Publications by authors named "Peter G Kerr"

182 Publications

Attitudes and Practices of Australian Nephrologists Toward Implementation of Clinical Genomics.

Kidney Int Rep 2021 Feb 10;6(2):272-283. Epub 2020 Nov 10.

The KidGen Collaborative, Australian Genomics Health Alliance, Melbourne, Australia.

Introduction: Genomic testing is becoming widely available as a diagnostic tool, although widespread implementation is not yet established in nephrology.

Methods: An anonymous electronic survey was administered to investigate experience and confidence with genomic tests, perceived clinical utility of genomic services, preferences for service delivery models, and readiness for implementation among nephrologists. Questions were guided by a comprehensive literature review and published tools, including a validated theoretical framework for implementation of genomic medicine: Consolidated Framework for Implementation Research (CFIR).

Results: Responses were received from 224 clinicians, of which 172 were eligible for analysis. Most clinicians (132 [76%]) had referred at least one patient to a genetics clinic. Despite most clinicians (136 [85%]) indicating that they believed genetic testing would be useful, only 39 (23%) indicated they felt confident to use results of genomic testing, with pediatric clinicians feeling more confident compared with adult clinicians (12 of 20 [60%] vs. 27 of 149 [18%]),  < 0.01, Fisher exact). A multidisciplinary renal genetics clinic was the preferred model among clinicians surveyed (98 of 172 [57%]). A key implementation barrier highlighted related to the hospital or organizational culture and/or environment. Specific barriers noted in quantitative and qualitative responses included inadequate staffing, learning resources, and funding.

Conclusions: Our findings suggest support for genomic testing among nephrologists, with a strong preference for a multidisciplinary model (involving a nephrologist, clinical geneticist, and genetic counselor). Broad-ranging interventions are urgently required to shift the current culture and ensure successful implementation of genomics in nephrology, including reducing knowledge gaps, increased funding and resources, disease-specific guidelines, and streamlining of testing processes.
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http://dx.doi.org/10.1016/j.ekir.2020.10.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7879212PMC
February 2021

Relationship between measured and prescribed dialysate sodium in haemodialysis: a systematic review and meta-analysis.

Nephrol Dial Transplant 2021 Mar;36(4):695-703

The George Institute for Global Health, UNSW Sydney, Sydney, Australia.

Background: Dialysate sodium (DNa) prescription policy differs between haemodialysis (HD) units, and the optimal DNa remains uncertain. We sought to summarize the evidence on the agreement between prescribed and delivered DNa, and whether the relationship varied according to prescribed DNa.

Methods: We searched MEDLINE and PubMed from inception to 26 February 2020 for studies reporting measured and prescribed DNa. We analysed results reported in aggregate with random-effects meta-analysis. We analysed results reported by individual sample, using mixed-effects Bland-Altman analysis and linear regression. Pre-specified subgroup analyses included method of sodium measurement, dialysis machine manufacturer and proportioning method.

Results: Seven studies, representing 908 dialysate samples from 10 HD facilities (range 16-133 samples), were identified. All but one were single-centre studies. Studies were of low to moderate quality. Overall, there was no statistically significant difference between measured and prescribed DNa {mean difference = 0.73 mmol/L [95% confidence interval (CI) -1.12 to 2.58; P = 0.44]} but variability across studies was substantial (I2 = 99.3%). Among individually reported samples (n = 295), measured DNa was higher than prescribed DNa by 1.96 mmol/L (95% CI 0.23-3.69) and the 95% limits of agreement ranged from -3.97 to 7.88 mmol/L. Regression analysis confirmed a strong relationship between prescribed and measured DNa, with a slope close to 1:1 (β = 1.16, 95% CI 1.06-1.27; P < 0.0001).

Conclusions: A limited number of studies suggest that, on average, prescribed and measured DNa are similar. However, between- and within-study differences were large. Further consideration of the precision of delivered DNa is required to inform rational prescribing.
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http://dx.doi.org/10.1093/ndt/gfaa287DOI Listing
March 2021

Availability, coverage, and scope of health information systems for kidney care across world countries and regions.

Nephrol Dial Transplant 2020 Dec 22. Epub 2020 Dec 22.

Department of Medicine, Faculty of Medicine, King Chulalong Memorial Hospital, Chulalongkorn University, Bangkok,Thailand.

Background: Health information systems (HIS) are fundamental tools for the surveillance of health services, estimation of disease burden and prioritization of health resources. Several gaps in the availability of HIS for kidney disease were highlighted by the first iteration of the Global Kidney Health Atlas.

Methods: As part of its second iteration, the International Society of Nephrology conducted a cross-sectional global survey between July and October 2018 to explore the coverage and scope of HIS for kidney disease, with a focus on kidney replacement therapy (KRT).

Results: Out of a total of 182 invited countries, 154 countries responded to questions on HIS (85% response rate). KRT registries were available in almost all high-income countries, but few low-income countries, while registries for non-dialysis chronic kidney disease (CKD) or acute kidney injury (AKI) were rare. Registries in high-income countries tended to be national, in contrast to registries in low-income countries, which often operated at local or regional levels. Although cause of end-stage kidney disease, modality of KRT and source of kidney transplant donors were frequently reported, few countries collected data on patient-reported outcome measures and only half of low-income countries recorded process-based measures. Almost no countries had programs to detect AKI and practices to identify CKD-targeted individuals with diabetes, hypertension and cardiovascular disease, rather than members of high-risk ethnic groups.

Conclusions: These findings confirm significant heterogeneity in the global availability of HIS for kidney disease and highlight important gaps in their coverage and scope, especially in low-income countries and across the domains of AKI, non-dialysis CKD, patient-reported outcomes, process-based measures and quality indicators for KRT service delivery.
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http://dx.doi.org/10.1093/ndt/gfaa343DOI Listing
December 2020

Home and facility haemodialysis patients: a comparison of outcomes in a matched cohort.

Nephrol Dial Transplant 2020 Dec 11. Epub 2020 Dec 11.

Monash Health, Clayton, Victoria, Australia.

Background: Home haemodialysis (HHD) is utilised significantly less often than facility haemodialysis globally with few exceptions despite being associated with improved survival, and better quality of life. Previously, HHD was exclusively offered to younger patients with few comorbidities. However, with the increasing burden of end-stage kidney disease (ESKD) alongside an ageing population, increasing numbers of older patients are being treated with HHD. This study aims to re-evaluate survival and related outcomes in the context of this epidemiological shift.

