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American Journal of Veterinary Research Feb 2024To compare the influence of fluid on carboplatin elution, and assess the feasibility of ultrafiltration (UF) probe sampling.
OBJECTIVE
To compare the influence of fluid on carboplatin elution, and assess the feasibility of ultrafiltration (UF) probe sampling.
SAMPLE
20 samples of 5 mg carboplatin in 1.0 mL 30% poloxamer 407 eluting in Dulbecco's phosphate-buffered saline (DPBS) or canine plasma and 6 samples of UF probe sampling in 0.01 mg/mL carboplatin in DPBS or plasma.
METHODS
Carboplatin-gel specimens in dialysis tubing (12- to 14-kDa pores) were placed in 100 mL of DPBS or canine plasma (37 °C and 600 rpm stirring) in a nonlidded and lidded experiment. Samples were collected in decreasing frequency for 96 hours. The 0.01-mg/mL carboplatin solutions in DPBS and plasma were sampled 6 times by UF probe (30-kDa pores) or direct aspiration. Platinum was measured using inductively coupled plasma mass spectrometry.
RESULTS
High fluid evaporation was noted in the nonlidded but not the lidded experiment. A burst release was seen in plasma (first 2 hours) and DPBS (first 5 hours) with the highest hourly increase in the first hour in both DPBS (6,040 ppb/h) and plasma (2,612 ppb/h), with no further increase after the first 22 hours. Platinum content in the specimens was higher at 96 hours than the surrounding fluid. Higher platinum concentrations were measured by both direct and UF probe sampling in DPBS than in plasma.
CLINICAL RELEVANCE
Platinum concentrations measured in DPBS were higher than in plasma, but elution patterns were similar. Ultrafiltration probes can be used to sample platinum in vitro and could be used in vivo to measure local unbound Pt tissue concentrations in local chemotherapy delivery.
Topics: Animals; Dogs; Carboplatin; Platinum; Ultrafiltration; Renal Dialysis; Phosphates
PubMed: 38029512
DOI: 10.2460/ajvr.23.09.0205 -
Kidney Medicine Dec 2023Stigma contributes to ineffective treatment for pain among individuals with kidney failure on dialysis, particularly with buprenorphine pain treatment. To address...
RATIONALE & OBJECTIVE
Stigma contributes to ineffective treatment for pain among individuals with kidney failure on dialysis, particularly with buprenorphine pain treatment. To address stigma, we adapted a Design Sprint, an industry-developed structured exercise where an interdisciplinary group works over 5 days to clarify the problem, identify and choose a solution, and build and test a prototype.
STUDY DESIGN
Adapted Design Sprint which clarified the problem to be solved, proposed solutions, and created a blueprint for the selected solution.
SETTINGS & PARTICIPANTS
Five individuals with pain and kidney disease receiving dialysis, 5 physicians (nephrology, palliative care, and addiction medicine) and 4 large dialysis organization leaders recruited for specific expertise or experience. Conducted through online platform (Zoom) and virtual white board (Miro board).
ANALYTICAL APPROACH
Descriptions of the Design Sprint adaptations and processes.
RESULTS
To facilitate patient comfort, a patient-only phase included four 90-minute sessions over 2-weeks, during which patient participants used a mapping process to define the critical problem and sketch out solutions. In a physician-only phase, consisting of two 120-minute sessions, participants accomplished the same tasks. During a combined phase of two 120-minute sessions, patients, physicians, and large dialysis organization representatives vetted and developed solutions from earlier phases, leading to an intervention blueprint. Videoconferencing technology allowed for geographically diverse representation and facilitated participation from patients experiencing medical illness. The electronic whiteboard permitted interactive written contributions and voting on priorities instead of only verbal discussion, which may privilege physician participants. A skilled qualitative researcher facilitated the sessions.
LIMITATIONS
Challenges included the time commitment of the sessions, absences owing to illness or emergencies, and technical difficulties.
CONCLUSIONS
An adapted Design Sprint is a novel method of efficiently and rapidly incorporating multiple stakeholders to develop solutions for clinical challenges in kidney disease.
PLAIN LANGUAGE SUMMARY
Stigma contributes to ineffective treatment for pain among individuals with kidney failure on dialysis, particularly when using buprenorphine, an opioid pain medicine with a lower risk of sedation used to treat addiction. To develop a stigma intervention, we adapted a Design Sprint, an industry-developed structured exercise where an interdisciplinary group works over 5 days to clarify the problem, identify and choose a solution, and build and test a prototype. We conducted 3 sprints with (1) patients alone, (2) physicians alone, and (3) combined patients, physicians, and dialysis organization representatives. This paper describes the adaptations and products of sprints as a method for gathering diverse stakeholder voices to create an intervention blueprint efficiently and rapidly.
