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PubMed2002

The development of pediatric nephrology.

Pediatric nephrology, as a discipline, arose from descriptive studies of childhood glomerulonephritis in Europe and the field of pediatric metabolism in the United States. While pediatric scientists before 1950 were concerned with fluid and electrolyte metabolism, regulation of intracellular and extracellular fluid, acid-base homeostasis, and parenteral fluid therapy, the defined field of nephrology developed after the Second World War around six major advances: ACTH and glucocorticoid therapy for nephrotic syndrome; renal biopsy to diagnose glomerular disease; the role of immunologic factors in glomerular injury; the use of dialysis as renal replacement therapy; renal transplantation as the optimal form of therapy in children with end stage renal failure; and recognition of renal disease in the etiology of 80% of cases of childhood hypertension. These discoveries led to focused research, the definition of specific training in nephrology, establishment of an American, European, and an International Society of Pediatric Nephrology, as well as an American Sub-Board of Pediatric Nephrology, and the inception of a journal, Pediatric Nephrology, now in its 15th year. Major research themes have included developmental nephrology, transplantation immunology, and concerns about growth in children with renal disease. Many clinical entities have been described in detail, some of which are almost confined to children. The scientific basis of pediatric nephrology, ongoing patient care needs, and its technical aspects - renal biopsy, dialysis and transplantation - assure its continuing future as a major pediatric discipline on all continents.

Child↗

PubMed2003

[History of nephrology and extracorporeal drug removal at the L. Pasteur Hospital in Kosice].

The authors describe the development of clinical nephrology from 1948 to 2002 at the Medical Faculty of the P. J. Safarík University and L. Pasteur Faculty Hospital from the aspect of therapeutic and preventive care, teaching and research activities. The dialysis centre which was established in 1966 at the Medical Clinic of the Faculty Hospital in Kosice continued in the activities as the Nephrological laboratory which was founded in 1954. This laboratory still operates under the conditions of the Nephrological Clinic. In 1964 at the Medical Clinic the first percutaneous renal biopsy was implemented. In 1966 the first peritoneal dialysis was implemented and the first haemodialysis in a patient with chronic renal failure, later gradually all so far known therapeutic methods were introduced which replace renal function and are used in acute and chronic renal failure and in acute intoxication. On March 18, 1977 in the authors' department the first haemoperfusion over active charcoal was made successfully in a patient intoxicated with parquat. It was the first haemoperfusion in the former Czechoslovak Republic. From 1991 at the Clinic a Sub-chair of nephrology and dialysis was established attached to the Institute for Postgraduate Training, later SPAM. Within the framework of the latter several nephrological courses were organized as well as courses in extracorporeal elimination treatment and in acute toxicology. The department acted also as a training place for future nephrologists before the specialization examination in nephrology. Since 1981 successfully several research grants concerned with the use of haemoperfusion over active charcoal and other sorbents in acute intoxications were completed as well as grants focused on metabolic vitamin disorders in chronic renal failure. On October 24 1997 in our department within the framework of the P. J. Safarík University Medical Faculty and L. Pasteur Faculty Hospital the Nephrological Clinic was established, the first one in the Slovak Republic. This stimulated further qualitative development of nephrology not only in Kosice but in the whole of Slovakia.

Hemoperfusion↗

PubMed1988

Diagnosis related groups, resource utilization, age, and outcome for hospitalized nephrology patients.

Economic incentives are rapidly changing for hospitals under the prospective Diagnosis Related Group (DRG) hospital reimbursement scheme. The purpose of this project was to study resource use, age, and outcome for nephrology admissions to a large academic medical center. Total hospital costs for the 784 nephrology admissions (January 1, 1985 to December 31, 1986) were $5,037,460. Mean hospital cost per patient and mortality generally increased with age. DRG payment for patients in the 13 nephrology DRGs analyzed would have produced an aggregate loss of $483,584; however, all age categories of patients 55 years of age and over generated significant losses (the highest was for patients 85 years and above, $5,343 loss per patient). Diabetic nephrology patients generated greater resource consumption compared with nondiabetic nephrology patients, as well as patients in medical and surgical DRGs with chronic renal failure compared with patients in these same DRGs without chronic renal failure. Older nephrology patients also demonstrated higher emergency and ICU admission and blood requirements than younger patients. This study suggests that the current DRG reimbursement scheme may be inequitable vis a vis older nephrology patients, as well as those with diabetes mellitus and chronic renal failure. Financial disincentives by DRGs may affect both the access and quality of care for groups of nephrology patients in the future.

