrologist-driven tunnelled dialysis catheter insertion service in South East Asia.

INTRODUCTION: Tunnelled dialysis catheters (TDCs) are being increasingly inserted by nephrologists globally but there is limited experience and paucity of published outcomes data from South-East Asia (SEA). This study was conducted to analyse the outcomes of TDC insertion by nephrologists from a single centre in SEA. METHODS: All patients who underwent TDC insertion by nephrologists from October 2013 to June 2016 were included. TDC survival was calculated using Kaplan-Meier survival method. Impact of variables was assessed using Cox proportional hazards model. RESULTS: A total of 344 TDCs were inserted in 274 patients. The most common indication was haemodialysis initiation (60.2%) followed by existing catheter dysfunction (CD) (12.2%), failed vascular access (10.2%) and catheter-related bacteraemia (CRB) (9.9%). Insertion was successful in 97% patients. The most common location was the right internal jugular vein (87%). The cumulative survival for all TDCs inserted, as defined by the time to non-elective removal of a TDC, at 3, 6 and 9 months was 83%, 61%, and 44%, respectively. Median catheter survival was 231 days. Common indications for removal were CD (13.4%) and CRB or suspected infection (12.5%). Common complications were bleeding (8.72%), infection (13.7%) and CD (16.5%). Median time to infection was 103 days. In multivariate analysis, male gender was associated with poor catheter survival, for primary insertions (p = 0.015, HR 0.62) and diabetes was associated with TDC infection (p = 0.024, OR 1.1). CONCLUSIONS: This is one of the first reports of TDC insertion by nephrologists from SEA. Our outcomes compare favourably with those reported in the literature.

Effectiveness of a day care program in supporting patients on peritoneal dialysis and their caregivers.

PURPOSE: Physical inactivity and social isolation are major problems faced by peritoneal dialysis (PD) patients. Respite care is also an unmet need for their caregivers. The study aimed to evaluate the benefits of day care service for PD patients. METHOD: Khoo Teck Puat Hospital collaborated with St Luke's Eldercare (SLEC) to provide day care services for PD patients. The day care provided assistance with two PD exchanges and activities for patients to maintain health and improve social interaction. Outcome indicators included: (1) enrollment status, length of stay and peritonitis rate; (2) quality of life and mental status evaluations on patients and caregivers with the 12-item Short-Form Health Survey, Hospital Anxiety and Depression Scale and Zarit Burden Interview Short-Form 12; and (3) qualitative data collected via interviews with patients, caregivers, healthcare providers and SLEC staff. RESULTS: Sixty-four patients were referred, and 16 eventually participated. Mean age of participants was 67.2 (range 54-85) years. For patients who stayed >1 month (n = 9), length of stay was 205.0 days (58-428) and frequency of attendance was 2.9 (0.6-4.8) times/week. There were no peritonitis episodes while patients were in the program. Mental improvement was noticed for most patients and caregivers, but physical improvement was less obvious. Caregivers also felt less burden. CONCLUSIONS: Day care service is effective in alleviating the burden of caregivers and beneficial to patients with relatively good functional status. However, persuading patients and their caregivers to take up the program was a challenge.

Transjugular tunnelled dialysis catheter tip placement into the inferior vena cava upper segment after length overestimation.

PURPOSE: The right atrium is preferred over the superior vena cava (SVC) for tunnelled dialysis catheter (TDC) tip placement as it offers the best compromise between optimal catheter performance and complications. However, clinical practice guidelines are not all unanimous on this as a universal recommendation. Right atrial tip placement may also fail due to variations in body surface area, venous anatomy or TDC designs and lengths. Moreover, the presence of recurrent long intra-cardiac fibrin sheath or cardiac rhythm management device leads serves as contraindications. Extra-cardiac tip placement in the azygous, hepatic veins and lower segment of the inferior vena cava (IVC) is an alternative but is invariably associated with poor blood flow and shortened patency. METHODS: We report the concept of extra-cardiac tip placement into the larger calibre hepatic segment IVC via a transjugular approach in two diabetic haemodialysis patients with overestimated TDC length out of 380 insertions. RESULTS: Blood flow was maintained above 250 ml/min for 5-6 months and no tip migration ensued. CONCLUSIONS: The IVC upper segment is a reliable site for extra-cardiac tip placement in select cases but its safety and efficacy need to be further studied in larger clinical trials.