PubMed: 38028030
DOI: 10.1016/j.xkme.2023.100729 -
Saudi Journal of Kidney Diseases and... Nov 2022
Topics: Humans; Icodextrin; Dialysis Solutions; Skin; Hypersensitivity; Glucose
PubMed: 38018724
DOI: 10.4103/1319-2442.390262 -
Blood Purification 2024The rapid advancement of artificial intelligence and big data analytics, including descriptive, diagnostic, predictive, and prescriptive analytics, has the potential to...
INTRODUCTION
The rapid advancement of artificial intelligence and big data analytics, including descriptive, diagnostic, predictive, and prescriptive analytics, has the potential to revolutionize many areas of medicine, including nephrology and dialysis. Artificial intelligence and big data analytics can be used to analyze large amounts of patient medical records, including laboratory results and imaging studies, to improve the accuracy of diagnosis, enhance early detection, identify patterns and trends, and personalize treatment plans for patients with kidney disease. Additionally, artificial intelligence and big data analytics can be used to identify patients' treatment who are not receiving adequate care, highlighting care inefficiencies in the dialysis provider, optimizing patient outcomes, reducing healthcare costs, and consequently creating values for all the involved stakeholders.
OBJECTIVES
We present the results of a comprehensive survey aimed at exploring the attitudes of European physicians from eight countries working within a major hemodialysis network (Fresenius Medical Care NephroCare) toward the application of artificial intelligence in clinical practice.
METHODS
An electronic survey on the implementation of artificial intelligence in hemodialysis clinics was distributed to 1,067 physicians. Of the 1,067 individuals invited to participate in the study, 404 (37.9%) professionals agreed to participate in the survey.
RESULTS
The survey showed that a substantial proportion of respondents believe that artificial intelligence has the potential to support physicians in reducing medical malpractice or mistakes.
CONCLUSION
While artificial intelligence's potential benefits are recognized in reducing medical errors and improving decision-making, concerns about treatment plan consistency, personalization, privacy, and the human aspects of patient care persist. Addressing these concerns will be crucial for successfully integrating artificial intelligence solutions in nephrology practice.
Topics: Humans; Artificial Intelligence; Nephrologists; Renal Dialysis; Surveys and Questionnaires; Nephrology
PubMed: 38008072
DOI: 10.1159/000534604 -
Membranes Oct 2023In the last twenty-five years, extensive work has been done on ion exchange membrane bioreactors (IEMB) combining Donnan dialysis and anaerobic reduction to remove trace...
In the last twenty-five years, extensive work has been done on ion exchange membrane bioreactors (IEMB) combining Donnan dialysis and anaerobic reduction to remove trace oxyanions (e.g., perchlorate, nitrate, chlorate, arsenate) from contaminated water sources. Most studies used Donnan dialysis contactors with high recirculation rates on the feed side, so under continuous operation, the effective concentration on the feed side of the membrane is the same as the exit concentration (CSTR mode). We have built, characterized, and modelled a plug flow Donnan dialysis contactor (PFR) that maximizes concentration on the feed side and operated it on feed solutions spiked with perchlorate and nitrate ion using ACS and PCA-100 anion exchange membranes. At identical feed inlet concentrations with the ACS membrane, membrane area loading rates are three-fold greater, and fluxes are more than double in the PFR contactor than in the CSTR contactor. A model based on the nonlinear adsorption of perchlorate in ACS membrane correctly predicted the trace ion concentration as a function of space-time in experiments with ACS. For PCA membrane, a linear flux dependence on feed concentration correctly described trace ion feed concentration as a function of space-time. Anion permeability for PCA-100 was high enough that the overall mass transfer was affected by the film boundary layer resistance. These results provide a basis for efficiently scaling up Donnan dialysis contactors and incorporating them in full-scale IEMB setups.
PubMed: 37999342
DOI: 10.3390/membranes13110856 -
Annals of Biomedical Engineering Mar 2024Inadequate clearance of protein-bound uremic toxins (PBUTs) during dialysis is associated with morbidities in chronic kidney disease patients. The development of...
Inadequate clearance of protein-bound uremic toxins (PBUTs) during dialysis is associated with morbidities in chronic kidney disease patients. The development of high-permeance membranes made from materials such as graphene raises the question whether they could enable the design of dialyzers with improved PBUT clearance. Here, we develop device-level and multi-compartment (body) system-level models that account for PBUT-albumin binding (specifically indoxyl sulfate and p-cresyl sulfate) and diffusive and convective transport of toxins to investigate how the overall membrane permeance (or area) and system parameters including flow rates and ultrafiltration affect PBUT clearance in hemodialysis. Our simulation results indicate that, in contrast to urea clearance, PBUT clearance in current dialyzers is mass-transfer limited: Assuming that the membrane resistance is dominant, raising PBUT permeance from 3 × 10 to 10 m s (or equivalently, 3.3 × increase in membrane area from ~ 2 to ~ 6 m) increases PBUT removal by 48% (from 22 to 33%, i.e., ~ 0.15 to ~ 0.22 g per session), whereas increasing dialysate flow rates or adding adsorptive species have no substantial impact on PBUT removal unless permeance is above ~ 10 m s. Our results guide the future development of membranes, dialyzers, and operational parameters that could enhance PBUT clearance and improve patient outcomes.
