Chronic kidney disease management in primary care

Contains fulltext : 176490.pdf (publisher's version ) (Open Access)Radboud University, 30 oktober 2017Promotores : Assendelft, W.J.J., Wetzels, J.F.M. Co-promotores : Grauw, W.J.C. de, Scherpbier-de Haan, N.D

Teleconsultatie voor de huisarts en de nefroloog.

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Initial implementation of a web-based consultation process for patients with chronic kidney disease

Contains fulltext : 118664.pdf (publisher's version ) (Open Access)PURPOSE A Web-based consultation system (telenephrology) enables family physicians to consult a nephrologist about a patient with chronic kidney disease. Relevant data are exported from the patient's electronic file to a protected digital environment from which advice can be formulated by the nephrologist. The primary purpose of this study was to assess the potential of telenephrology to reduce in-person referrals. METHODS In an observational, prospective study, we analyzed telenephrology consultations by 28 family practices and 5 nephrology departments in the Netherlands between May 2009 and August 2011. The primary outcome was the potential reduction of in-person referrals, measured as the difference between the number of intended referrals as stated by the family physician and the number of referrals requested by the nephrologist. The secondary outcome was the usability of the system, expressed as time invested, the implementation in daily work hours, and the response time. Furthermore, we evaluated the questions asked. RESULTS One hundred twenty-two new consultations were included in the study. In the absence of telenephrology, 43 patients (35.3%) would have been referred by their family physicians, whereas the nephrologist considered referral necessary in only 17 patients (13.9%) (P <.001). The family physician would have treated 79 patients in primary care. The nephrologist deemed referral necessary for 10 of these patients. Time investment per consultation amounted to less than 10 minutes. Consultations were mainly performed during office hours. Response time was 1.6 days (95% CI, 1.2-1.9 days). Most questions concerned estimated glomerular filtration rate, proteinuria, and blood pressure. CONCLUSION A Web-based consultation system might reduce the number of referrals and is usable. Telenephrology may contribute to an effective use of health facilities by allowing patients to be treated in primary care with remote support by a nephrologist

Impact on cardiovascular risk follow-up from a shift to the CKD-EPI formula for eGFR reporting: a cross-sectional population-based primary care study

Contains fulltext : 188152.pdf (publisher's version ) (Open Access)OBJECTIVE: To assess the impact on cardiovascular risk factor management in primary care by the introduction of chronic kidney disease epidemiological collaboration (CKD-EPI) for estimated-glomerular filtration rate (eGFR) reporting. DESIGN AND SETTING: Cross-sectional study of routine healthcare provision in 47 primary care practices in The Netherlands with Modification of Diet and Renal Disease Study eGFR reporting. METHODS: eGFR values were recalculated using CKD-EPI in patients with available creatine tests. Patients reclassified from CKD stage 3a to CKD stage 2 eGFR range were compared to those who remained in stage 3a for differences in demographic variables, blood pressure, comorbidity, medication usage and laboratory results. RESULTS: Among the 60 673 adult patients (37% of adult population) with creatine values, applying the CKD-EPI equation resulted in a 16% net reduction in patients with CKD stage 3 or worse. Patients reclassified from stage 3a to 2 had lower systolic blood pressure (139.7 vs 143.3 mm Hg p20% within 10 years. CONCLUSIONS: Use of the CKD-EPI equation will result in many patients being removed from CKD registers and the associated follow-up. Current risk factor assessment in this group may be lacking from routine data and some patients within this group are at an increased risk for cardiovascular events

Rumen escape protein in concentrate ingredients determined with the nylon bag and enzymatic techniques

Rumen escape protein (REP) was determined for 26 concentrate feed ingredients using the nylon bag technique and in vitro using a proteolytic enzyme preparation of Streptomyces griseus. In vitro, the samples were incubated for 0, 1, 6 and 24 h. The highest correlation was observed between percentage REP (%REP), determined with the nylon bag technique, and the in vitro undegradable fraction after 1 h of incubation (%U1) (R2= 0.77). Longer incubation times weakened the relationship. %REP could be estimated from %U1 according to: %REP = -0.76 (±5.99) + 0.81 (±0.09) × %U1. The 0 h incubation, representing in vitro solubility, had a relationship (R2 = 0.67) with in situ %REP, suggesting that %REP is mainly determined by crude protein (CP) solubility and to a lesser extent by degradation. © 2002 Elsevier Science B.V. All rights reserved

Rumen escape protein in grass and grass silage deterimened with a nylon bag and an enzymatic technique