Methods: A matched cohort design was used to compare all-cause mortality, transplantation, average biochemical values and graft survival 6 months post-transplant between HHD and facility haemodialysis patients. 181 HHD patients from a major hospital network were included, with 413 facility haemodialysis patients from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) matched by age, gender, and cause of ESKD. Survival analysis and competing risks analysis (for transplantation) were performed.

Results: After adjusting for BMI, smoking status, racial group, and comorbidities, HHD was associated with significantly reduced risk of death compared to facility HD patients (HR = 0.47, 95% CI 0.30-0.74). Transplantation rates were comparable, with high rates of graft survival at 6 months in both groups. Haemoglobin, calcium, and parathyroid hormone levels did not vary significantly. However, home HD patients had significantly lower phosphate levels.

Conclusions: In this study, improved survival outcomes were observed in patients on home compared to facility dialysis, with comparable rates of transplantation, graft survival and biochemical control.
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http://dx.doi.org/10.1093/ndt/gfaa358DOI Listing
December 2020

Patient and caregiver perspectives on burnout in peritoneal dialysis.

Perit Dial Int 2020 Nov 11:896860820970064. Epub 2020 Nov 11.

Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA.

Background: Peritoneal dialysis (PD) can offer patients more autonomy and flexibility compared with in-center hemodialysis (HD). However, burnout - defined as mental, emotional, or physical exhaustion that leads to thoughts of discontinuing PD - is associated with an increased risk of transfer to HD. We aimed to describe the perspectives of burnout among patients on PD and their caregivers.

Methods: In this focus group study, 81 patients and 45 caregivers participated in 14 focus groups from 9 dialysis units in Australia, Hong Kong, and the United States. Transcripts were analyzed thematically.

Results: We identified two themes. contributed to burnout, as patients and caregivers felt overwhelmed by the daily regimen, perceived their life to be coming to a halt, tolerated the PD regimen for survival, and had to bear the burden and uncertainty of what to expect from PD alone. against burnout encompassed establishing a new normal, drawing inspiration and support from family, relying on faith and hope for motivation, and finding meaning in other activities.

Conclusions: For patients on PD and their caregivers, burnout was intensified by perceiving PD as an unrelenting, isolating responsibility that they had no choice but to endure, even if it held them back from doing other activities in life. More emphasis on developing strategies to adapt and build resilience could prevent or minimize burnout.
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http://dx.doi.org/10.1177/0896860820970064DOI Listing
November 2020

Home based therapies: can wishes be realized?

Nephrol Dial Transplant 2020 11;35(11):1836-1839

Department of Nephrology, Monash Medical Centre, Monash University, Clayton, Victoria, Australia.

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http://dx.doi.org/10.1093/ndt/gfaa082DOI Listing
November 2020

The impact of the Christmas holiday effect on interdialytic weight gain in hemodialysis patients: A multicenter observational retrospective cohort study.

Hemodial Int 2021 Apr 3;25(2):257-264. Epub 2020 Nov 3.

Department of Nephrology, Monash Health, Melbourne, Victoria, Australia.

Introduction: The 3-day interdialytic interval (IDI) is associated with high interdialytic weight gain (IDWG), but little is known about the effect of public or religious holidays on IDWG. Consequently, we evaluated the impact of the "Christmas holiday effect" on IDWG of hemodialysis patients.

Methods: A retrospective cohort study of adult hemodialysis patients (over 18 years) was conducted across five dialysis units in Australia. Demographic and clinical data were collected from electronic medical records. IDWG was established for three time points; regular 3-day IDI, 2-day IDI preceding the Christmas holiday and a 3-day IDI that included the Christmas holiday. Paired t-tests and logistic regression were used to compare differences in mean IDWG before and after the Christmas holiday and to examine factors associated with high IDWG, respectively.

Findings: Two hundred and fifty-two patients, 69% of whom were male, with mean (SD) age of 65.4 ± 15.3 years, were studied. Most had end-stage kidney disease due to diabetes (44%), and they had been on hemodialysis for a median of 25.5 (IQR, 60-10) months. There was a significant increase in absolute IDWG (MD 0.21 kg, 95% CI -0.07 to 0.36; P = 0.004) and relative IDWG (MD 0.3%, 95% CI 0.10-0.40; P = 0.01) after the holiday 3-day IDI compared with the regular 3-day IDI. Older age (OR 0.12; 95% CI 0.02-0.55) and a unit increase in hemoglobin (OR 0.94; 95% CI 0.89-0.99) were associated with lower odds of high relative IDWG while speaking a language other than English increased the odds for high relative IDWG (OR 5.03; 95% CI 1.12-22.65).

Conclusion: Absolute and relative IDWG increased significantly after the Christmas holiday. Individualizing dialysis needs may improve outcomes for these patients.
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http://dx.doi.org/10.1111/hdi.12901DOI Listing
April 2021

Long-Term Graft and Patient Outcomes Following Kidney Transplantation in End-Stage Kidney Disease Secondary to Hyperoxaluria.

Transplant Proc 2021 Apr 24;53(3):839-847. Epub 2020 Sep 24.

School of Medicine, University of Melbourne, Parkville, Victoria, Australia; Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia.

Background: End-stage kidney disease secondary to hyperoxaluria presents a major challenge for transplant physicians given concern regarding disease recurrence. Few contemporary studies have reported long-term outcomes following transplantation in this population.

Methods: This study examined the outcomes of all adult patients with end-stage kidney disease secondary to hyperoxaluria who received a kidney or combined liver-kidney transplant in Australia and New Zealand between 1965 and 2015. Patients with hyperoxaluria were propensity score matched to control patients with reflux nephropathy. The primary outcome was graft survival. Secondary outcomes included graft function, acute rejection, and patient survival.

Results: Nineteen transplants performed in 16 patients with hyperoxaluria were matched to 57 transplants in patients with reflux nephropathy. Graft survival was inferior in patients with hyperoxaluria receiving a kidney transplant alone (subhazard ratio [SHR] = 3.83, 95% confidence interval [CI], 1.22-12.08, P = .02) but not in those receiving a combined liver-kidney transplant (SHR = 0.63, 95% CI, 0.08-5.21, P = .67). Graft failure risk was particularly high in patients with hyperoxaluria receiving a kidney transplant alone after more than 1 year of renal replacement therapy (SHR = 8.90, 95% CI, 2.35-33.76, P = .001). Posttransplant estimated glomerular filtration rate was lower in patients with hyperoxaluria (10.97 mL/min/1.73 m, 95% CI, 0.53-21.42, P = .04). There was no difference between groups in the risk of acute rejection or death with a functioning graft.

