Biomedical subjects

Giancarlo Marinangeli

Publications and source records attributed to Giancarlo Marinangeli.

2 recordsLinked to original sources

PubMedDate not supplied

Structured pre-dialysis programs: more than just timely referral?

BACKGROUND: Patients who begin chronic dialysis within 3 months of seeing a nephrologist (late referral)have increased morbidity and mortality. However, it is not known whether formal pre-dialysis education programs (PEPs) are more advantageous, regarding early dialysis outcomes and resource use, than unstructured specialist follow-up. METHODS: We prospectively collected information on specialist care, unstructured or PEP, modality choice and hospitalizations in the 1st 3 months of dialysis for all consecutive patients who started dialysis between 1st January 1999 and 30th June 2002 in two Italian centers. RESULTS: The 229 patients who participated in this study (62% male, median age 70 yrs) had a high prevalence of diabetes (27.5%) and cardiovascular disease (60%). Of these, 22.7% received unstructured follow-up and 40.6% received PEP care. Peritoneal dialysis (PD) was the first choice modality for 41.5% of patients and 55% had a planned start. Excluding late referrals (36.7%), the likelihood of PD selection was similar between PEP and unstructured care (52.7% vs. 40.4%, p = NS), while that of a planned start was greater among PEP patients (91.4% vs. 38.5%, p < 0.001). Multivariate analysis showed that only PEP (but not unstructured care) vs. late referral had a significant association with reduced odds of hemodialysis (HD) selection (OR: 0.301, [95%CI 0.153, 0.594]), emergency start (0.031 [0.013, 0.075]), 1st hospitalization > 5 days (0.165 [0.081, 0.333]), and further hospitalizations (0.346 [0.174, 0.685]). Late referrals independently predicted the lack of modality selection (1.847 [1.007, 3.388]). CONCLUSIONS: A structured PEP seemed to improve early dialysis outcomes and resource usage beyond that gained by a timely referral, except for the opportunity to select modality.

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PubMedDate not supplied

Multidisciplinary chronic kidney disease management improves survival on dialysis.

BACKGROUND: Delayed nephrology referral is associated with increased morbidity and mortality after patients begin dialysis. However, whether a pre-dialysis educational program (PEP) confers any survival advantage in comparison to unstructured specialist care is not established. METHODS: Cox's regression analysis was used to estimate the association between the type of pre-dialysis follow-up and mortality in all consecutive end-stage renal disease (ESRD) adults starting dialysis therapy in two centers, between 1 January 1999 and 30 June 2002, and followed until 30 June 2003. RESULTS: 229 patients participated in the study. The patients tended to be male (62%), elderly (median age 70 yrs) and to have cardiovascular diseases (60%). Median follow-up on dialysis was 37.8 months, with 624 patient-yrs at risk and a 0.15 yr(-1) mortality rate. Patients receiving regular unstructured care (22.7%) appeared to have similar risk for death as late referrals (36.7%), while PEP patients (40.6%) showed longer survival (hazard ratio 0.48 (95% CI 0.27, 0.87)), allowing for demographics, comorbidities, duration of the pre-dialysis follow-up and dialysis modality. Planned dialysis commencement, a better metabolic status at dialysis initiation and the previous use of angiotensin converting enzyme inhibitors were the main factors associated with improved outcomes. The survival advantage associated with PEP was still present after late referrals or observation for < or = 1 yr were excluded, as well as when survival analysis was limited to the 1st year after dialysis initiation. CONCLUSION: A multidisciplinary approach to chronic kidney diseases seems more effective than just timely referral to nephrologists in improving patient survival on dialysis.

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