Rumen escape protein (REP) was determined for six grasses and 16 grass silages using a nylon bag technique and an in vitro technique using a proteolytic enzyme preparation of Streptomyces griseus. In vitro, the samples were incubated for 0, 1, 6 and 24 h. The highest correlation observed between percentage REP (%REP), determined with the nylon bag technique, and the in vitro undegradable fraction (U) occurred at 24 h of incubation (%U24; R2=0.71). Shorter incubation periods weakened the relationship (R2=0.46¿0.59). Percentage REP could be estimated from %U24 as %REP=3.3 (±4.02) + 1.31 (±0.19) *%U24. For the incubation periods investigated, results show that the highest relationship with %REP occurred with an incubation period of 24 h for these grass and grass silage samples

Rumen escape protein in grass and grass silage deterimened with a nylon bag and an enzymatic technique

Rumen escape protein (REP) was determined for six grasses and 16 grass silages using a nylon bag technique and an in vitro technique using a proteolytic enzyme preparation of Streptomyces griseus. In vitro, the samples were incubated for 0, 1, 6 and 24 h. The highest correlation observed between percentage REP (%REP), determined with the nylon bag technique, and the in vitro undegradable fraction (U) occurred at 24 h of incubation (%U24; R2=0.71). Shorter incubation periods weakened the relationship (R2=0.46¿0.59). Percentage REP could be estimated from %U24 as %REP=3.3 (±4.02) + 1.31 (±0.19) *%U24. For the incubation periods investigated, results show that the highest relationship with %REP occurred with an incubation period of 24 h for these grass and grass silage samples

Estimating rumen degradability of forages from semi-natural grasslands, using nylon bag and gas production techniques

To determine the ruminal digestion of forages from extensively managed semi-natural grasslands, degradation characteristics and kinetics of silages of three different forages in the rumen of lactating dairy cows were estimated in vitro using the gas production technique (GPT), and in situ using the nylon bag technique. Silages originated from intensively managed grassland (IMG), extensively managed species-poor grassland (SPP) and extensively managed species-rich grassland (SPR). Some individual species originating from extensively managed species-poor and species-rich grasslands were used to estimate their degradability with GPT in order to compare the differences among the species occurring on these two types of grassland. All samples were also analysed for in vitro organic matter digestibility. In situ degradability was estimated by nylon bag incubation in the rumen of three dairy cows at two different periods. Rate of organic matter degradation was highest for IMG (4.93 and 4.54% h-1), intermediate for SPR (3.50 and 4.11% h-1) and lowest for SPP (2.62 and 2.72% h-1). The rates of degradation for protein and neutral detergent fibre were highest for IMG. The undegradable fraction was the same for SPP and SPR. Highest cell wall fermentation was observed for IMG and lowest for SPP, but SPP and SPR did not differ statistically in this respect. Cell wall degradability of the individual species from the species-poor and species-rich grasslands were highest for Lolium perenne and Dactylis glomerata and lowest for Lathyrus pratensis and Anthriscus sylvestris. It is concluded that SPR has the highest potential to become a component of the dairy cow ration

Estimating rumen degradability of forages from semi-natural grasslands, using nylon bag and gas production techniques

To determine the ruminal digestion of forages from extensively managed semi-natural grasslands, degradation characteristics and kinetics of silages of three different forages in the rumen of lactating dairy cows were estimated in vitro using the gas production technique (GPT), and in situ using the nylon bag technique. Silages originated from intensively managed grassland (IMG), extensively managed species-poor grassland (SPP) and extensively managed species-rich grassland (SPR). Some individual species originating from extensively managed species-poor and species-rich grasslands were used to estimate their degradability with GPT in order to compare the differences among the species occurring on these two types of grassland. All samples were also analysed for in vitro organic matter digestibility. In situ degradability was estimated by nylon bag incubation in the rumen of three dairy cows at two different periods. Rate of organic matter degradation was highest for IMG (4.93 and 4.54% h-1), intermediate for SPR (3.50 and 4.11% h-1) and lowest for SPP (2.62 and 2.72% h-1). The rates of degradation for protein and neutral detergent fibre were highest for IMG. The undegradable fraction was the same for SPP and SPR. Highest cell wall fermentation was observed for IMG and lowest for SPP, but SPP and SPR did not differ statistically in this respect. Cell wall degradability of the individual species from the species-poor and species-rich grasslands were highest for Lolium perenne and Dactylis glomerata and lowest for Lathyrus pratensis and Anthriscus sylvestris. It is concluded that SPR has the highest potential to become a component of the dairy cow ration