Adolescent↗

PubMed2002

Predictors of nephrological morbidity after coronary artery bypass surgery.

AIM: The aim of this study was to analyse the nephrological morbidity after myocardial revascularization. METHODS AND RESULTS: We analysed the pre- per and postoperative data of 3815 patients who underwent a primary isolated coronary bypass grafting between January 1987 and December 1995. Nephrological complications were divided into renal dysfunction and requiring dialysis. The increase in nephrological complications (1.2-4%) is the result of an increase of patients with renal dysfunction. Unifactorial risk analysis identified age, diabetes, hypertension, nephrological pathology, perfusion time, aortic cross-clamp time, emergency operation and perioperative myocardial infarction as risk factors. Multifactorial risk analysis identified age, diabetes, hypertension, nephrological pathology, perfusion time, perioperative myocardial infarction and the cohorts operated upon in 1990-92, 1993-95 as independent risk factors for renal dysfunction, and age, nephrological pathology and perioperative myocardial infarction for those needing dialysis. CONCLUSION: Several variables have been identified as risk factors for nephrological complications; especially important are pre-existing nephrological pathology and perioperative myocardial infarction.

Aged↗

PubMed2005

Does predialysis nephrology care influence patient survival after initiation of dialysis?

BACKGROUND: Early nephrology referral of patients with chronic kidney disease (CKD) has been suggested to reduce mortality after initiation of dialysis. This retrospective cohort study of incident dialysis patients between 1995 and 1998 was performed to address the association between frequency of nephrology care during the 24 months before initiation of dialysis and first-year mortality after initiation of dialysis. METHODS: Patient data were obtained from the Centers for Medicare & Medicaid Services. Patients who started dialysis between 1995 and 1998, and were Medicare-eligible for at least 24 months before initiation of dialysis, were included. One or more nephrology visits during a month was considered a month of nephrology care (MNC). RESULTS: Of the total 109,321 patients, only 50% had received nephrology care during the 24 months before initiation of dialysis. Overall, first-year mortality after initiation of dialysis was 36%. Cardiac disease was the major cause of mortality (46%). After adjusting for comorbidity, higher mortality was associated with increasing age (HR, 1.04 per year increase; 95% CI, 1.03 to 1.04) and more frequent visits to generalists (HR, 1.009 per visit increase; 95% CI, 1.003 to 1.014) and specialists (HR, 1.012 per visit increase; 95% CI, 1.011 to 1.013). Compared to patients with >/=3 MNC in the six months before initiation of dialysis, higher mortality was observed among those with no MNC during the 24 months before initiation of dialysis (HR, 1.51; 95% CI, 1.45 to 1.58), no MNC during the six months before initiation of dialysis (HR, 1.28; 95% CI, 1.20 to 1.36), and one or two MNC during the six months before initiation of dialysis (HR, 1.23; 95% CI, 1.18 to 1.29). CONCLUSION: Nephrology care before dialysis is important, and consistency of care in the immediate six months before dialysis is a predictor of mortality. Consistent nephrology care may be more important than previously thought, particularly because the frequency and severity of CKD complications increase as patients approach dialysis.

Aged↗

PubMedDate not supplied

Interventional nephrology in a federal hospital: economics of health care.

Interventional nephrology is now an accepted subspecialty of nephrology that is revolutionizing the standard of care for renal failure patients. Interventional nephrology deals with the placement of tunneled cuffed catheters (TCCs) and maintenance of permanent vascular accesses, thus assisting in timely care. Prior to 2000 most end-stage renal disease (ESRD) patients from the Overton Brooks Veterans Affairs Medical Center (OBVAMC) were referred to an outlying hospital for TCC placement and endovascular procedures (EVPs) of permanent dialysis access. The referral process was cumbersome for the patients and expensive to the Medicine Service. OBVAMC started an interventional nephrology service in 2000. The current study reports the financial benefits of starting an interventional nephrology service at our institution. All procedures performed during the period from April 2000 to April 2004 were analyzed. The procedures were performed in the cardiac catheterization laboratory. The total payment (physician's and hospital fees) to the referral hospital for procedures prior to April 2000 was used to estimate the average savings to the Medicine Service over the last 4 years. A total of 129 TCCs and 43 EVPs were performed during this period. The estimated expense to OBVAMC would have been US dollars 603,978 for TCCs and US dollars 288,100 for EVPs based on charges prior to April 2000. The actual expense to the hospital, including facility fees and disposables, was US dollars 156,013. The net savings to OBVAMC over the last 4 years was US dollars 736,065. Interventional nephrology provided to a small population of renal failure patients in a tertiary federal health care facility has resulted in huge savings for the hospital. Increasing awareness of this procedural aspect of nephrology benefits not only the patients, but also helps ease the financial burden of ever-escalating health care costs.