Conclusion: Compared to reflux nephropathy, hyperoxaluria was associated with inferior graft survival in patients receiving a kidney transplant alone. Long-term graft function was lower in patients with hyperoxaluria, but the risks of acute rejection and death were not different.
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http://dx.doi.org/10.1016/j.transproceed.2020.08.028DOI Listing
April 2021

Clinical impact of genomic testing in patients with suspected monogenic kidney disease.

Genet Med 2021 Jan 17;23(1):183-191. Epub 2020 Sep 17.

Murdoch Children's Research Institute, Melbourne, Australia.

Purpose: To determine the diagnostic yield and clinical impact of exome sequencing (ES) in patients with suspected monogenic kidney disease.

Methods: We performed clinically accredited singleton ES in a prospectively ascertained cohort of 204 patients assessed in multidisciplinary renal genetics clinics at four tertiary hospitals in Melbourne, Australia.

Results: ES identified a molecular diagnosis in 80 (39%) patients, encompassing 35 distinct genetic disorders. Younger age at presentation was independently associated with an ES diagnosis (p < 0.001). Of those diagnosed, 31/80 (39%) had a change in their clinical diagnosis. ES diagnosis was considered to have contributed to management in 47/80 (59%), including negating the need for diagnostic renal biopsy in 10/80 (13%), changing surveillance in 35/80 (44%), and changing the treatment plan in 16/80 (20%). In cases with no change to management in the proband, the ES result had implications for the management of family members in 26/33 (79%). Cascade testing was subsequently offered to 40/80 families (50%).

Conclusion: In this pragmatic pediatric and adult cohort with suspected monogenic kidney disease, ES had high diagnostic and clinical utility. Our findings, including predictors of positive diagnosis, can be used to guide clinical practice and health service design.
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http://dx.doi.org/10.1038/s41436-020-00963-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7790755PMC
January 2021

A Randomized Trial on the Effect of Phosphate Reduction on Vascular End Points in CKD (IMPROVE-CKD).

J Am Soc Nephrol 2020 11 11;31(11):2653-2666. Epub 2020 Sep 11.

Australasian Kidney Trials Network, The University of Queensland, Brisbane, Queensland, Australia.

Background: Hyperphosphatemia is associated with increased fibroblast growth factor 23 (FGF23), arterial calcification, and cardiovascular mortality. Effects of phosphate-lowering medication on vascular calcification and arterial stiffness in CKD remain uncertain.

Methods: To assess the effects of non-calcium-based phosphate binders on intermediate cardiovascular markers, we conducted a multicenter, double-blind trial, randomizing 278 participants with stage 3b or 4 CKD and serum phosphate >1.00 mmol/L (3.10 mg/dl) to 500 mg lanthanum carbonate or matched placebo thrice daily for 96 weeks. We analyzed the primary outcome, carotid-femoral pulse wave velocity, using a linear mixed effects model for repeated measures. Secondary outcomes included abdominal aortic calcification and serum and urine markers of mineral metabolism.

Results: A total of 138 participants received lanthanum and 140 received placebo (mean age 63.1 years; 69% male, 64% White). Mean eGFR was 26.6 ml/min per 1.73 m; 45% of participants had diabetes and 32% had cardiovascular disease. Mean serum phosphate was 1.25 mmol/L (3.87 mg/dl), mean pulse wave velocity was 10.8 m/s, and 81.3% had abdominal aortic calcification at baseline. At 96 weeks, pulse wave velocity did not differ significantly between groups, nor did abdominal aortic calcification, serum phosphate, parathyroid hormone, FGF23, and 24-hour urinary phosphate. Serious adverse events occurred in 63 (46%) participants prescribed lanthanum and 66 (47%) prescribed placebo. Although recruitment to target was not achieved, additional analysis suggested this was unlikely to have significantly affected the principle findings.

Conclusions: In patients with stage 3b/4 CKD, treatment with lanthanum over 96 weeks did not affect arterial stiffness or aortic calcification compared with placebo. These findings do not support the role of intestinal phosphate binders to reduce cardiovascular risk in patients with CKD who have normophosphatemia.

Clinical Trial Registry Name And Registration Number: Australian Clinical Trials Registry, ACTRN12610000650099.
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http://dx.doi.org/10.1681/ASN.2020040411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7608977PMC
November 2020

Peritoneal Dialysis Use and Practice Patterns: An International Survey Study.

Am J Kidney Dis 2021 03 12;77(3):315-325. Epub 2020 Aug 12.

Department of Nephrology, General University Hospital, Charles University, Prague, Czech Republic.

Rationale & Objective: Approximately 11% of people with kidney failure worldwide are treated with peritoneal dialysis (PD). This study examined PD use and practice patterns across the globe.

Study Design: A cross-sectional survey.

Setting & Participants: Stakeholders including clinicians, policy makers, and patient representatives in 182 countries convened by the International Society of Nephrology between July and September 2018.

Outcomes: PD use, availability, accessibility, affordability, delivery, and reporting of quality outcome measures.

Analytical Approach: Descriptive statistics.

Results: Responses were received from 88% (n=160) of countries and there were 313 participants (257 nephrologists [82%], 22 non-nephrologist physicians [7%], 6 other health professionals [2%], 17 administrators/policy makers/civil servants [5%], and 11 others [4%]). 85% (n=156) of countries responded to questions about PD. Median PD use was 38.1 per million population. PD was not available in 30 of the 156 (19%) countries responding to PD-related questions, particularly in countries in Africa (20/41) and low-income countries (15/22). In 69% of countries, PD was the initial dialysis modality for≤10% of patients with newly diagnosed kidney failure. Patients receiving PD were expected to pay 1% to 25% of treatment costs, and higher (>75%) copayments (out-of-pocket expenses incurred by patients) were more common in South Asia and low-income countries. Average exchange volumes were adequate (defined as 3-4 exchanges per day or the equivalent for automated PD) in 72% of countries. PD quality outcome monitoring and reporting were variable. Most countries did not measure patient-reported PD outcomes.

