Interventions to Improve Clinical Outcomes in Indigenous or Remote Patients With Chronic Kidney Disease: A Scoping Review.

BACKGROUND: Chronic kidney disease (CKD) associates with a significant health care burden with a disproportionate impact on indigenous persons or people living in remote areas. Although screening programs have expanded in these communities, there remains a paucity of evidence-based interventions to enhance clinical renal outcomes in these populations. OBJECTIVE: The objective of this study was to identify evidence-based interventions to enhance renal outcomes in these populations. DESIGN: A scoping review was conducted for studies in the Cochrane, MEDLINE, and Embase databases and from major nephrology meetings. SETTING: Chronic kidney disease, including those on dialysis. PATIENTS: Remote or indigenous populations. MEASUREMENTS: Studies that performed an intervention that was followed by measurement of renal outcomes or patient-centered outcomes (ie, quality of life) were included. METHODS: All studies were described by study type, intervention, and clinical outcome, and trends were identified by both authors. Meta-analysis was not conducted due to study heterogeneity. RESULTS: Thirty-two studies met inclusion criteria, only 2 (6.3%) of which were randomized controlled trials. Intervention types included multidisciplinary (34.4%), satellite (32.3%), telehealth (25.0%), or other (9.4%). All multidisciplinary interventions were performed in the CKD (non-dialysis) setting and reported improved patient travel time, waiting time, quality of life, kidney function, proteinuria, and blood pressure. Telehealth interventions improved program cost, patient attendance, hospitalization, and quality of life. Satellite interventions were performed in the hemodialysis setting, with 1 study evaluating acute hemodialysis. Satellite interventions improved patient travel time, dialysis clearance, quality of life, and survival, but increased program costs. LIMITATIONS: The study was restricted to interventional trials assessing clinical outcomes and to studies in developed countries, which likely excluded some research contributing to this field. CONCLUSIONS: There is significant heterogeneity among studies of interventions for patients with CKD who are indigenous or live remotely. Interventions were more likely to be successful when the remote or indigenous community was included in program development, with a culturally safe approach. More large, high-quality studies are needed to identify effective interventions to enhance clinical renal outcomes in indigenous or remote populations. TRIAL REGISTRATION: This trial is registered under PROSPERO, Registration Number 128453.

CONTEXTE: L'insuffisance rénale chronique (IRC) s'accompagne d'un fardeau de santé dont les répercussions touchent de façon disproportionnée les populations autochtones et les résidents des régions éloignées. Bien que les programmes de dépistage se soient répandus dans ces communautés, peu d'interventions fondées sur des données probantes et visant l'amélioration des issues rénales sont en place dans ces populations. OBJECTIF: Répertorier les interventions fondées sur des données probantes et visant l'amélioration des issues rénales dans ces populations. TYPE D'ÉTUDE: Une revue de cadrage menée dans les bases de données Cochrane, Medline et Embase, et à partir des principales conférences en néphrologie. CADRE: L'insuffisance rénale chronique, incluant les patients dialysés. SUJETS: Des patients autochtones ou résidents de régions éloignées. MESURES: Ont été incluses les études qui avaient procédé à une intervention suivie de la mesure des issues rénales ou des résultats axés sur le patient (ex. qualité de vie). MÉTHODOLOGIE: Les études ont été définies par le type d'étude, l'intervention et les résultats cliniques. Les tendances ont été déterminées par les auteurs. L'hétérogénéité des études n'a pas permis de procéder à une méta-analyse. RÉSULTATS: Trente-deux études satisfaisaient les critères d'inclusion, dont seulement deux (6,3 %) étaient des essais contrôlés à répartition aléatoire. L'intervention était multidisciplinaire (34,4 %), satellite (32,3 %), en télésanté (25,0 %) ou autre (9,4 %). Toutes les interventions multidisciplinaires avaient été faites en contexte d'IRC (sans dialyse) et avaient amélioré le temps de déplacement, le temps d'attente, la qualité de vie, la fonction rénale, la protéinurie et la pression artérielle du patient. Les interventions en télésanté avaient permis de réduire les coûts du programme et le nombre d'hospitalisations, tout en améliorant la participation du patient et sa qualité de vie. Les interventions satellites avaient été menées en contexte d'hémodialyse, et l'une d'elles évaluait l'hémodialyse aigüe. Les interventions satellites avaient amélioré la clairance par dialyse, ainsi que le temps de déplacement, la qualité de vie et la survie du patient, mais occasionnaient des coûts plus élevés. LIMITES: L'étude se limitait à des essais sur le terrain analysant les résultats cliniques et à des études en pays développés, ce qui a probablement exclu certaines études contribuant à ce domaine. CONCLUSION: On observe une importante hétérogénéité dans les études analysant les interventions en IRC tournées vers les patients d'origine autochtone ou de régions éloignées. Les interventions avaient plus de chances de réussite si les populations visées participaient à l'élaboration du programme, et si elles s'inscrivaient dans une approche respectueuse des valeurs culturelles. Des études robustes et de plus grande envergure sont nécessaires pour cibler les interventions qui permettent d'améliorer les issues rénales cliniques chez les populations autochtones ou éloignées.