Angioplasty, Balloon↗

PubMed2004

Comparison of natural product use between primary care and nephrology patients.

BACKGROUND: The use of natural products is increasing, but healthcare professionals may underestimate the use of these agents by patients. It is unknown whether natural product use differs between primary care and specialty clinic patients, such as those in a nephrology clinic. OBJECTIVE: To compare patterns of natural product use between primary care and nephrology clinic patients. METHODS: One thousand adult patients from each clinic were randomly mailed an anonymous questionnaire to determine current and past use of natural products. RESULTS: A total of 491 surveys were returned, for an overall response rate of 26% (25% primary care; 28% nephrology clinic). Current use of natural products was similar between the primary care and nephrology groups (34% vs 29%, respectively; p = NS). Primary care patients were more likely to have taken a natural product in the past (57% vs 45%; p < 0.05); Echinacea was the most common product taken by those patients (26%). Green tea was the most common natural product taken by nephrology clinic patients (18%). More primary care patients took Echinacea compared with nephrology clinic patients (26% vs 12%; p < 0.01). Adverse reactions led to discontinuation of the natural product in 7% of respondents. CONCLUSIONS: Active use of natural products was similar between the survey respondents. Documentation and monitoring of natural product use by healthcare professionals working with primary care and nephrology clinic patients are recommended.

Dietary Supplements↗

PubMed2003

[A study on the projected workforce of nephrology clinical nurse specialist (CNS) in Korea].

PURPOSE: The purpose of this study was to study the projected workforce of nephrology CNS in Korea. METHOD: Need models, ratio methods and expert opinion were used for projecting needs for the nephrology CNS. RESULT: In 2001, there are 28,046 ESRD(end stage of renal disease)patients, 304 renal replacement centers and 1695 nephrology nurses in Korea. the hemodialysis patients per hemodialysis nurse was 12. The number of nephrology CNS required to meet the demand for caring of ESRD patients in 2002, 2005 and 2020 was estimated at 616, 837 and 3105, respectively. 47 ESRD patients per nephrology CNS was revealed as a workforce standard before 2005. After 2005, It was 31 ESRD patients per nephrology CNS. CONCLUSION: This study founded the need to project future increments and development in supply of qualified nephrology CNS.

English Abstract↗

PubMed2003

Developing a comprehensive diagnostic and interventional nephrology program at an academic center.

Procedure-related delays in the treatment of patients with renal disease can be minimized and nephrology care can be delivered more efficiently by a nephrologist trained in nephrology-related procedures. Referrals to a radiologist for renal ultrasound and biopsy, to a surgeon for dialysis access placement, and to an interventional radiologist for dialysis catheter placement and vascular access procedures are time consuming and inconvenient to patients with renal disease. Moreover, such an approach may result in delays in the availability of critical diagnostic information and a break in the continuity of care. In an effort to optimize the care of nephrology patients, we developed a diagnostic and interventional nephrology (DIN) program that effectively deals with nephrology-related procedures in a timely manner. At present, some of the commonly performed nephrology-related procedures at our center include diagnostic ultrasonography, ultrasound-guided renal biopsy, peritoneal dialysis access procedures, permanent tunneled hemodialysis catheter placement, and endovascular procedures for arteriovenous dialysis access dysfunction. To date, we have performed 893 procedures during a period of 2 years. This article describes our approach and the tools required to develop a DIN program at an academic medical center.

Academic Medical Centers↗

PubMed1999

Latin American nephrology: scientific production and impact of the publications.