Limitations: Low responses from policy makers; limited ability to provide more in-depth explanations underpinning outcomes from each country due to lack of granular data; lack of objective data.

Conclusions: Large inter- and intraregional disparities exist in PD availability, accessibility, affordability, delivery, and reporting of quality outcome measures around the world, with the greatest gaps observed in Africa and South Asia.
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http://dx.doi.org/10.1053/j.ajkd.2020.05.032DOI Listing
March 2021

Hemodialysis Use and Practice Patterns: An International Survey Study.

Am J Kidney Dis 2021 03 13;77(3):326-335.e1. Epub 2020 Aug 13.

Department of Medicine, Faculty of Medicine, King Chulalong Memorial Hospital, Chulalongkorn University, Bangkok, Thailand; Bhumirajanagarindra Kidney Institute, Bangkok, Thailand.

Rationale & Objective: Hemodialysis (HD) is the most common form of kidney replacement therapy. This study aimed to examine the use, availability, accessibility, affordability, and quality of HD care worldwide.

Study Design: A cross-sectional survey.

Setting & Participants: Stakeholders (clinicians, policy makers, and consumer representatives) in 182 countries were convened by the International Society of Nephrology from July to September 2018.

Outcomes: Use, availability, accessibility, affordability, and quality of HD care.

Analytical Approach: Descriptive statistics.

Results: Overall, representatives from 160 (88%) countries participated. Median country-specific use of maintenance HD was 298.4 (IQR, 80.5-599.4) per million population (pmp). Global median HD use among incident patients with kidney failure was 98.0 (IQR, 81.5-140.8) pmp and median number of HD centers was 4.5 (IQR, 1.2-9.9) pmp. Adequate HD services (3-4 hours 3 times weekly) were generally available in 27% of low-income countries. Home HD was generally available in 36% of high-income countries. 32% of countries performed monitoring of patient-reported outcomes; 61%, monitoring of small-solute clearance; 60%, monitoring of bone mineral markers; 51%, monitoring of technique survival; and 60%, monitoring of patient survival. At initiation of maintenance dialysis, only 5% of countries used an arteriovenous access in almost all patients. Vascular access education was suboptimal, funding for vascular access procedures was not uniform, and copayments were greater in countries with lower levels of income. Patients in 23% of the low-income countries had to pay >75% of HD costs compared with patients in only 4% of high-income countries.

Limitations: A cross-sectional survey with possibility of response bias, social desirability bias, and limited data collection preventing in-depth analysis.

Conclusions: In summary, findings reveal substantial variations in global HD use, availability, accessibility, quality, and affordability worldwide, with the lowest use evident in low- and lower-middle-income countries.
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http://dx.doi.org/10.1053/j.ajkd.2020.05.030DOI Listing
March 2021

Identifying Outcomes Important to Patients with Glomerular Disease and Their Caregivers.

Clin J Am Soc Nephrol 2020 05 30;15(5):673-684. Epub 2020 Apr 30.

Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia.

Background And Objectives: Shared decision making in patients with glomerular disease remains challenging because outcomes important to patients remain largely unknown. We aimed to identify and prioritize outcomes important to patients and caregivers and to describe reasons for their choices.

Design: We purposively sampled adult patients with glomerular disease and their caregivers from Australia, Hong Kong, the United Kingdom, and the United States. Participants identified, discussed, and ranked outcomes in focus groups using the nominal group technique; a relative importance score (between zero and one) was calculated. Qualitative data were analyzed thematically.

Results: Across 16 focus groups, 134 participants (range, 19-85 years old; 51% women), including 101 patients and 33 caregivers, identified 58 outcomes. The ten highest-ranked outcomes were kidney function (importance score of 0.42), mortality (0.29), need for dialysis or transplant (0.22), life participation (0.18), fatigue (0.17), anxiety (0.13), family impact (0.12), infection and immunity (0.12), ability to work (0.11), and BP (0.11). Three themes explained the reasons for these rankings: constraining day-to-day experience, impaired agency and control over health, and threats to future health and family.

Conclusions: Patients with glomerular disease and their caregivers highly prioritize kidney health and survival, but they also prioritize life participation, fatigue, anxiety, and family impact.
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http://dx.doi.org/10.2215/CJN.13101019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7269216PMC
May 2020

Placental Pathology in Pregnancies After Kidney Transplantation.

Transplantation 2020 07;104(7):e214-e215

Department of Nephrology, Monash Health and Monash University, Clayton, Australia.

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http://dx.doi.org/10.1097/TP.0000000000003119DOI Listing
July 2020

Health-related quality of life among patients with comorbid diabetes and kidney disease attending a codesigned integrated model of care: a longitudinal study.

BMJ Open Diabetes Res Care 2020 01;8(1)

School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia

Objective: To evaluate the impact of an integrated diabetes and kidney disease model of care on health-related quality of life (HRQOL) of patients with comorbid diabetes and chronic kidney disease (CKD).

Research Design And Methods: A longitudinal study of adult patients (over 18 years) with comorbid diabetes and CKD (stage 3a or worse) who attended a new diabetes kidney disease service was conducted at a tertiary hospital. A questionnaire consisting of demographics, clinical data, and the Kidney Disease Quality of Life (KDQOL-36) was administered at baseline and after 12 months. Paired t-tests were used to compare baseline and 12-month scores. A subgroup analysis examined the effects by patient gender. Multiple regression analysis examined the factors associated with changes in scores.

Results: 179 patients, 36% of whom were female, with baseline mean±SD age of 65.9±11.3 years, were studied. Across all subscales, HRQOL did not significantly change over time (p value for all mean differences >0.05). However, on subgroup analysis, symptom problem list and physical composite summary scores increased among women (MD=9.0, 95% CI 1.25 to 16.67; p=0.02 and MD=4.5, 95% CI 0.57 to 8.42; p=0.03 respectively) and physical composite scores decreased among men (MD=-3.35, 95% CI -6.26 to -0.44; p=0.03).

Conclusion: The HRQOL of patients with comorbid diabetes and CKD attending a new codesigned, integrated diabetes and kidney disease model of care was maintained over 12 months. Given that HRQOL is known to deteriorate over time in this high-risk population, the impact of these findings on clinical outcomes warrants further investigation.
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http://dx.doi.org/10.1136/bmjdrc-2019-000842DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6954749PMC
January 2020

Smad4 promotes diabetic nephropathy by modulating glycolysis and OXPHOS.

