Estimated Glomerular Filtration Rate Decline as a Predictor of Dialysis in Kidney Transplant Recipients

&lt;b&gt;&lt;i&gt;Background:&lt;/i&gt;&lt;/b&gt; It is now common for individuals to require dialysis following the failure of a kidney transplant. Management of complications and preparation for dialysis are suboptimal in this group. To aid planning, it is desirable to estimate the time to dialysis requirement. The rate of decline in the estimated glomerular filtration rate (eGFR) may be used to this end. &lt;b&gt;&lt;i&gt;Methods:&lt;/i&gt;&lt;/b&gt; This study compared the rate of eGFR decline prior to dialysis commencement between individuals with failing transplants and transplant-naïve patients. The rate of eGFR decline was also compared between transplant recipients with and without graft failure. eGFR was calculated using the four-variable MDRD equation with rate of decline calculated by least squares linear regression. &lt;b&gt;&lt;i&gt;Results:&lt;/i&gt;&lt;/b&gt; The annual rate of eGFR decline in incident dialysis patients with graft failure exceeded that of the transplant-naïve incident dialysis patients. In the transplant cohort, the mean annual rate of eGFR decline prior to graft failure was 7.3 ml/min/1.73 m&lt;sup&gt;2&lt;/sup&gt; compared to 4.8 ml/min/1.73 m&lt;sup&gt;2&lt;/sup&gt; in the transplant-naïve group (p &lt; 0.001) and 0.35 ml/min/1.73 m&lt;sup&gt;2&lt;/sup&gt; in recipients without graft failure (p &lt; 0.001). Factors associated with eGFR decline were recipient age, decade of transplantation, HLA mismatch and histological evidence of chronic immunological injury. &lt;b&gt;&lt;i&gt;Conclusions:&lt;/i&gt;&lt;/b&gt; Individuals with graft failure have a rapid decline in eGFR prior to dialysis commencement. To improve outcomes, dialysis planning and management of chronic kidney disease complications should be initiated earlier than in the transplant-naïve population.</jats:p

Research information in nurses' clinical decision-making: What is useful?

AIM: To examine those sources of information which nurses find useful for reducing the uncertainty associated with their clinical decisions. BACKGROUND: Nursing research has concentrated almost exclusively on the concept of research implementation. Few, if any, papers examine the use of research knowledge in the context of clinical decision-making. There is a need to establish how useful nurses perceive information sources are, for reducing the uncertainties they face when making clinical decisions. DESIGN: Cross-case analysis involving qualitative interviews, observation, documentary audit and Q methodological modelling of shared subjectivities amongst nurses. The case sites were three large acute hospitals in the north of England, United Kingdom. One hundred and eight nurses were interviewed, 61 of whom were also observed for a total of 180 hours and 122 nurses were involved in the Q modelling exercise. RESULTS: Text-based and electronic sources of research-based information yielded only small amounts of utility for practising clinicians. Despite isolating four significantly different perspectives on what sources were useful for clinical decision-making, it was human sources of information for practice that were overwhelmingly perceived as the most useful in reducing the clinical uncertainties of nurse decision-makers. CONCLUSIONS: It is not research knowledge per se that carries little weight in the clinical decisions of nurses, but rather the medium through which it is delivered. Specifically, text-based and electronic resources are not viewed as useful by nurses engaged in making decisions in real time, in real practice, but those individuals who represent a trusted and clinically credible source are. More research needs to be carried out on the qualities of people regarded as clinically important information agents (specifically, those in clinical nurse specialist and associated roles) whose messages for practice appear so useful for clinicians

Nurse-led models of chemotherapy care: mixed economy or nurse–doctor substitution?

Aim: This paper reports a study exploring the perspectives of people affected by cancer (service users) and health care professionals' about current medical consultant-led services and the acceptability of a proposed nurse-led ambulatory chemotherapy service.Background: A number of studies have evaluated a nurse-led model of cancer care delivery but little work has been undertaken in chemotherapy settings. Furthermore, many of these studies give little information on how the perspective of users was incorporated in the design and evaluation of these services.Methods: Service users (n = 26) and health care professionals (n = 22) were recruited across the South East of England. A qualitative study was undertaken… Using a semi-structured interview schedule, participants were asked to give their perceptions of current chemotherapy services and the potential of a nurse-led service. A thematic analysis of data was undertaken.Findings: This paper focuses on the theme of the current and future context of a chemotherapy service. Three sub-themes were identified: contextualizing roles, defining therapeutic outcomes, and demonstrating effectiveness. All interviewees saw this role as different but complementary to the role of medical staff. There were mixed opinions from service users and professionals on the acceptability of nurse-led chemotherapy provision. In defining potential outcomes of nurse-led care, service users described benefits in terms of service and economic outcomes. Professionals saw additional benefits in terms of patient-based outcomes. Professionals and service users expressed the need for appropriate education of nurses for this role and rigorous evaluation of any new service before widespread implementation.Conclusions: Understanding the perspective of users is imperative when re-designing cancer nursing services. Implementation of nurse-led models in chemotherapy services should be preceded by staff education and followed by systematic evaluation