BACKGROUND: During the last two decades, there has been a significant change in the origin and impact of the world's biomedical scientific production, particularly in countries in which the investment in research accounts for an important portion of the gross national product (GNP). However, in less developed countries, budget restrictions and the lack of policies toward research may determine a limited growth of the scientific production. METHODS: We examined the number and impact of peer-reviewed publications from Latin America included in the Institute of Scientific Information (ISI) and MEDLINE databases. In addition, we analyzed the number of abstracts submitted to the congresses of the International Society of Nephrology (ISN), American Society of Nephrology (ASN), and Latin American Society of Nephrology and Hypertension (SLANH). RESULTS: The number of peer-reviewed publications in nephrology from authors in Latin America during the last 20 years represented less than 1% of the world's total. Only 13 out of the 22 Latin American countries accounted for these publications. The citation impact (3.52) was below the world average (7.82). However, this index showed a tendency towards growth in the five most productive countries. Likewise, the number of abstracts submitted to international meetings of nephrology by authors in Latin American countries has shown a steady growth in the recent years, but remains proportionately low compared with the rest of the world. CONCLUSIONS: This study indicates that although efforts toward improving the quantity and quality of research in Latin America have been made, the final results are less than other regions in the world. Possible factors responsible for the low performance include a failure in academic motivation and lack of pressure for publication, as well as limited research funding. Therefore, important efforts from local and international nephrological communities are needed to boost research in Latin America.

Developing Countries↗

PubMed2004

The short- and long-term impact of multi-disciplinary clinics in addition to standard nephrology care on patient outcomes.

BACKGROUND: This two country case control study of incident dialysis patients evaluates the outcomes of patients exposed to formalized multi-disciplinary clinic (MDC) programmes vs standard nephrologist care. METHODS: Patients commencing dialysis in two centres (Vancouver, Canada and Cremona, Italy) were evaluated at and after dialysis start, as a function of MDC exposure vs nephrologist care alone. Only chronic kidney disease patients, with longer than 3 months of exposure to nephrology care, who had not previously received kidney replacement therapy were included. Study outcomes included laboratory parameters and survival. The MDC was similar in both countries and average exposure was 6-8 h per patient-year, as compared to 2-4 h for standard care. All patients had equal access to resources prior to dialysis and with respect to dialysis start, as all had been referred to the same local nephrology practices. RESULTS: During the evaluation period 288 patients commenced dialysis after receiving more than 3 months nephrology care prior to dialysis. There were no major demographic differences between the cohorts. Mean duration of nephrology care prior to dialysis was 42 months, and dialysis was initiated at similar low glomerular filtration rate (GFR), though statistically significantly different (7.0 and 8.4 ml/min/m2, P = 0.001). The MDC patients had higher haemoglobin (102 vs 90 g/l, P<0.0001), albumin (37.0 vs 34.8 g/l, P = 0.002) and calcium levels (2.29 vs 2.16 mmol/l, P<0.0001) at dialysis start. Survival was significantly better in the MDC group demonstrated by Kaplan-Meier analysis (P = 0.01). Cox proportional hazards analysis demonstrated standard nephrology clinic vs MDC attendance was a statistically significant independent predictor of death (hazards ratio = 2.17, 95% confidence interval 1.11-4.28) after adjusting for other variables known to impact outcomes. CONCLUSIONS: This analysis of outcomes in two different countries suggests that despite equal and long exposure to nephrology care prior to dialysis, there appears to be an association of survival advantage for those patients exposed to formalized clinic care in addition to standard nephrologist follow-up. While other known predictors of survival such as adequacy of dialysis and severity of illness measures were not included in the model, those parameters require time on dialysis to be accumulated. Thus, the data do suggest that knowledge of patient status at the time of dialysis start is important. Further research is needed to determine which specific components of care both prior to dialysis and after its commencement are most important with respect to outcomes.

Adult↗

PubMed2006

Management of cardiovascular risk factors in advanced type 2 diabetic nephropathy: a comparative analysis in nephrology, diabetology and primary care settings.

OBJECTIVES: Advanced diabetic nephropathy (DN) is characterized by a marked development of cardiovascular and renal disease. These patients are frequently managed by different health professionals with the consequence that the quality of care may differ substantially. To compare the management of cardiovascular risk factors in patients with type 2 DN and an estimated glomerular filtration rate (GFR) of 15-60 ml/min per 1.73 m2 followed in nephrology, diabetology and primary care. METHODS: This multicentre cross-sectional study verified the control of blood pressure (BP), total cholesterol, triglycerides, glycosylated haemoglobin A1c (HbA1c) and haemoglobin in patients exclusively followed in either nephrology (n = 266), diabetology (n = 246) or primary care (n = 195) of the same metropolitan area for at least 1 year. RESULTS: Primary care patients were older and had a greater prevalence of previous cardiovascular events. The GFR was lower in nephrology than in diabetology and primary care (33 +/- 13 versus 47 +/- 9 and 40 +/- 12 ml/min per 1.73 m2, P < 0.0001). The prevalence of BP target (< 130/80 mmHg) was similarly low in nephrology, diabetology and primary care (14, 13 and 10%, P = 0.421) probably because of insufficient prescription of diuretics and low-salt diet. Whereas the prevalence of the triglycerides target was similar, that of total cholesterol (< 200 mg/dl) was larger in diabetology (63%) than in nephrology and primary care (59 and 46%, P = 0.003) because of greater statin prescription in hypercholesterolemic individuals (70, 50 and 41%, respectively, P = 0.002). The attainment of HbA1c less than 7% was less frequent in diabetology (32%) than in nephrology and primary care (61 and 46%, P = 0.0003) despite a more frequent prescription of insulin/oral agents in diabetology. The control of anaemia was better in diabetology. Multivariate analysis adjusted for the patient case-mix and physician-level clustering confirmed these differences except for anaemia. CONCLUSION: Patients with advanced DN, despite the worst renal and cardiovascular prognosis, are at high risk of being under-treated independently of the type of clinical setting.