EMBO Rep 2020 02 9;21(2):e48781. Epub 2020 Jan 9.

Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China.

Diabetic nephropathy (DN) is the leading cause of end-stage kidney disease. TGF-β1/Smad3 signalling plays a major pathological role in DN; however, the contribution of Smad4 has not been examined. Smad4 depletion in the kidney using anti-Smad4 locked nucleic acid halted progressive podocyte damage and glomerulosclerosis in mouse type 2 DN, suggesting a pathogenic role of Smad4 in podocytes. Smad4 is upregulated in human and mouse podocytes during DN. Conditional Smad4 deletion in podocytes protects mice from type 2 DN, independent of obesity. Mechanistically, hyperglycaemia induces Smad4 localization to mitochondria in podocytes, resulting in reduced glycolysis and oxidative phosphorylation and increased production of reactive oxygen species. This operates, in part, via direct binding of Smad4 to the glycolytic enzyme PKM2 and reducing the active tetrameric form of PKM2. In addition, Smad4 interacts with ATPIF1, causing a reduction in ATPIF1 degradation. In conclusion, we have discovered a mitochondrial mechanism by which Smad4 causes diabetic podocyte injury.
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http://dx.doi.org/10.15252/embr.201948781DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7001498PMC
February 2020

Risk factors for foot ulceration in adults with end-stage renal disease on dialysis: a prospective observational cohort study.

BMC Nephrol 2019 11 21;20(1):423. Epub 2019 Nov 21.

Discipline of Podiatry, School of Allied Health, Health Services and Sport, La Trobe University, Melbourne, Victoria, 3086, Australia.

Background: Dialysis patients experience high rates of foot ulceration. Although risk factors for ulceration have been extensively studied in patients with diabetes, there is limited high-quality, longitudinal evidence in the dialysis population. Therefore, this study investigated risk factors for foot ulceration in a stable dialysis cohort.

Methods: We prospectively collected clinical, demographic, health status, and foot examination information on 450 adults with end-stage renal disease from satellite and home-therapy dialysis units in Melbourne, Australia over 12 months. The primary outcome was foot ulceration. Cox proportional hazard modelling and multinomial regression were used to investigate risk factors.

Results: Among 450 dialysis patients (mean age, 67.5 years; 64.7% male; 94% hemodialysis; 50.2% diabetes), new cases of foot ulceration were identified in 81 (18%) participants. Overall, risk factors for foot ulceration were neuropathy (HR 3.02; 95% CI 1.48 to 6.15) and previous ulceration (HR 2.86; CI 1.53 to 5.34). In those without history of ulceration, nail pathology (RR 3.85; CI 1.08 to 13.75) and neuropathy (RR 2.66; CI 1.04 to 6.82) were risk factors. In those with history of ulceration, neuropathy (RR 11.23; CI 3.16 to 39.87), peripheral arterial disease (RR 7.15; CI 2.24 to 22.82) and cerebrovascular disease (RR 2.08; CI 1.04 to 4.16) were risk factors. There were 12 (2.7%) new amputations, 96 (21.3%) infections, 24 (5.3%) revascularizations, 42 (9.3%) foot-related hospitalizations, and 52 (11.6%) deaths.

Conclusions: Neuropathy and previous ulceration are major risk factors for foot ulceration in dialysis patients. Risk factors differ between those with and without prior ulceration. The risk factors identified will help to reduce the incidence of ulceration and its associated complications.
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http://dx.doi.org/10.1186/s12882-019-1594-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868750PMC
November 2019

Status of care for end stage kidney disease in countries and regions worldwide: international cross sectional survey.

BMJ 2019 10 31;367:l5873. Epub 2019 Oct 31.

Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand.

Objective: To determine the global capacity (availability, accessibility, quality, and affordability) to deliver kidney replacement therapy (dialysis and transplantation) and conservative kidney management.

Design: International cross sectional survey.

Setting: International Society of Nephrology (ISN) survey of 182 countries from July to September 2018.

Participants: Key stakeholders identified by ISN's national and regional leaders.

Main Outcome Measures: Markers of national capacity to deliver core components of kidney replacement therapy and conservative kidney management.

Results: Responses were received from 160 (87.9%) of 182 countries, comprising 97.8% (7338.5 million of 7501.3 million) of the world's population. A wide variation was found in capacity and structures for kidney replacement therapy and conservative kidney management-namely, funding mechanisms, health workforce, service delivery, and available technologies. Information on the prevalence of treated end stage kidney disease was available in 91 (42%) of 218 countries worldwide. Estimates varied more than 800-fold from 4 to 3392 per million population. Rwanda was the only low income country to report data on the prevalence of treated disease; 5 (<10%) of 53 African countries reported these data. Of 159 countries, 102 (64%) provided public funding for kidney replacement therapy. Sixty eight (43%) of 159 countries charged no fees at the point of care delivery and 34 (21%) made some charge. Haemodialysis was reported as available in 156 (100%) of 156 countries, peritoneal dialysis in 119 (76%) of 156 countries, and kidney transplantation in 114 (74%) of 155 countries. Dialysis and kidney transplantation were available to more than 50% of patients in only 108 (70%) and 45 (29%) of 154 countries that offered these services, respectively. Conservative kidney management was available in 124 (81%) of 154 countries. Worldwide, the median number of nephrologists was 9.96 per million population, which varied with income level.

Conclusions: These comprehensive data show the capacity of countries (including low income countries) to provide optimal care for patients with end stage kidney disease. They demonstrate substantial variability in the burden of such disease and capacity for kidney replacement therapy and conservative kidney management, which have implications for policy.
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http://dx.doi.org/10.1136/bmj.l5873DOI Listing
October 2019

mTOR-mediated podocyte hypertrophy regulates glomerular integrity in mice and humans.

JCI Insight 2019 09 19;4(18). Epub 2019 Sep 19.

Prostate Cancer Translational Research Laboratory, Peter MacCallum Cancer Centre.