Trajectory of quality of life for poor prognosis stage 5D chronic kidney disease with and without dialysis.

BACKGROUND: Renal replacement therapy (RRT) has not always been shown to benefit end-stage renal failure patients who are elderly or have multiple comorbidities in terms of survival or symptom control. Conservative management may be a viable alternative offering comparable health-related quality of life. METHODS: This is a prospective observational study of 101 patients who reached an estimated glomerular filtration rate of 8-12 ml/min and were either ≥75 years old or had an age-adjusted Charlson Comorbidity Index ≥8. Patients were all initially on conservative management; 38 later commenced renal replacement therapy while the rest remained conservatively managed. The Kidney Disease Quality of Life-Short Form was assessed at baseline and various scheduled time points over 24 months. The mixed model methodology was used to estimate the quality of life patterns and adjust for covariates. RESULTS: In the conservative management group, the Physical Component Summary and Mental Component Summary scores were stable and showed no significantly different trajectories from the RRT group (both p > 0.05). Though RRT was associated with an improvement in the Cognitive Function Scale score, it was also associated with worse scores on the Effect of Kidney Disease and Burden of Kidney Disease Scale scores. CONCLUSIONS: RRT does not improve health-related quality of life of end-stage kidney failure patients who are elderly or have a high comorbidity burden.

Evaluation of adherence and depression among patients on peritoneal dialysis.

INTRODUCTION: It is challenging for dialysis patients to maintain adherence to their medical regimen, and symptoms of depression are prevalent among them. Limited data is available about adherence and depression among patients receiving peritoneal dialysis (PD). This study aimed to examine the rates of treatment non-adherence and depression in PD patients. METHODS: A total of 20 PD patients (response rate 71.4%; mean age 64.4 ± 11.6 years) were assessed using the Beliefs about Medicines Questionnaire, Self Efficacy for Managing Chronic Disease Scale, Hospital Anxiety and Depression Scale (HAD) and Kidney Disease Quality of Life-Short Form. A self-reported adherence (PD exchanges, medication and diet) scale developed for the study was also included. Medical information (e.g. most recent biochemistry results) was obtained from chart review. RESULTS: The mean self-reported scores indicated an overall high level of adherence, although a significant proportion of patients were non-adherent. Among the latter, 20% of patients were non-adherent to medication and 26% to diet due to forgetfulness, while 15% and 26% of patients admitted to deliberate non-adherence to medication and diet, respectively. Treatment modality, employment, self-care status and self-efficacy were associated with overall adherence. Using a cutoff point of 8 for HAD depression and anxiety subscales, 40% of patients were found to be depressed and 30% had symptoms of anxiety. CONCLUSION: This is the first study to document treatment adherence and depression among PD patients in Singapore. Findings of high prevalence of depression and anxiety, and reports of poor adherence warrant development of intervention programmes.

Measurement properties of the Chinese Version of the Kidney Disease Quality of Life-Short Form (KDQOL-SF™) in end-stage renal disease patients with poor prognosis in Singapore.