ECG machine QTc intervals are inaccurate in hemodialysis patients.

BACKGROUND: Nephrologists need effective screening tools to identify hemodialysis patients at elevated risk for sudden cardiac death, the leading cause of death in this population. QTc intervals longer than 450 ms in males and 470 ms in females, measured by the gold standard tangent method (trueQTc), are prolonged and increase sudden cardiac death in healthy populations and patients with long QT syndrome. METHODS: We performed a retrospective ECG and chart review of hemodialysis patients. Our first objective was to determine if machine-measured QTc intervals (macQTc) could be used to identify dialysis patients with prolonged trueQTc. Our second objective was to determine at what macQTc could prolonged trueQTc be confidently diagnosed. RESULTS: macQTc differed from the trueQTc by an average of 16.54 ms, and by at least 20 ms in 46.8, 36.1, 53.6, 50.0 and 57.1% of all, short-hours daily hemodialysis, intermittent conventional hemodialysis, frequent nocturnal hemodialysis and intermittent nocturnal hemodialysis patients, respectively. The positive predictive value, negative predictive value, sensitivity and specificity of prolonged macQTc predicting prolonged trueQTc was 57.6, 92.6, 79.1 and 81.8%, respectively. Thus, macQTc is inaccurate at predicting the gold standard trueQTc in hemodialysis patients. macQTc greater than 480 ms in hemodialysis patients predicts trueQTc prolongation with a positive predictive value of 95.2%, but with a low sensitivity of 32.3%. CONCLUSION: In hemodialysis patients, ECG macQTc intervals are insufficiently sensitive or specific to predict prolonged trueQTc intervals, unless >480 ms.

Peritoneal dialysis versus hemodialysis in patients with delayed graft function.

Delayed graft function (DGF) in kidney transplantation affects adverse outcomes. It remains unclear whether the post-transplant dialysis modality alters perioperative or long-term graft outcomes. We performed a retrospective observational quality initiative at two Canadian renal transplant centers, in which DGF occurred in the recipient, necessitating one of peritoneal dialysis (PD) or hemodialysis (HD). There was no difference in baseline factors between patients with post-transplant PD (n = 14) or HD (n = 63). The use of PD was associated with an increased risk of wound infection/leakage (PD 5/14 vs. HD 6/63, p = 0.024), shorter length of hospitalization (13.7 vs. 18.7 d, p = 0.009) and time requiring dialysis post-operatively (6.5 vs 11.0 d, p = 0.043). There were no differences in readmission to hospital within 6 months (4/14 vs. 23/63, p = 0.759), graft loss (0/14 vs. 2/63, p = 1.000) or acute rejection episodes (1/14 vs. 4/63, p = 1.000) at one yr, and GFR did not differ between the PD or HD groups at 30 d (35.7 vs. 33.8 mL/min/m(2), p = 0.731), six months (46.9 vs. 45.5 mL/min/m(2), p = 0.835) or one yr (46.6 vs. 44.5 mL/min/m(2), p = 0.746). Further research is needed to determine which transplant patients are most appropriate to undergo PD catheter removal at the time of transplantation.

Dietary lipids alter the effect of steroids on the transport of fructose following intestinal resection in rats.

BACKGROUND: Glucocorticosteroids alter intestinal morphology and transport. We tested the hypothesis that the desired intestinal adaptive response following intestinal resection may be enhanced further by the locally active steroid budesonide, and by feeding a saturated as compared with a polyunsaturated fatty acid diet. METHODS: An in-vitro uptake method was used to assess intestinal fructose uptake by rats of semisynthetic diets enriched in saturated or polyunsaturated fatty acids, and injected with budesonide or control solution. RESULTS: Budesonide increased ileal fructose uptake in chow and PUFA-fed animals, but reduced jejunal fructose uptake in rats fed SFA. GLUT5 and GLUT2 protein and mRNA did not correlate with changes in fructose uptake. Steroids reduced jejunal proglucagon expression in animals fed chow. Animals fed SFA and given budesonide had a reduction in jejunal ODC mRNA compared with those fed PUFA or chow. CONCLUSIONS: (1) budesonide increases ileal fructose uptake following intestinal resection, and this beneficial effect is prevented by feeding SFA rather than PUFA; (2) fructose uptake does not correlate with GLUT5 and GLUT2 protein and mRNA; (3) ODC and proglucagon may be involved in this adaptive response.