Topics: Humans; Uremic Toxins; Uremia; Protein Binding; Renal Dialysis; Toxins, Biological
PubMed: 37993752
DOI: 10.1007/s10439-023-03397-6 -
Frontiers in Nephrology 2023The COVID-19 pandemic resulted in an unprecedented burden on intensive care units (ICUs). With increased demands and limited supply, critical care resources, including... (Review)
Review
The COVID-19 pandemic resulted in an unprecedented burden on intensive care units (ICUs). With increased demands and limited supply, critical care resources, including dialysis machines, became scarce, leading to the undertaking of value-based cost-effectiveness analyses and the rationing of resources to deliver patient care of the highest quality. A high proportion of COVID-19 patients admitted to the ICU required dialysis, resulting in a major burden on resources such as dialysis machines, nursing staff, technicians, and consumables such as dialysis filters and solutions and anticoagulation medications. Artificial intelligence (AI)-based big data analytics are now being utilized in multiple data-driven healthcare services, including the optimization of healthcare system utilization. Numerous factors can impact dialysis resource allocation to critically ill patients, especially during public health emergencies, but currently, resource allocation is determined using a small number of traditional factors. Smart analytics that take into account all the relevant healthcare information in the hospital system and patient outcomes can lead to improved resource allocation, cost-effectiveness, and quality of care. In this review, we discuss dialysis resource utilization in critical care, the impact of the COVID-19 pandemic, and how AI can improve resource utilization in future public health emergencies. Research in this area should be an important priority.
PubMed: 37965069
DOI: 10.3389/fneph.2023.1266967 -
JAMA Internal Medicine Dec 2023Patients with advanced chronic kidney disease (CKD) have the best chance for a longer and healthier life if they receive a kidney transplant. However, many barriers...
IMPORTANCE
Patients with advanced chronic kidney disease (CKD) have the best chance for a longer and healthier life if they receive a kidney transplant. However, many barriers prevent patients from receiving a transplant.
OBJECTIVES
To evaluate the effect of a multicomponent intervention designed to target several barriers that prevent eligible patients from completing key steps toward receiving a kidney transplant.
DESIGN, SETTING, AND PARTICIPANTS
This pragmatic, 2-arm, parallel-group, open-label, registry-based, superiority, cluster randomized clinical trial included all 26 CKD programs in Ontario, Canada, from November 1, 2017, to December 31, 2021. These programs provide care for patients with advanced CKD (patients approaching the need for dialysis or receiving maintenance dialysis).
INTERVENTIONS
Using stratified, covariate-constrained randomization, allocation of the CKD programs at a 1:1 ratio was used to compare the multicomponent intervention vs usual care for 4.2 years. The intervention had 4 main components, (1) administrative support to establish local quality improvement teams; (2) transplant educational resources; (3) an initiative for transplant recipients and living donors to share stories and experiences; and (4) program-level performance reports and oversight by administrative leaders.
MAIN OUTCOMES AND MEASURES
The primary outcome was the rate of steps completed toward receiving a kidney transplant. Each patient could complete up to 4 steps: step 1, referred to a transplant center for evaluation; step 2, had a potential living donor contact a transplant center for evaluation; step 3, added to the deceased donor waitlist; and step 4, received a transplant from a living or deceased donor.
RESULTS
The 26 CKD programs (13 intervention, 13 usual care) during the trial period included 20 375 potentially transplant-eligible patients with advanced CKD (intervention group [n = 9780 patients], usual-care group [n = 10 595 patients]). Despite evidence of intervention uptake, the step completion rate did not significantly differ between the intervention vs usual-care groups: 5334 vs 5638 steps; 24.8 vs 24.1 steps per 100 patient-years; adjusted hazard ratio, 1.00 (95% CI, 0.87-1.15).
CONCLUSIONS AND RELEVANCE
This novel multicomponent intervention did not significantly increase the rate of completed steps toward receiving a kidney transplant. Improving access to transplantation remains a global priority that requires substantial effort.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT03329521.
Topics: Humans; Kidney Transplantation; Renal Dialysis; Renal Insufficiency, Chronic; Ontario; Kidney; Systems Analysis
PubMed: 37922156
DOI: 10.1001/jamainternmed.2023.5802 -
Clinical Kidney Journal Nov 2023People living with chronic kidney disease (CKD) need to be able to live well with their condition. The provision of psychosocial interventions (psychological,...