CONTEXT: The Kidney Disease Quality of Life (KDQOL™) instrument is widely used to assess care of end-stage renal disease (ESRD) patients. OBJECTIVES: This study aimed to demonstrate the measurement properties of the Chinese (simplified characters) version of the KDQOL-Short Form™ (KDQOL-SF™) in ethnic Chinese ESRD patients in Singapore. METHODS: Seventy-eight new ESRD patients, initially conservatively managed, were interviewed and followed-up; 31 later commenced dialysis. Quality of life (with the KDQOL-SF), Karnofsky Performance Status, and estimated glomerular filtration rate (eGFR) were assessed at 0, 3, 6, 9, 12, 18, and 24 months. Nonparametric statistics were used to assess correlation and changes. RESULTS: The patterns of descriptive summary and floor and ceiling effects were similar to those reported in the original English version. Most of the kidney disease-targeted scales and the generic scales of the KDQOL-SF demonstrated 1) criterion validity in terms of correlation with objectively measured and/or subjectively rated variables, 2) convergent/divergent validity in terms of correlation patterns between kidney disease-targeted and generic scales, and 3) responsiveness to change in terms of difference before and after dialysis, except for Work Status. Internal consistency reliability was satisfactory, but that for the Work Status scale was too low (alpha=0.32) and for two other kidney disease-targeted scales, Sexual Function and Dialysis Staff Encouragement, was too high (1.0). CONCLUSION: Most of the scales in the Chinese version of the KDQOL-SF were valid and achieved internal consistency reliability, except for the Work Status scale. Also, the internal consistency reliability of two disease-targeted scales was too high, suggesting room for reduction of some items to reduce burden on respondents.

Influence of ethnicity on health-related quality of life of hemodialysis patients in Singapore.

OBJECTIVES: The association between health-related quality of life (HRQoL) and ethnicity has been studied among hemodialysis (HD) patients in several countries with varying results. However, the effect of ethnicity on the HRQoL of HD patients in the Asian context has yet to be evaluated. This study seeks to examine the HRQoL of HD patients in Singapore and to understand the influence of ethnicity on their HRQoL. METHODS: A census-style survey inclusive of the KDQoL-SF. The AMA was conducted among all HD patients from 22 dialysis centers across Singapore. Multiple linear regression models were used to analyze the influence of ethnicity on each SF-36 scale while adjusting for the influence of socioeconomic status (SES) factors and other determinants of HRQoL. RESULTS: Data from 1,249 HD patients were analyzed. Response rate was 63.3%. Compared with other ethnicities, Chinese were most likely to report lower HRQoL. After adjusting for sex, age, and other possible determinants of HRQoL, the influence of ethnicity on HRQoL persisted, with significant mean differences in role-physical, general health, role-emotional, and physical component summary scales. CONCLUSIONS: After adjusting for demographic, SES, and other factors, ethnicity remained an important factor influencing HRQoL of Singaporean HD patients. Further studies are needed to identify modifiable factors that might explain the interethnic differences in HRQoL among HD patients.

What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?

AIM: Previous studies have focused either on advance medical directives rather than advance care planning (ACP), or on patient's perspectives on ACP rather than those of the health-care providers. This study aimed to explore the knowledge, attitudes and experience of renal health-care professionals in Singapore on ACP for patients with end-stage renal failure. METHODS: A 41-item questionnaire was distributed to physicians, nurses, medical social workers (MSW) and other allied health professionals working in renal units. The questionnaire had four sections: demographics of the respondents, knowledge of, attitudes to and experience with ACP. RESULTS: Of a total of 620 survey forms, 562 were returned, giving a response rate of 90.6%. Medical social workers and physicians had higher knowledge scores than the rest. Of doctors and MSW, 82.4% and 100%, respectively, considered ACP discussions as part of their role, but only 37.1% of nurses and 38.1% of other allied health-care professionals thought likewise. Nurses appeared to be the least confident in conducting ACP discussions, and most fearful of upsetting patients and families. Medical social workers were the most confident. The main barriers for physicians appeared to be lack of time, concerns regarding family backlash and the perception that patients were not prepared to discuss ACP. CONCLUSION: Training of renal health-care professionals in ACP should aim to correct misunderstandings surrounding ACP, address potential barriers and impart communication skills. In particular, renal nurses will need encouragement to initiate discussions and be equipped with the skills to do so.

Impact of changing trend in cold ischaemic time on operating times in renal transplantation.

