Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Hyperchloremic Metabolic Acidosis due to Cholestyramine: A Case Report and Literature Review

Cholestyramine is a bile acid sequestrant that has been used in the treatment of hypercholesterolemia, pruritus due to elevated bile acid levels, and diarrhea due to bile acid malabsorption. This medication can rarely cause hyperchloremic nonanion gap metabolic acidosis, a complication featured in this report of an adult male with concomitant acute kidney injury. This case emphasizes the caution that must be taken in prescribing cholestyramine to patients who may also be volume depleted, in renal failure, or taking spironolactone.Peer Reviewe

Modifiable Risk Factors for Early Mortality on Hemodialysis

Data of incident hemodialysis patients from 2001 to 2007 were abstracted from The Renal Disease Registry (TRDR) from central Ontario, Canada and followed until December 2008 to determine 90-day mortality rates for incident hemodialysis patients. Modifiable risk factors of early mortality were determined by a Cox model. In total, 876 of 4807 incident patients died during their first year on dialysis; 304 (34.7%) deaths occurred within the first 90 days of dialysis initiation. The majority of deaths were attributed to a cardiovascular event or infection and more likely occurred in older patients and those with cardiovascular co-morbidities. Of potentially modifiable risk factors, low body mass index (ud_less_than18.5), a surrogate for malnutrition, was a strong predictor of early mortality [adjusted hazard ratio (HR) 4.22 (CI: 3.12–5.17)]. Also, central venous catheter use was associated with a 2.40 fold increase risk of death (CI: 1.4–3.90). Patients who attended a multidisciplinary pre-dialysis clinic were less likely to die (HR: 0.60, CI: 0.47–0.78). The first 90 days after initiation of dialysis is a period of especially high risk of death. We have identified potentially modifiable risk factors in vascular access type, pre-dialysis care and nutritional status.Peer Reviewe

Benefits of a Transfer Clinic in Adolescent and Young Adult Kidney Transplant Patients

Background: Adolescent and young adult kidney transplant recipients have worse graft outcomes than older and younger age groups. Difficulties in the process of transition, defined as the purposeful, planned movement of adolescents with chronic health conditions from child to adult-centered health care systems, may contribute to this. Improving the process of transition may improve adherence post-transfer to adult care services. Objective: The purpose of this study is to investigate whether a kidney transplant transfer clinic for adolescent and young adult kidney transplant recipients transitioning from pediatric to adult care improves adherence post-transfer. Methods: We developed a joint kidney transplant transfer clinic between a pediatric kidney transplant program, adult kidney transplant program, and adolescent medicine at two academic health centers. The transfer clinic facilitated communication between the adult and pediatric transplant teams, a face-to-face meeting of the patient with the adult team, and a meeting with the adolescent medicine physician. We compared the outcomes of 16 kidney transplant recipients transferred before the clinic was established with 16 patients who attended the clinic. The primary outcome was a composite measure of non-adherence. Non-adherence was defined as either self-reported medication non-adherence or displaying two of the following three characteristics: non-attendance at clinic, non-attendance for blood work appointments, or undetectable calcineurin inhibitor levels within 1 year post-transfer. Results: The two groups were similar at baseline, with non-adherence identified in 43.75 % of patients. Non-adherent behavior in the year post-transfer, which included missing clinic visits, missing regular blood tests, and undetectable calcineurin inhibitor levels, was significantly lower in the cohort which attended the transfer clinic (18.8 versus 62.5 %, p = 0.03). The median change in estimated glomerular filtration rate (eGFR) in the year following transfer was smaller in the group that attended the transition clinic (–0.9 ± 13.2 ml/min/1.73 m 2 ) compared to those who did not (–12.29 ± 14.9 ml/min/1.73 m 2 ), p = 0.045. Conclusions: Attendance at a single kidney transplant transfer clinic was associated with improved adherence and renal function in the year following transfer to adult care. If these changes are sustained, they may improve long-term graft outcomes for adolescent kidney transplant recipients