The locally acting glucocorticosteroid budesonide enhances intestinal sugar uptake following intestinal resection in rats.

BACKGROUND AND AIMS: Locally and systemically acting corticosteroids alter the morphology and transport function of the intestine. This study was undertaken to assess the effect of budesonide, prednisone, and dexamethasone on sugar uptake. METHODS: Adult male Sprague Dawley rats underwent transection or resection of 50% of the middle portion of the small intestine, and in vitro uptake of sugars was measured. RESULTS: The 50% enterectomy did not alter jejunal or ileal uptake of glucose or fructose. Prednisone had no effect on the uptake of glucose or fructose in resected animals. In contrast, in resected rats budesonide increased by over 120% the value of the jejunal maximal transport rate for the uptake of glucose, and increased by over 150% ileal uptake of fructose. Protein abundance and mRNA expression of the sodium dependent glucose transporter in brush border membrane (SGLT1), sodium independent fructose transporter in the brush border membrane (GLUT5), sodium independent glucose and fructose transporter in the basolateral and brush border membranes (GLUT2), and Na(+)/K(+) ATPase alpha1 and beta1 did not explain the enhancing effect of budesonide on glucose or fructose uptake. Budesonide, prednisone, and dexamethasone reduced jejunal expression of the early response gene c-jun. In resected animals, expression of the mRNA of ornithine decarboxylase (ODC) in the jejunum was reduced, and corticosteroids reduced jejunal expression of the mRNA of proglucagon. CONCLUSIONS: These data suggest that the influence of corticosteroids on sugar uptake in resected animals may be achieved by post translational processes involving signalling with c-jun, ODC, and proglucagon, or other as yet unknown signals. It remains to be determined whether budesonide may be useful to stimulate the absorption of sugars following intestinal resection in humans.

Intestinal resection- and steroid-associated alterations in gene expression were not accompanied by changes in lipid uptake.

BACKGROUND/AIMS: Glucocorticosteroids alter the morphology and transport function of the intestine of adult rats. This study was undertaken to assess the possible effect on intestinal lipid uptake of the locally acting steroid budesonide, or the systemically active prednisone or dexamethasone. METHODS: Sprague-Dawley rats underwent intestinal transection or 50% intestinal resection. Budesonide, prednisone, dexamethasone, or control vehicle was given for 2 weeks from the time of surgery. Uptake was measured using ring uptake technique. RESULTS: Resection had no effect on the mRNA expression for the early response genes, for proglucagon, or for the ileal lipid binding protein (ILBP), but was associated with reduced jejunal ornithine decarboxylase (ODC) mRNA and with reduced jejunal mRNA for the liver fatty acid binding protein (L-FABP). All three steroids reduced jejunal mRNA for proglucagon and c-jun, and did not affect the mRNA for L-FABP or for ILBP. These resection- and steroid-associated changes in gene expression were not associated with alterations in the intestinal uptake of long chain fatty acids or cholesterol. CONCLUSIONS: The resection-associated alterations in the RNA expression of ODC and L-FABP and the steroid-associated changes in mRNA expression of c-jun and proglucagon were not accompanied by variations in lipid uptake.

Dietary lipids alter the effect of steroids on the uptake of lipids following intestinal resection in rats.

Steroids alter the transport function of the intestine. This study was undertaken to assess the effect of glucocorticosteroids on lipid uptake in rats fed either a saturated (SFA) or a polyunsaturated fatty acid (PUFA) diet. Sprague-Dawley rats underwent transection or 50% resection of the small intestine. The steroids had no effect on the uptake of lipids. However, resection decreased the jejunal uptake of palmitic acid in animals fed SFA and increased the jejunal uptake of palmitic and linoleic acids in those fed PUFA. In animals undergoing intestinal resection, fed SFA, and given control vehicle, there was a reduction in jejunal proglucagon mRNA expression as compared to those fed chow or PUFA. Ornithine decarboxylase (ODC) mRNA expression in the jejunum of resected animals was reduced. In summary, dietary lipids modify the uptake of lipids in resected animals and ODC and proglucagon may be involved in this adaptive response.