Adult↗

PubMedDate not supplied

[Evolution of E.M. Tareev views in the field of nephrology].

An original nephrological scientific conception of E. M. Tareev developed in five stages. Stage one (1917-1929) is a functional-physiological approach to renal pathology. The first book devoted to this problem was "Bright' Disease" (1929). At stage II (1929-1936) E. M. Tareev closely investigated pathogenesis and clinical aspects of renal diseases. His views at that time were reflected in the book "Renal Diseases" (1936). Fundamental, experimental and clinical basis of the nephrological conception was formulated at stage III (1936-1952). At stage IV (1952-1968) E. M. Tareev proposed a new classification of renal diseases presented in the book "Nephritides" (1958). Stage V (1968-1986) was devoted to the integrating role of nephrology. Two books "Fundamentals of Nephrology" (1972) and "Clinical Nephrology" (1983) contributed much to fundamentals of current nephrology.

History, 20th Century↗

PubMedDate not supplied

[Nephrology evidence and guidelines: current tools and several still open questions].

BACKGROUND: It is widely accepted that decision making should be based on evidence. Although nephrology is a relatively young discipline of internal medicine that should be quick to adopt evidence-based decision making policies, several problems are slowing the progress to an era of evidence-based nephrology. These problems may be identified as: a) an inadequate knowledge-base for problems related to the utilization of evidence-based research resources; b) the unavailability of adequate evidence sources in nephrology; and c) the small investment and funding for clinical research. METHODS: This review outlines the major problems of evidence-based nephrology and looks particularly at the strengths and weaknesses of study designs for evidence-based nephrology. The primary guidelines for evidence-based preparation are presented together with possible strategies to meet the challenge of adopting evidence-based policies in nephrology. CONCLUSIONS: This challenge is particularly important now; after several years of extraordinary basic science research, we face the problem of improving clinical practice by applying this same progress in basic science. This transition has failed because of the small investment provided for clinical research.

Evidence-Based Medicine↗

PubMed1990

Appropriate training in paediatric nephrology for developing countries: hypothesis and proposals.

Appropriate training in paediatric nephrology is a comprehensive approach designed to develop skills and capabilities to deal with the following basic components of medical care: (1) medical competence for clinical and research activities; (2) interpersonal relationships directed at maintaining patients' freedom and autonomy; and (3) adequate incorporation of technological, financial and managerial aspects of paediatric nephrology services. Inappropriate training causes frequent, dramatic and paradoxical negative feedback in developing countries: shortage of functioning medical equipment, skilled manpower and trained paediatric nephrologists co-exist with unused high-cost medical equipment and loss of skilled health care professionals. Appropriate training, tailored to the needs and resources of developing countries, could be an efficient way to develop high-quality paediatric nephrology care. Efficient training must develop self-reliant, self-sufficient and skilled health care professionals in the local economic, educational, technological and political context. Regional and international co-operation is essential to promote adequate training in paediatric nephrology. Developing countries lack an effective and accurate information communication network for selecting modern technology for paediatric nephrology. The development of this network through international co-operation, is an urgent requirement.

Developing Countries↗

PubMed2002

Nephrology consultation in acute renal failure: does timing matter?