BACKGROUND
People living with chronic kidney disease (CKD) need to be able to live well with their condition. The provision of psychosocial interventions (psychological, psychiatric and social care) and physical rehabilitation management is variable across England, as well as the rest of the UK. There is a need for clear recommendations for standards of psychosocial and physical rehabilitation care for people living with CKD, and guidance for the commissioning and measurement of these services. The National Health Service (NHS) England Renal Services Transformation Programme (RSTP) supported a programme of work and modified Delphi process to address the management of psychosocial and physical rehabilitation care as part of a larger body of work to formulate a comprehensive commissioning toolkit for renal care services across England. We sought to achieve expert consensus regarding the psychosocial and physical rehabilitation management of people living with CKD in England and the rest of the UK.
METHODS
A Delphi consensus method was used to gather and refine expert opinions of senior members of the kidney multi-disciplinary team (MDT) and other key stakeholders in the UK. An agreement was sought on 16 statements reflecting aspects of psychosocial and physical rehabilitation management for people living with CKD.
RESULTS
Twenty-six expert practitioners and other key stakeholders, including lived experience representatives, participated in the process. The consensus (>80% affirmative votes) amongst the respondents for all 16 statements was high. Nine recommendation statements were discussed and refined further to be included in the final iteration of the 'Systems' section of the NHS England RSTP commissioning toolkit. These priority recommendations reflect pragmatic solutions that can be implemented in renal care and include recommendations for a holistic wellbeing assessment for all people living with CKD who are approaching dialysis, or who are at listing for kidney transplantation, which includes the use of validated measurement tools to assess the need for further intervention in psychosocial and physical rehabilitation management. It is recommended that the scores from these measurement tools be included in the NHS England Renal Data Dashboard. There was also a recommendation for referral as appropriate to NHS Talking Therapies, psychology, counselling or psychotherapy, social work or liaison psychiatry for those with identified psychosocial needs. The use of digital resources was recommended to be used in addition to face-to-face care to provide physical rehabilitation, and all healthcare professionals should be educated to recognize psychosocial and physical rehabilitation needs and refer/sign-post people with CKD to appropriate services.
CONCLUSION
There was high consensus amongst senior members of the kidney MDT and other key stakeholders, including those with lived experience, in the UK on all aspects of the psychosocial and physical rehabilitation management of people living with CKD. The results of this process will be used by NHS England to inform the 'Systems' section of the commissioning toolkit and data dashboard and to inform the National Standards of Care for people living with CKD.
PubMed: 37915908
DOI: 10.1093/ckj/sfad116 -
BMC Nephrology Oct 2023Without effective intervention, primary hyperoxaluria type 1 (PH1) causes oxalate-induced kidney damage, leading to end-stage kidney disease and serious complications... (Observational Study)
Observational Study
BACKGROUND
Without effective intervention, primary hyperoxaluria type 1 (PH1) causes oxalate-induced kidney damage, leading to end-stage kidney disease and serious complications throughout the body. Although PH1 carries a heavy burden that impacts quality of life, literature on the experiences of those living with PH1 and caring for patients with PH1 is limited. This study aimed to describe the diagnostic journey in PH1 and characterize patients' and caregivers' self-reported experiences throughout the disease course.
METHODS
This was an observational study involving in-depth, semi-structured telephone interviews. Dominant trends were assessed using constant comparative analysis to identify themes in interviewees' descriptions of their experiences. Individuals aged ≥ 12 years and caregivers of children aged 6-17 years with genetically confirmed PH1 were eligible. Informed consent/assent and ability to read and speak English were required.
RESULTS
Interviewees (16 patients, 12 caregivers) reported a prolonged diagnostic journey due to low disease awareness, among other factors. Upon diagnosis, PH1 was frequently symptomatic, typically involving kidney stone-related symptoms but also potentially symptoms arising beyond the kidneys. PH1 most commonly led to worry and social impairment in adolescents, impaired physical function in adults, and a range of impacts on caregivers. In late-stage disease, dialysis was the most burdensome aspect of living with PH1 (due to time requirements, limitations from living with a catheter, etc.), and this burden was exacerbated by the COVID-19 pandemic. Benefits desired from PH1 management included reductions in laboratory measures of oxalate burden, kidney stone and urination frequency, and oxalate-related skin ulcers.
CONCLUSIONS
PH1 greatly impacts patients' and caregivers' lives, primarily due to burdensome disease manifestations and associated emotional, physical, and practical impacts, as well as disease management challenges - particularly those related to dialysis in late-stage disease.
Topics: Child; Adult; Adolescent; Humans; Pandemics; Quality of Life; Renal Dialysis; Hyperoxaluria, Primary; Oxalates; Kidney Calculi; Patient Outcome Assessment
PubMed: 37884879
DOI: 10.1186/s12882-023-03365-1