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February 22, 2013 General Nephrology, Interviews No comments

The prevalence of potentially inappropriate medication prescribing in elderly patients with CKD

Hemodialysis.com Author Interview: Prof Sunil Bhandari

Consultant Nephrologist/Honorary Clinical Professor
Director of Clinical Studies HYMS
Head of School of Medicine (East)
Chair of MBBS Programme Board

Hemodialysis.com: What are the main findings of the study?

Prof: Bhandari: The prevalence of potentially inappropriate (contra-indicated, dosing error based on eGFR) medication prescribing in elderly patients (>70years) with chronic kidney disease stages 3-5 (mean eGFR 17ml/min/1.73m²) is high at 56%. The main drugs inappropriately prescribed are antibiotics (21%) and antihypertensive (19%).

Marie Benz, MD on Google+

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2013 World Congress
- World Congress of Nephrology 2013 – Macaulay Onuigbo MD | Second Blog
  
  Macaulay Onuigbo MD MSc FWACP FASN MBA
  Second Blog from the 2013 World Congress of Nephrology, Hong Kong for Hemodialysis.com.
  
  Macaulay Onuigbo MD FASN MBA
  Associate Professor of Medicine, Mayo Clinic, Rochester
  Nephrologist/Transplant Physician/Hypertension Specialist, Mayo Clinic Health System, Eau Claire, WI.
  
  Monday, June 3 2013, last official day of the World Congress of Nephrology.
  
  The plenary session 7 title was “RRT in AKI – Avoiding prohibitive costs and dangerous complexity”.
  A packed audience in Convention Hall A attended this session.
  
  The following presentations on RRT and AKI were presented by eminent physicians from around the world:
  
  1. Vinsonneau Christophe MD discussed intermittent hemodialysis and ultrafiltration: The different modalities of CCRT were reviewed and he acknowledged the the fact that up until now, it remained unclear whether any particular modality (CVVH, CVVHD, CVVHDF) was superior. He compared literature data between AKI outcomes when treated with CRRT versus intermittent HD: no clear cut advantages. However, the consensus appears to be that in severely hypotensive patients dependent on many pressors, and in patients with brain edema, that CRRT was a preferred RRT modality, where available. There appears to be less exacerbation of disequilibrium syndrome with continuous replacement modalities as against intermittent HD in the latter.
  
  2. Mark R. Marshall MD discussed SLED: He described the great variety of practice patterns under the umbrella of “SLED” and emphasized on PIRRT (Prolonged Intermittent Renal Replacement Therapy) as the most appropriate descriptive nomenclature for this modality of RRT. He also discussed Nursing staff preferences to the different varieties of SLED in the ICU. The controversy of whether higher blood flow rates in SLED led to more hemodynamic instability was very well discussed and Dr. Marshall held the view that given the high (super-saturation) dialysate flow rate compared to the blood flow rate, he did not believe that higher flow rates in SLED contributed to hypotension.
  
  3. Georgi Abraham MD from India discussed PD in AKI: He demonstrated that PD is indeed an effective RRT modality for the management of AKI, in adults, in pediatrics and even more so among infants. Indeed in infants and smaller children, it would appear that hemodialysis was not even practically possible as a treatment option for AKI. He demonstrated very good AKI outcomes – renal recovery – in various centers in India.
  
  4. Paanu Neesh MD reviewed the use or non-use of CRRT in the developing world: This review noted the difficulty of lumping the so-called developing countries all in one group in discussions regarding healthcare access. This is so since this group of countries represented such a wide scatter of countries with annual healthcare expenditure per capita ranging from as low as $25 to over $5,000. As a result, CRRT was absolutely absent in some countries whereas it was fairly represented in the richer developing countries. In South America, there remained this disparity of use of CRRT modalities. She also came to the conclusion that PD as a treatment modality for AKI was underutilized, even in such resource-poor countries as the developing countries.
  
  Again, today, the moderated poster sessions were very actively attended with elaborate and educational discussions around the different poster groups.
  
  Fresenius Kabi sponsored presentations on the use of ketoanalogues in the management of CKD during one of the afternoon lunch symposia. The following physicians gave the presentations as follows:
  
  1. Garneata Garneatailiana MD from Romania: This presenter discuused the findings of a Romanian trial that compared the use of keto/amino acid analogues compared to standard low prtein renal diet in Romania. This presentation described the experience of using keto/amino acid supplements in late stage CKD in a prospective, open, parallel, randomized controlled 48-weeks’ study among patients aged >18 years with eGFR <30 ml/min/1.73 sq m BSA and proteinuria <1g/g urinary creatinine, and showed that the rate of decline of eGFR was slowed down by this agent and led to reduced need for the initiation of RRT and increased time to ESRD. BUN levels were less with ketoanalogues and the use of ketoanalogues increased bicarbonate levels. Phosphorus levels were also shown to be lower with ketoanalogues. The conclusion was that ketoanalogues for slowing down CKD were effective and safe in compliant patients. Compliance with medications (as much as 15-17 tablets a day) was a major problem here. Exclusion criteria included diabetes mellitus, heart failure, poorly controlled hypertension, and noncompliance with keto/amino acid analogues.
  