The cellular origins of glomerulosclerosis involve activation of parietal epithelial cells (PECs) and progressive podocyte depletion. While mammalian target of rapamycin-mediated (mTOR-mediated) podocyte hypertrophy is recognized as an important signaling pathway in the context of glomerular disease, the role of podocyte hypertrophy as a compensatory mechanism preventing PEC activation and glomerulosclerosis remains poorly understood. In this study, we show that glomerular mTOR and PEC activation-related genes were both upregulated and intercorrelated in biopsies from patients with focal segmental glomerulosclerosis (FSGS) and diabetic nephropathy, suggesting both compensatory and pathological roles. Advanced morphometric analyses in murine and human tissues identified podocyte hypertrophy as a compensatory mechanism aiming to regulate glomerular functional integrity in response to somatic growth, podocyte depletion, and even glomerulosclerosis - all of this in the absence of detectable podocyte regeneration. In mice, pharmacological inhibition of mTOR signaling during acute podocyte loss impaired hypertrophy of remaining podocytes, resulting in unexpected albuminuria, PEC activation, and glomerulosclerosis. Exacerbated and persistent podocyte hypertrophy enabled a vicious cycle of podocyte loss and PEC activation, suggesting a limit to its beneficial effects. In summary, our data highlight a critical protective role of mTOR-mediated podocyte hypertrophy following podocyte loss in order to preserve glomerular integrity, preventing PEC activation and glomerulosclerosis.
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http://dx.doi.org/10.1172/jci.insight.99271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6795295PMC
September 2019

Isolated proteinuria due to CUBN homozygous mutation - challenging the investigative paradigm.

BMC Nephrol 2019 08 22;20(1):330. Epub 2019 Aug 22.

Murdoch Children's Research Institute, Melbourne, Australia.

Background: Proteinuria is a common clinical presentation, the diagnostic workup for which involves many non-invasive and invasive investigations. We report on two siblings that highlight the clinically relevant functional role of cubulin for albumin resorption in the proximal tubule and supports the use of genomic sequencing early in the diagnostic work up of patients who present with proteinuria.

Case Presentation: An 8-year-old boy was referred with an incidental finding of proteinuria. All preliminary investigations were unremarkable. Further assessment revealed consanguineous family history and a brother with isolated proteinuria. Renal biopsy demonstrated normal light microscopy and global glomerular basement membrane thinning on electron microscopy. Chromosomal microarray revealed long continuous stretches of homozygosity (LCSH) representing ~ 4.5% of the genome. Shared regions of LCSH between the brothers were identified and their further research genomic analysis implicated a homozygous stop-gain variant in CUBN (10p12.31).

Conclusions: CUBN mutations have been implicated as a hereditary cause of megaloblastic anaemia and variable proteinuria. This is the second reported family with isolated proteinuria due to biallelic CUBN variants in the absence of megaloblastic anaemia, demonstrating the ability of genomic testing to identify genetic causes of nephropathy within expanding associated phenotypic spectra. Genomic sequencing, undertaken earlier in the diagnostic trajectory, may reduce the need for invasive investigations and the time to definitive diagnosis for patients and families.
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http://dx.doi.org/10.1186/s12882-019-1474-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6704575PMC
August 2019

The impact of an integrated diabetes and kidney service on patients, primary and specialist health professionals in Australia: A qualitative study.

PLoS One 2019 15;14(7):e0219685. Epub 2019 Jul 15.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.

Background: To address guideline-practice gaps and improve management of patients with both diabetes and chronic kidney disease (CKD), we involved patients, health professionals and patient advocacy groups in the co-design and implementation of an integrated diabetes-kidney service.

Objective: In this study, we explored the experiences of patients and health-care providers, within this integrated diabetes and kidney service.

Methods: 5 focus groups and 2 semi-structured interviews were conducted amongst attending patients, referring primary health professionals, and attending specialist health professionals. Maximal variation sampling was used for both patients and referring primary health professionals to ensure an equal representation of males and females, and patients of different CKD stages. All discussions were audiotaped and transcribed verbatim, before being thematically analysed independently by 2 researchers.

Results: The mean age (SD) for specialist health professionals, primary care professionals and patients who participated was 45 (11), 44 (15) and 68 (5) years with men being 50%, 80% and 76% of the participants respectively. Key strengths of the diabetes and kidney service were noted to be better integration of care and a perception of improved health and management of health. Whilst some aspects of access such as time between referral and initial appointment and having fewer appointments improved, other aspects such as in-clinic waiting times and parking remained problematic. Specialist health professionals noted that health professional education could be improved. Patient self-management was also noted by to be an issue with some patients requesting more information and some health professionals expressing difficulty in empowering some patients.

Conclusions: Health professionals and patients reported that a co-designed integrated diabetes kidney service improved integration of care and improved health and management of health. However, some aspects of the process of care, health professional education and patient self-management remained challenging.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0219685PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6629146PMC
March 2020

The Use of Live Cell Imaging and Automated Image Analysis to Assist With Determining Optimal Parameters for Angiogenic Assay .

Front Cell Dev Biol 2019 10;7:45. Epub 2019 Apr 10.

Department of Anatomy and Developmental Biology, Biomedicine Discovery Institute, Monash University, Melbourne, VIC, Australia.

Testing angiogenic potential and function of cells in culture is important for the understanding of the mechanisms that can modulate angiogenesis, especially when discovering novel anti- or pro-angiogenic therapeutics. Commonly used angiogenic assays include tube formation, proliferation, migration, and wound healing, and although well-characterized, it is important that methodology is standardized and reproducible. Human endothelial progenitor cells (EPCs) are critical for post-natal vascular homeostasis and can be isolated from human peripheral blood. Endothelial colony forming cells (ECFCs) are a subset of EPCs and are of interest as a possible therapeutic target for hypoxic diseases such as kidney disease, as they have a high angiogenic potential. However, once ECFCs are identified in culture, the exact timing of passaging has not been well-described and the optimal conditions to perform angiogenic assays such as seeding density, growth media (GM) concentrations and end-points of these assays is widely varied in the literature. Here, we describe the process of isolating, culturing and passaging ECFCs from patients with end-stage renal disease (ESRD), aided by image analysis. We further describe optimal conditions, for human bladder endothelial cells (hBECs), challenged in angiogenic assays and confirm that cell density is a limiting factor in accurately detecting angiogenic parameters. Furthermore, we show that GM along is enough to alter the angiogenic potential of cells, seeded at the same density. Lastly, we report on the success of human ECFCs in angiogenic assays and describe the benefits of live-cell imaging combined with time-lapse microscopy for this type of investigation.
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http://dx.doi.org/10.3389/fcell.2019.00045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6468051PMC
April 2019

A need-based approach to self-management education for adults with co-morbid diabetes and chronic kidney disease.