Attitudes and Opinions of Canadian Nephrologists Toward Continuous Quality Improvement Options

Background and objectives: A shift to holding individual physicians accountable for patient outcomes, rather than facilities, is intuitively attractive to policy makers and to the public. We were interested in nephrologists’ attitudes to, and awareness of, quality metrics and how nephrologists would view a potential switch from the current model of facility-based quality measurement and reporting to publically available reports at the individual physician level. Design, setting, participants, and measurements: The study was conducted using a web-based survey instrument (Online Appendix 1). The survey was initially pilot tested on a group of 8 nephrologists from across Canada. The survey was then finalized and e-mailed to 330 nephrologists through the Canadian Society of Nephrology (CSN) e-mail distribution list. The 127 respondents were 80% university based, and 33% were medical/dialysis directors. Results: The response rate was 43%. Results demonstrate that 89% of Canadian nephrologists are engaged in efforts to improve the quality of patient care. A minority of those surveyed (29%) had training in quality improvement. They feel accountable for this and would welcome the inclusion of patient-centered metrics of care quality. Support for public reporting as an effective strategy on an individual nephrologist level was 30%. Conclusions: Support for public reporting of individual nephrologist performance was low. The care of nephrology patients will be best served by the continued development of a critical mass of physicians trained in patient safety and quality improvement, by focusing on patient-centered metrics of care delivery, and by validating that all proposed new methods are shown to improve patient care and outcomes

The effect of optimising clinical performance measures on outcomes in haemodialysis patients

Background: Chronic kidney disease is a worldwide public health problem that is increasing in incidence and prevalence. In 1997, the Dialysis Outcomes Quality Initiative (DOQI) of the National Kidney Foundation (NKF) advised that certain performance measures be met to improve end stage renal failure patient survival. Aims: To examine whether attainment of the performance measures was associated with decreased mortality and hospitalisation in an Irish setting. The effect of comorbidities on survival and target attainment was also analysed. Methods: A one-year retrospective analysis of 304 haemodialysis patients attending Beaumont Hospital. The Charlson Comorbidity Index (CCI) was calculated to determine the effect of comorbidity on survival and attainment of the targets. Results: The number of targets met was positively correlated with survival rates (P=0.0028), and negatively correlated with both the percentage of patients hospitalised (P=0.0036) and the number of comorbidities (P=0.020). Conclusions: Our findings highlight the importance of quality of care in haemodialysis patients, and the need to implement strategies to ensure attainment of NKF-DOQI guidelines targets.</p

Supporting the Establishment of New Home Dialysis Programs Through the Explore Home Dialysis Program

Introduction: The globally increasing prevalence of chronic kidney disease has resulted in an ever-growing demand for renal replacement therapy. Although programs are present around the world, there is a paucity of immersive educational programs that train clinicians and administrators to develop new home dialysis programs. Explore Home Dialysis (EHD) is a program created to fill this gap. Methods: We present the results of the evaluation of the EHD program. Our team interviewed 23 clinicians and administrators who participated in the EHD program. We also assessed country-specific needs and challenges associated with home dialysis. Results: The 4 main findings include (i) the evaluation of the effectiveness of the EHD program; (ii) the need for an educational program to train individuals on how to deploy home dialysis programs; (iii) evidence that such an educational program is beneficial to participants and for the establishment of new home dialysis programs; and (iv) the identification of barriers to the development of home dialysis programs in countries represented in this study. The data show an increased demand, with strong patient and provider interest in establishing new programs, interest in accessing resources to train clinical and administrative staff in how to run a home dialysis program, and positive feedback about the EHD program in general. Conclusions: The data from this study were used in the next iteration of the EHD program, to inform clinicians about challenges in the deployment of new home dialysis programs, and to present educational resources that need to be developed in the future. Keywords: chronic kidney disease, clinicians, home dialysis, program evaluatio