INTRODUCTION: The European Working Time Directive (EWTD) is calling for reduction in the working hours of doctors. Renal transplantation is well-recognised as an out-of-hours specialty. Our study looks at whether our renal transplant centre's attempt to reduce cold ischaemic time (CIT) has impacted on the pattern of operating times since this may have implications on the surgeons' working hours. PATIENTS AND METHODS: We studied 883 adult cadaver kidney transplants performed between 1 January 1992 and 31 December 2002. CIT and time of surgery was obtained from a local audit database () and that held by UK Transplant. Time of surgery was divided into 07:30-17:59 (day),18:00-23:59 (evening) and 00:00-07:29 (night). RESULTS: CIT has decreased since 1992, with a significant reduction after 1998 (P = 0.0001). There was, however, no difference in the percentage of operations performed during the three time periods before and after 1998. Between 1999-2002, 51.4% of transplants took place out of hours (i.e. 18:00-07:29). CONCLUSIONS: Reduction in CIT does not appear to have impacted on our operating times. The large amount of out-of-hours work is, however, not compliant with EWTD requirements.

Cold ischemia time, surgeon, time of day, and surgical complications.

BACKGROUND: Surgical factors are an important cause of early renal allograft loss and contribute to patient morbidity and mortality. The United Kingdom National Confidential Enquiry into Peri-operative Deaths has reported that operating out of normal working hours was associated with higher patient mortality because of inexperienced surgeons. In this study, we looked into whether operating outside normal working hours or the grade of the surgeon affected the incidence of surgical complications. We also examined the relationship between cold ischemic time (CIT) and likelihood of surgical complications. PATIENTS AND METHODS: We performed a retrospective review of 322 adult recipients who received their first cadaver kidney transplant in our center between January 1, 1998 and June 30, 2001. Information on surgical complications were collected from patients' records. CIT, time of surgery, and grade of the operating surgeons was obtained from a local audit database (www.nwkta.org.) and the database held by UK Transplant. RESULTS: Surgical complication(s) were less likely to occur if one of the surgeons was a consultant (P =0.002). We found no association between cold storage and incidence of surgical complication(s). The median CIT was 21.30 (range 3.3-43.5) hours, n=229, in the group without complications compared with 21.80 (8.8-47.9) hours, n=77, for those with complications. The incidence of surgical complications was the same regardless of whether the operation took place during the day, evening, or night. CONCLUSIONS: Prolonged CIT and operating out of normal working hours did not increase the incidence of surgical complications. Presence of a consultant did, however, reduce the likelihood of a surgical complication occurring.

Expression of a functional asialoglycoprotein receptor in human renal proximal tubular epithelial cells.

BACKGROUND: The asialoglycoprotein receptor (ASGPR) is a C lectin which binds and endocytoses serum glycoproteins. In humans, the ASGPR is shown mainly to occur in hepatocytes, but does occur extrahepatically in thyroid, in small and large intestines, and in the testis. In the kidney, there has been evidence both for and against its existence in mesangial cells. METHODS: Standard light microscopy examination of renal tissue stained with an antibody against the ASGPR was performed. The mRNA expression for the ASGPR H1 and H2 subunits in primary human renal proximal tubular epithelial cells (RPTEC), in the human proximal tubular epithelial cell line HK2, and in human renal cortex was investigated using reverse-transcribed nested polymerase chain reaction. ASGPR protein expression as well as ligand binding and uptake were also examined using confocal microscopy and flow cytometry (fluorescence-activated cell sorting). RESULTS: Light microscopy of paraffin renal biopsy sections stained with a polyclonal antibody against the ASGPR showed proximal tubular epithelial cell staining of the cytoplasm and particularly in the basolateral region. Renal cortex and RPTEC specifically have mRNA for both H1 and H2 subunits of the ASGPR, but HK2 only expresses mRNA for H1. Using a monoclonal antibody, the presence of the ASGPR in RPTEC was shown by fluorescence-activated cell sorting and immunofluorescent staining. Specific binding and uptake of fluorescein isothiocyanate labelled asialofetuin which is a specific ASGPR ligand was also demonstrated in RPTEC. CONCLUSIONS: Primary renal proximal tubular epithelial cells have a functional ASGPR, consisting of the H1 and H2 subunits, that is capable of specific ligand binding and uptake.