BMC Nephrol 2019 04 2;20(1):113. Epub 2019 Apr 2.

School of Public Health and Preventive Medicine, Monash University, Alfred Centre, 99 Commercial Road, Melbourne, 3004, Australia.

Background: Self-management education needs have not been assessed in patients with complex co-morbid conditions such as diabetes and chronic kidney disease (CKD). The objectives of this study were to 1) determine the self-management education needs for patients with co-morbid diabetes and CKD and 2) co-develop an educational resource meeting the self-management education needs of patients with co-morbid diabetes and CKD.

Methods: Patients with co-morbid diabetes and CKD attending a co-designed, patient-centred outpatient diabetes and kidney clinic at a tertiary metropolitan hospital were recruited for semi-structured interviews. Maximal variation sampling was used, ensuring adequate representation of different gender, age, diabetes duration and stage of CKD. Data were thematically analysed using grounded theory.

Results: Forty-two patients participated. Most were male (67%) and the mean age was 64.8 (11.1) years. The majority of patients preferred an educational resource in the form of a Digital Versatile Disc (DVD) and they thought that current education could be improved. In particular patients wanted further education on 1) management of diabetes and kidney disease (including nutrition and lifestyle, and prevention of the progression of kidney disease) and 2) complications of comorbid diabetes and kidney disease.

Conclusion: Patients with co-morbid diabetes and kidney disease have education gaps on the management of, and complications of diabetes and kidney disease. Interventions aimed at improving patient education need to be delivered through education resources co-developed by patients and health staff. A targeted education resource in the form of a DVD, addressing these needs, may potentially close these gaps.
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http://dx.doi.org/10.1186/s12882-019-1296-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6444589PMC
April 2019

Fish oil and aspirin effects on arteriovenous fistula function: Secondary outcomes of the randomised omega-3 fatty acids (Fish oils) and Aspirin in Vascular access OUtcomes in REnal Disease (FAVOURED) trial.

PLoS One 2019 26;14(3):e0213274. Epub 2019 Mar 26.

The George Institute for Global Health, Sydney, Australia.

Background: Arteriovenous fistulas (AVF) for haemodialysis often experience early thrombosis and maturation failure requiring intervention and/or central venous catheter (CVC) placement. This secondary and exploratory analysis of the FAVOURED study determined whether omega-3 fatty acids (fish oils) or aspirin affected AVF usability, intervention rates and CVC requirements.

Methods: In 567 adult participants planned for AVF creation, all were randomised to fish oil (4g/d) or placebo, and 406 to aspirin (100mg/d) or placebo, starting one day pre-surgery and continued for three months. Outcomes evaluated within 12 months included AVF intervention rates, CVC exposure, late dialysis suitability failure, and times to primary patency loss, abandonment and successful cannulation.

Results: Final analyses included 536 participants randomised to fish oil or placebo (mean age 55 years, 64% male, 45% diabetic) and 388 randomised to aspirin or placebo. Compared with placebo, fish oil reduced intervention rates (0.82 vs 1.14/1000 patient-days, incidence rate ratio [IRR] 0.72, 95% confidence interval [CI] 0.54-0.97), particularly interventions for acute thrombosis (0.09 vs 0.17/1000 patient-days, IRR 0.53, 95% CI 0.34-0.84). Aspirin significantly reduced rescue intervention rates (IRR 0.45, 95% CI 0.27-0.78). Neither agent significantly affected CVC exposure, late dialysis suitability failure or time to primary patency loss, AVF abandonment or successful cannulation.

Conclusion: Although fish oil and low-dose aspirin given for 3 months reduced intervention rates in newly created AVF, they had no significant effects on CVC exposure, AVF usability and time to primary patency loss or access abandonment. Reduction in access interventions benefits patients, reduces costs and warrants further study.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0213274PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6435148PMC
December 2019

Global access of patients with kidney disease to health technologies and medications: findings from the Global Kidney Health Atlas project.

Kidney Int Suppl (2011) 2018 Feb 19;8(2):64-73. Epub 2018 Jan 19.

Department of Medicine, University of Calgary, Calgary, Alberta, Canada.

Access to essential medications and health products is critical to effective management of kidney disease. Using data from the ISN Global Kidney Health Atlas multinational cross-sectional survey, global access of patients with kidney disease to essential medications and health products was examined. Overall, 125 countries participated, with 118 countries, composing 91.5% of the world's population, providing data on this domain. Most countries were unable to access eGFR and albuminuria in their primary care settings. Only one-third of low-income countries (LICs) were able to measure serum creatinine and none were able to access eGFR or quantify proteinuria. The ability to monitor diabetes mellitus through serum glucose and glycated hemoglobin measurements was suboptimal. Pathology services were rarely available in tertiary care in LICs (12%) and lower middle-income countries (45%). While acute and chronic hemodialysis services were available in almost all countries, acute and chronic peritoneal dialysis services were rarely available in LICs (18% and 29%, respectively). Kidney transplantation was available in 79% of countries overall and in 12% of LICs. While over one-half of all countries publicly funded RRT and kidney medications with or without copayment, this was less common in LICs and lower middle-income countries. In conclusion, this study demonstrated significant gaps in services for kidney care and funding that were most apparent in LICs and lower middle-income countries.
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http://dx.doi.org/10.1016/j.kisu.2017.10.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6336224PMC
February 2018

Global overview of health systems oversight and financing for kidney care.

Kidney Int Suppl (2011) 2018 Feb 19;8(2):41-51. Epub 2018 Jan 19.

Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.

