Design of a consensus-based geriatric assessment tailored for older chronic kidney disease patients:results of a pragmatic approach

PURPOSE: Unidentified cognitive decline and other geriatric impairments are prevalent in older patients with advanced chronic kidney disease (CKD). Despite guideline recommendation of geriatric evaluation, routine geriatric assessment is not common in these patients. While high burden of vascular disease and existing pre-dialysis care pathways mandate a tailored geriatric assessment, no consensus exists on which instruments are most suitable in this population to identify geriatric impairments. Therefore, the aim of this study was to propose a geriatric assessment, based on multidisciplinary consensus, to routinely identify major geriatric impairments in older people with advanced CKD. METHODS: A pragmatic approach was chosen, which included focus groups, literature review, inventory of current practices, an expert consensus meeting, and pilot testing. In preparation of the consensus meeting, we composed a project team and an expert panel (n = 33), drafted selection criteria for the selection of instruments, and assessed potential instruments for the geriatric assessment. RESULTS: Selection criteria related to general geriatric domains, clinical relevance, feasibility, and duration of the assessment. The consensus-assessment contains instruments in functional, cognitive, psychological, somatic, patient preferences, nutritional status, and social domains. Administration of (seven) patient questionnaires and (ten) professional-administered instruments, by nurse (practitioners), takes estimated 20 and 40 min, respectively. Results are discussed in a multidisciplinary meeting including at least nephrology and geriatric expertise, informing nephrology treatment decisions, and follow-up interventions among which comprehensive geriatric assessment. CONCLUSION: This first multidisciplinary consensus on nephrology-tailored geriatric assessment intent to benefit clinical care and enhance research comparability for older patients with advanced CKD

A systematic review on the epidemiological data of erythema nodosum leprosum, a type 2 leprosy reaction.

BACKGROUND: Erythema Nodosum Leprosum (ENL) is a humoral immunological response in leprosy that leads to inflammatory skin nodules which may result in nerve and organ damage, and may occur years after antibiotic treatment. Multiple episodes are frequent and suppression requires high doses of immunosuppressive drugs. Global occurrence is unknown. METHODOLOGY/PRINCIPAL FINDINGS: Systematic review of evidence on ENL incidence resulted in 65 papers, predominantly from India (24) and Brazil (9), and inclusive of four reviews. Average incidences are based on cumulative incidence and size of study populations (n>100). In field-based studies 653/54,737 (1.2%) of all leprosy cases, 194/4,279 (4.5%) of MB cases, and 86/560 (15.4%) of LL cases develop ENL. Some studies found a range of 1-8 per 100 person-years-at-risk (PYAR) amongst MB cases. Hospital samples indicate that 2,393/17,513 (13.7%) of MB cases develop ENL. Regional differences could not be confirmed. Multiple ENL episodes occurred in 39 to 77% of ENL patients, with an average of 2.6. Some studies find a peak in ENL incidence in the first year of treatment, others during the second and third year after starting MDT. The main risk factor for ENL is a high bacteriological index. CONCLUSIONS/SIGNIFICANCE: Few studies reported on ENL as a primary outcome, and definitions of ENL differed between studies. Although, in this review averages are presented, accurate data on global and regional ENL incidence is lacking. Large prospective studies or accurate surveillance data would be required to clarify this. Health staff needs to be aware of late reactions, as new ENL may develop as late as five years after MDT completion, and recurrences up to 8 years afterwards

Incidence of ENL in hospital populations (n>100).

*<p>It should be noted here that cumulative incidence is presented as these have been published, although not all numbers could be traced and justified after conducting calculations while some inconsistencies were noticed. So therefore, these numbers should be treated with caution.</p>†<p>Studies that conducted slit skin smears. Studies not indicated with this footnote did not provide information on conducting slit skin smears.</p>‡<p>Assessed late leprosy reaction during surveillance that started after MB-MDT course until smear negativity. This study is excluded from the calculations.</p>§<p>Assessed admissions due to leprosy reactions. This study is excluded from the calculations because n is not well defined.</p

Flow diagram of included studies.

<p>Flow diagram of included studies.</p

Incidence of ENL in field based studies (n>100).

*<p>It should be noted here that cumulative incidence is presented as these have been published, although not all numbers could be traced and justified after conducting calculations while some inconsistencies were noticed. So therefore, these numbers should be treated with caution.</p>†<p>Studies that conducted slit skin smears. Studies not indicated with this footnote did not provide information on conducting slit skin smears.</p

Findings on multiple episodes, number and duration of ENL episodes.

†<p>Only cases with multiple episodes of ENL reported, this accounted for 28.4% of MB cases. This study is excluded from the calculations.</p>‡<p>49 (45%)single, 27 (25%) two, 13 (12%) three, 6 (5%)four, 2 (2%) five, 5 (5%) >five episodes.</p>§<p>45(49%) single, 28 (30%)two, 14 (11%) three, 5 (5%) four or more episodes.</p>**<p>Of the original cohort of 116 patients, 28 were excluded because they had too short follow-up and could not be categorized.</p>††<p>37.5% having acute multiple ENL (i.e. more than one episode lasting less than six months, steady decrease in steroid tapering) and 62.5% chronic ENL (i.e. episode lasting for more than six months).</p>‡‡<p>13 (25%)single, 12 (24%)two, 14 (27%)three, 11(22%)four, 1(2%)five episodes.</p>§§<p>Vaccine versus control group; 3 vs 3 single, 4 vs 4 two, 3 vs 2 three, 0 vs 3 more than three episodes.</p>***<p>An episode of ENL was taken as a separate event if more than 3 months had elapsed since the last episode.</p

Incidence of ENL reported per person years at risk.

<p>(A) Incidence for studies reporting incidence per 100 PYAR. (B) Incidence over time during different study periods for a Bangladesh <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0002440#pntd.0002440-Richardus2" target="_blank">[43]</a> and Ethiopian <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0002440#pntd.0002440-Saunderson1" target="_blank">[41]</a> study.</p

Variation in proportion of cases developing ENL.

<p>(A) Incidence (%) for studies reporting for BB cases. (B) Idem for BL cases and (C) LL cases.</p

Health-related quality of life and symptoms of conservative care versus dialysis in patients with end-stage kidney disease: A systematic review

Background: Non-dialytic conservative care (CC) has been proposed as a viable alternative to maintenance dialysis for selected older patients to treat end-stage kidney disease (ESKD). This systematic review compares both treatment pathways on health-related quality of life (HRQoL) and symptoms, which are major outcomes for patients and clinicians when deciding on preferred treatment. Methods: We searched PubMed, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus and PsycINFO from inception to 1 October 2019 for studies comparing patient-reported HRQoL outcomes or symptoms between patients who chose either CC or dialysis for ESKD. Results: Eleven observational cohort studies were identified comprising 1718 patients overall. There were no randomized controlled trials. Studies were susceptible to selection bias and confounding. In most studies, patients who chose CC were older and had more comorbidities and worse functional status than patients who chose dialysis. Results were broadly consistent across studies, despite considerable clinical and methodological heterogeneity. Patient-reported physical health outcomes and symptoms appeared to be worse in patients who chose CC compared with patients who chose dialysis but had not yet started, but similar compared with patients on dialysis. Mental health outcomes were similar between patients who chose CC or dialysis, including before and after dialysis start. In patients who chose dialysis, the burden of kidney disease and impact on daily life increased after dialysis start. Conclusions: The available data, while heterogeneous, suggest that in selected older patients, CC has the potential to achieve similar HRQoL and symptoms compared with a dialysis pathway. High-quality prospective studies are needed to confirm these provisional findings