PURPOSE: Patients who develop acute renal failure in the intensive care unit (ICU) have extremely high rates of mortality and morbidity. The goals of this study were to identify correlates of the timing of nephrology consultation in acute renal failure, and to explore the relation between timing of consultation and outcomes. METHODS: We explored associations among timing of nephrology consultation and in-hospital mortality, lengths of hospital and ICU stay, and recovery of renal function in 215 ICU patients with acute renal failure at four U.S. teaching hospitals. We used multivariable logistic regression and propensity scores to adjust for confounding and selection effects. RESULTS: Nephrology consultation was delayed (>or=48 hours) in 61 patients (28%) (median time to consultation, 4 days). Lower serum creatinine levels (P <0.0001) and higher urine output (P = 0.002) were associated with delayed consultation. Delayed consultation was associated with increased mortality among dialyzed (31/42 [74%] vs. 50/103 [49%], P = 0.006) and nondialyzed patients (10/19 [53%] vs. 11/51 [22%], P = 0.01), and increases in lengths of hospital (median, 19 days vs. 16 days, P = 0.01) and ICU stay (17 days vs. 6 days, P <0.0001). The association between delayed consultation and mortality was attenuated by covariate adjustment, and was no longer statistically significant after adjustment for propensity score (odds ratio = 2.0; 95% confidence interval: 0.8 to 5.1). CONCLUSION: In acute renal failure, delayed nephrology consultation was associated with increased mortality and morbidity, whether or not dialysis was ultimately required. Using observational data, we cannot determine whether these findings reflect residual confounding, selection bias, adverse effects of delayed recognition of acute renal failure, or the benefits of nephrology consultation.

Acute Kidney Injury↗

PubMed1998

Nephrology nurse practitioners in a collaborative care model.

The use of nurse practitioners in the primary care setting is increasingly common. However, little information is available on their use in specialty care areas. This is especially true in nephrology, in which end-stage renal disease (ESRD) lends itself well to this type of practice. We describe our experience with a university-based collaborative care model for ESRD with nurse practitioners in nephrology. Our experience shows that nephrology nurse practitioners have a significant impact on extending the quality and quantity of patient care provided by the nephrologist. They facilitate a holistic patient-friendly approach, and, as an integral part of the collaborative model, there is an associated significant decrease in patient mortality relative to standard comparators. Nurse practitioners provide a large amount of care for ESRD patients in a relatively independent fashion but under the supervision and with the collaborative interaction of nephrologists. Patient satisfaction, approval, respect, and trust for the nurse practitioners are exceptional. The use of nephrology nurse practitioners provides the potential for augmenting patient care, satisfaction, and access to care. It provides an avenue for potential cost reduction in nephrology while maintaining quality of care. It further provides a partial solution to the anticipated shortage of nephrologists in the twenty-first century.

Humans↗

PubMed1999

Role of physician assistants in dialysis units and nephrology.

We surveyed physician assistants who work in nephrology to report their experience level, primary employer, salary, job responsibilities, and job satisfaction. Additional data were obtained from the Nephrology Manpower Study. The 67 responding physician assistants of 97 surveyed have 10.8 +/- 6.5 years (mean +/- standard deviation) total experience (6.2 +/- 5.0 years in nephrology). Typically, nephrologists (56.1%) or hospitals (30.3%) employ them. The majority (74%) earn $49,999 to $75,000; 79.1% work in outpatient units, 52.4% in inpatient units, 52.4% in hospitals, 43.3% in outpatient offices, and 23.9% in transplant units. In outpatient units, they manage 111 +/- 111 patients, mostly in free-standing (71.1%), for-profit (69.7%), corporately owned (87.3%) units in urban (80%) or suburban (18%) areas. Most (>85%) manage all dialysis- and nondialysis-related problems, including health maintenance; 84.3% are contacted first by staff, and 78% see patients more often than physicians. Of nephrologists who responded to the Manpower Study, 8.9% work with physician assistants and 20.7% work with nurse practitioners. Nephrologists in academic practice or private nephrology groups are more likely to use physician assistants (P < 0.05) and nurse practitioners (P < 0.005) than those in solo practice or multispecialty groups. Nephrologists with physician assistants (33.8 +/- 19.5 v 41.7 +/- 16.8 h/wk) or nurse practitioners (35.8 +/- 18.1 v 42.7 +/- 16.9 h/wk) tended to spend less time in direct patient care than those without physician extenders (P < 0.001). Nephrologists with renal fellows, however, spent the least time of all in direct patient care (30.0 +/- 15.9 v 47.3 +/- 14.9 h/wk; P < 0.001). Physician assistants can perform nearly all the medical tasks in dialysis units. They may offer one approach to providing effective and complete care for patients if nephrology manpower becomes limited.

Hemodialysis Units, Hospital↗