Reliable governance and health financing are critical to the abilities of health systems in different countries to sustainably meet the health needs of their peoples, including those with kidney disease. A comprehensive understanding of existing systems and infrastructure is therefore necessary to globally identify gaps in kidney care and prioritize areas for improvement. This multinational, cross-sectional survey, conducted by the ISN as part of the Global Kidney Health Atlas, examined the oversight, financing, and perceived quality of infrastructure for kidney care across the world. Overall, 125 countries, comprising 93% of the world's population, responded to the entire survey, with 122 countries responding to questions pertaining to this domain. National oversight of kidney care was most common in high-income countries while individual hospital oversight was most common in low-income countries. Parts of Africa and the Middle East appeared to have no organized oversight system. The proportion of countries in which health care system coverage for people with kidney disease was publicly funded and free varied for AKI (56%), nondialysis chronic kidney disease (40%), dialysis (63%), and kidney transplantation (57%), but was much less common in lower income countries, particularly Africa and Southeast Asia, which relied more heavily on private funding with out-of-pocket expenses for patients. Early detection and management of kidney disease were least likely to be covered by funding models. The perceived quality of health infrastructure supporting AKI and chronic kidney disease care was rated poor to extremely poor in none of the high-income countries but was rated poor to extremely poor in over 40% of low-income countries, particularly Africa. This study demonstrated significant gaps in oversight, funding, and infrastructure supporting health services caring for patients with kidney disease, especially in low- and middle-income countries.
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http://dx.doi.org/10.1016/j.kisu.2017.10.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6336220PMC
February 2018

Identifying patient-important outcomes in polycystic kidney disease: An international nominal group technique study.

Nephrology (Carlton) 2019 Dec 2;24(12):1214-1224. Epub 2019 May 2.

Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.

Aim: Patients with autosomal dominant polycystic kidney disease (ADPKD) are at increased risk of premature mortality, morbidities and complications, which severely impair quality of life. However, patient-centered outcomes are not consistently reported in trials in ADPKD, which can limit shared decision-making. We aimed to identify outcomes important to patients and caregivers and the reasons for their priorities.

Methods: Nominal group technique was adopted involving patients with ADPKD and caregivers who were purposively selected from eight centres across Australia, France and the Republic of Korea. Participants identified, ranked and discussed outcomes for trials in ADPKD. We calculated an importance score (0-1) for each outcome and conducted thematic analyses.

Results: Across 17 groups, 154 participants (121 patients, 33 caregivers) aged 19 to 78 (mean 54.5 years) identified 55 outcomes. The 10 highest ranked outcomes were: kidney function (importance score 0.36), end-stage kidney disease (0.32), survival (0.21), cyst size/growth (0.20), cyst pain/bleeding (0.18), blood pressure (0.17), ability to work (0.16), cerebral aneurysm/stroke (0.14), mobility/physical function (0.12), and fatigue (0.12). Three themes were identified: threatening semblance of normality, inability to control and making sense of diverse risks.

Conclusion: For patients with ADPKD and their caregivers, kidney function, delayed progression to end-stage kidney disease and survival were the highest priorities, and were focused on achieving normality, and maintaining control over health and lifestyle. Implementing these patient-important outcomes may improve the meaning and relevance of trials to inform clinical care in ADPKD.
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http://dx.doi.org/10.1111/nep.13566DOI Listing
December 2019

Patient-reported barriers and outcomes associated with poor glycaemic and blood pressure control in co-morbid diabetes and chronic kidney disease.

J Diabetes Complications 2019 01 12;33(1):63-68. Epub 2018 Oct 12.

School of Public Health and Preventive Medicine, Monash University, VIC, Australia; Diabetes and Vascular Medicine Unit, Monash Health, VIC, Australia; The George Institute for Global Health, NSW, Australia. Electronic address:

Aims: In patients with comorbid diabetes and chronic kidney disease, the extent to which patient-reported barriers to health-care and patient reported outcomes influence the quality of health care is not well established. This study explored the association between patient-reported barriers to health-care, patient activation, quality of life and diabetes self-care, with attainment of glycaemic and blood pressure (BP) targets.

Methods: This cross-sectional study recruited adults with diabetes and CKD (eGFR 20 to <60 ml/min/1.73m) across four hospitals. We combined clinical data with results from a questionnaire comprising measures of patient-identified barriers to care, the Patient Activation Measure (PAM), 12-Item Short Form Survey (SF-12), and the Summary of Diabetes Self-Care Activity (SDSCA).

Results: 199 patients, mean age 68.7 (SD 9.6), 70.4% male and 90.0% with type 2 diabetes were studied. Poor glycaemic control was associated with increased odds of patient reported "poor family support" (OR 4.90; 95% CI 1.80 to 13.32, p < 0.002). Poor BP control was associated with increased odds of patient reported, "not having a good primary care physician" (OR 6.01; 2.42 to 14.95, p < 0.001). The number of barriers was not associated with increased odds of poor control (all p > 0.05).

Conclusions: Specific patient-reported barriers, lack of patient perceived family and primary care physician support, are associated with increased odds of poor glycaemic and blood pressure control respectively. Interventions addressing these barriers may improve treatment target attainment.
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http://dx.doi.org/10.1016/j.jdiacomp.2018.09.020DOI Listing
January 2019

Patient reported barriers are associated with low physical and mental well-being in patients with co-morbid diabetes and chronic kidney disease.

Health Qual Life Outcomes 2018 Nov 19;16(1):215. Epub 2018 Nov 19.

School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.

Background: Little is known about how patient reported barriers to health care impact the quality of life (HRQoL) of patients with comorbid disease. We investigated patient reported barriers to health care and low physical and mental well-being among people with diabetes and chronic kidney disease (CKD).

Methods: Adults with diabetes and CKD (estimated Glomerular Filtration Rate < 60 ml/min/1.73m) were recruited and completed a questionnaire on barriers to health care, the 12-Item HRQoL Short Form Survey and clinical assessment. Low physical and mental health status were defined as mean scores < 50. Logistic regression models were used.

Results: Three hundred eight participants (mean age 66.9 ± 11 years) were studied. Patient reported 'impact of the disease on family and friends' (OR 2.07; 95% CI 1.14 to 3.78), 'feeling unwell' (OR 4.23; 95% CI 1.45 to 12.3) and 'having other life stressors that make self-care a low priority' (OR 2.59; 95% CI 1.20 to 5.61), were all associated with higher odds of low physical health status. Patient reported 'feeling unwell' (OR 2.92; 95% CI 1.07 to 8.01), 'low mood' (OR 2.82; 95% CI 1.64 to 4.87) and 'unavailability of home help' (OR 1.91; 95% CI 1.57 to 2.33) were all associated with higher odds of low mental health status. The greater the number of patient reported barriers the higher the odds of low mental health but not physical health status.

Conclusions: Patient reported barriers to health care were associated with lower physical and mental well-being. Interventions addressing these barriers may improve HRQoL among people with comorbid diabetes and CKD.
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http://dx.doi.org/10.1186/s12955-018-1044-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6245917PMC
November 2018