  2. Chen Jing MD from China: This presenter discussed the problems associated with intermittent HD treatment for ESRD in China. This lecture opened up by showing statistics and graphics demonstrating the astronomical growth of the ESRD population in Shanghai, China, between 1999 and 2011, with a point prevalence of 180.6 per million population in 1999 shooting up to a point prevalence of 710.2 per million population in 2011. She subsequently described the high dietary noncompliance with much higher phosphorus loads among Chinese ESRD patients when compared to the rest of the world and stressed on the need for reduced phosphorus dietary intakes. This scenario was compounded by the use of generally low flux filters for hemodialysis in China, as well as the common practice of twice weekly and/or shorter HD treatment times among Chinese ESRD patients on intermittent HD treatment. She ended with some evidence for the benefit of the use of ketoanalogues together with the restriction of dietary protein intake in the ESRD population on maintenance hemodialysis with amelioration of refractory hyperphosphatemia. She also showed evidence for more preservation of residual renal function with the use of ketoanalogues supplemeted low dietary protein diet. Caution is however called when applying these findings to ESRD patients with incident malnutrition or inflammation.
  
  Over and out! See you again at the WCN 2015 taking place in South Africa!!!
  
  Macaulay Onuigbo MD MSc FWACP FASN MBA
  
  Marie Benz, MD on Google+
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- World Congress of Nephrology 2013 – Macaulay Onuigbo MD
  
  Macaulay Onuigbo MD MSc FWACP FASN MBA
  First Blog from the 2013 World Congress of Nephrology, Hong Kong for Hemodialysis.com.
  
  Macaulay Onuigbo MD FASN MBA
  Associate Professor of Medicine, Mayo Clinic, Rochester
  Nephrologist/Transplant Physician/Hypertension Specialist, Mayo Clinic Health System, Eau Claire, WI.
  
  Saturday, June 1 2013 was the first full day of the conference. The presentations given by eminent scholars covered the following topics:
  
  -       The increasing CKD problem as a major healthcare burden around the world
  
  -       Updates in the treatment of glomerulonephritis
  
  -       Approach to the sensitized patient in renal transplantation
  
  -       Mechanisms and consequences of AKI
  
  -       Complement-mediated diseases with an update on atypical hemolytic uremic syndrome (aHUS).
  
  Marie Benz, MD on Google+
  Read More »

Dialysis Company News
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Featured CDC Interview
- Bloodstream Infection Rates in Outpatient Hemodialysis Facilities Participating in a Collaborative Prevention Effort: A Quality Improvement Report
  
  Dr. Priti R. Patel, MD, MPH
  
  Division of Healthcare Quality Promotion
  National Center for Emerging and Zoonotic Infectious Diseases
  Centers for Disease Control and Prevention, Atlanta, GA
  
  Hemodialysis.com: What are the main findings of the study?
  
  Dr. Patel: In 2009, the Centers for Disease Control and Prevention (CDC) partnered with a group of outpatient dialysis centers on a collaborative initiative to prevent bloodstream infections (BSIs) in hemodialysis patients. Seventeen outpatient hemodialysis facilities worked together to implement a set of CDC-recommended interventions for BSI prevention. Rates of BSI and access-related BSI reported to CDC’s National Healthcare Safety Network (NHSN) were examined from January 2009 through March 2011. By implementing the interventions in a systematic manner, the facilities participating in this initiative were able to reduce their rate of overall BSI by 32% and rate of access-related BSI by 54%.
  
  The interventions used included chlorhexidine antiseptic for catheter exit-site care, staff training and competency assessments focused on catheter care and aseptic technique, hand hygiene and vascular access care audits, and feedback of infection and adherence rates to staff. Facility staff were also encouraged to use antimicrobial ointment on catheter exit sites. For a complete list of the BSI prevention steps recommended by CDC, please see http://www.cdc.gov/dialysis/prevention-tools/core-interventions.html.
  
  Marie Benz, MD on Google+
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Fresenius Social Program Awarded
- Storm Preparedness to Ensure Fresenius Dialysis Patients to Receive Uninterrupted Care
  
  WALTHAM, Mass. – May 21, 2013 – With construction crews still repairing damage from last year’s catastrophic Hurricane Sandy and residents of Moore, Okla. just starting

DOPPS Update May 2013
- Major bleeding events and risk stratification of antithrombotic agents in hemodialysis: results from the DOPPS
  
  Hemodialysis.com eInterview with Dr. Manish M. Sood Department of Medicine, St. Boniface General Hospital University of Manitoba, Winnipeg, Manitoba, Canada Hemodialysis.com: What are the main findings of Read More »
- DOPPS: Since bundle – Decreases in hemoglobin, EPO dose, Increases in IV Iron, Ferritin and PTH
  
  DOPPS Practice Monitor: Latest Update on Trends in US Hemodialysis Practice Following Policy Changes Major payment and regulatory changes have affected United States (US) dialysis care Read More »

Acumen News
- Acumen Nephrology Announces Acumen Practice Management
  
  NASHVILLE, Tenn. – Acumen Nephrology has introduced its new practice management product, Acumen® PM, which offers a full suite of options to streamline the practice of