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PubMed2002

Training, certification, and reimbursement for nephrology procedures.

The field of interventional nephrology is rapidly developing as an important new area of nephrology practice that holds great promise for improved patient care, outcomes, and cost control. This development is contingent on nephrologists acquiring the necessary knowledge and skills through suitable training and experience, and obtaining hospital privileges to perform these interventions. As more training programs are created, and credentialing criteria are established and accepted, it will become more practical for nephrologists to become interventionists. Reimbursement for interventional procedures can be complicated and confusing, with special problems applicable to a nephrology practice involved in the overall care of end-stage renal disease (ESRD) patients. It is essential to become familiar with applicable procedure codes, global periods, and code modifiers to correctly describe these procedures and receive correct reimbursement. Nephrologists work together with vascular access surgeons and interventional radiologists to provide care for dialysis patients. The role of each specialist in the management of vascular access depends on his or her level of interest, knowledge, and technical skill. These roles may vary considerably from one practice to another. There is potential for this area to become highly contentious, especially if one specialist feels threatened by the activities of another. Optimal patient care will be achieved only if all involved physicians take a serious intellectual interest in vascular access, develop superior clinical skills, and maintain cooperative, collegial, relationships.

Certification↗
PubMed1997

Nephrology and renal replacement therapy in Romania.

BACKGROUND: In the context of the transformation of the Health Systems of Central and Eastern European countries, the role of professional associations is increasing, especially as regards data collection, analysis, and implementation of programmes for development of nephrology and renal replacement therapy (RRT). METHODS: The Romanian Renal Registry sent questionnaires to the heads of Haemodialysis and Nephrology Centres. The need for renal replacement therapy was deduced from the annual incidence (127 patients p.m.p.) of chronic renal failure. RESULTS: Although the rates of increase in the numbers of Nephrology Departments (+82%), HD Centres (+142%), and total number of patients alive on RRT (+196%) from 1991 to 1995 were higher than the European mean, only 27-30% of the incident patients (459 of 1000-1200 patients) could be provided with RRT. Sixty-two percent of the need for RRT in the age group 25-44 years was met, while only 20% of children (age < 15 years) and people over 55 years requiring RRT received this treatment. Primary renal diseases in patients on RRT were glomerulonephritis (49%) or interstitial nephropathies (23%); diabetic nephropathies, nephroangiosclerosis and systemic diseases were rare (4, 2, and 1% respectively). Most of the CRF patients (88%) were treated by HD. Renal transplantation and peritoneal dialysis were seldom performed (8 and 4%). The cost of HD treatment in Romania (87 USD) is low, even though dialyser reuse is not common practice. CONCLUSIONS: The increase in renal replacement therapy in Romania was mainly due to the expansion of the number of haemodialysis centres. Although a significant progress was realized, only one-third of the patients needing RRT could be treated in Romania in 1995.

Adolescent↗
PubMed2004

Decisions concerning potentially life-sustaining treatments in paediatric nephrology: a multicentre study in French-speaking countries.

BACKGROUND: Few studies have looked at how decisions are made to withhold or to withdraw potentially life-sustaining treatments (LST) in paediatric nephrology. The aim of this work was to evaluate such practices in all nephrology centres in French-speaking European countries, so that guidelines could be discussed and drawn up by professionals. METHODS: We used semi-directed interviews to question health care professionals prospectively. We also retrospectively analysed the medical files of all children (n = 50) for whom a decision to withhold or to withdraw LST had been made in the last 5 years. The doctors (n = 31) who had been involved in the decision-making process were interviewed. RESULTS: All 31 of the French-speaking paediatric nephrology centres in Europe were included in this study. Of these, 18 had made decisions in the previous 5 years about withholding or withdrawing LST. Resultant quality of life, based on long-term living conditions, was the principal criterion used to make the decisions. Relational aspects of life and the child's prognosis were also considered. The decision-making processes were not always collective, even though interactions between doctors and the rest of the medical team seemed to be key elements to them. The parents' involvement in the decision-making process differed between centres. CONCLUSIONS: The criteria used to decide whether to withhold or to withdraw LST are not standardized, and no specific guidelines exist.

Child↗
PubMed2006

Decline in kidney function before and after nephrology referral and the effect on survival in moderate to advanced chronic kidney disease.

BACKGROUND: The burden of chronic kidney disease (CKD) is high, but its natural history and the benefit of routine nephrology care is unclear. This study investigated the decline in kidney function prior to and following nephrology referral and its association with mortality. METHODS: This study provides a retrospective review of the individual rates of glomerular filtration rate (GFR) decline (millilitre per minute per 1.73 m(2)/year) for the 5 years before and after referral in 726 new referrals with stages 3-5 CKD to one renal unit between 1997 and 2003. Blood pressures are averages at referral, 1 and 3 years post referral. Logistic regression and Cox's models tested factors predicting post-referral GFR decline and the impact on mortality. RESULTS: Mean (SD) age was 72 (14), and 389 (54%) patients had stages 4-5 CKD. GFR decline slowed significantly from -5.4 ml/min/1.73 m(2)/year (-13. to -2) before to -0.35 ml/min/1.73 m(2)/year (-3 to +3) after referral (P < 0.001). Blood pressure also reduced significantly (155/84 to 149/80, P < 0.05) with most changes occurring within 1 year of referral. Factors predicting a non-progressive post-referral decline included a lower systolic blood pressure at referral and 1 year after referral, a CKD diagnosis other than diabetic nephropathy, less baseline proteinuria and a non-progressive pre-referral GFR decline. A non-progressive post-referral GFR decline was independently associated with significantly better survival (hazard ratio 0.55, 95% CI 0.40-0.75, P <or = 0.001) after adjustment for known risk factors. CONCLUSIONS: Following nephrology referral, GFR decline slowed significantly and was associated with better survival. Earlier detection of patients with progressive CKD and interventions to slow progression may have benefits on both kidney and patient survival.

Aged↗
PubMed2006

The acquisition and exercise of nephrology nursing expertise: a grounded theory study.

AIMS AND OBJECTIVES: This purpose of this study was to describe the process of expertise acquisition in nephrology nursing practice. BACKGROUND: It has been recognized for a number of decades that experts, compared with other practitioners in a number of professions and occupations, are the most knowledgeable and effective, in terms of both the quantity and quality of output. Studies relating to expertise have been undertaken in a range of nursing contexts and specialties; to date, however, none have been undertaken which focus on nephrology nursing. DESIGN: This study, using grounded theory methodology, took place in one renal unit in New South Wales, Australia and involved six non-expert and 11 expert nurses. METHODS: Simultaneous data collection and analysis took place using participant observation, semi-structured interviews and review of nursing documentation. FINDINGS: The study revealed a three-stage skills-acquisitive process that was identified as non-expert, experienced non-expert and expert stages. Each stage was typified by four characteristics, which altered during the acquisitive process; these were knowledge, experience, skill and focus. CONCLUSION: This was the first study to explore nephrology nursing expertise and uncovered new aspects of expertise not documented in the literature and it also made explicit other areas, which had only been previously implied. Relevance to clinical practice. Of significance to nursing, the exercise of expertise is a function of the recognition of expertise by others and it includes the blurring of the normal boundaries of professional practice.

Clinical Competence↗
PubMedDate not supplied

Interventional nephrology in Brazil: current and future status.

The care of chronic kidney disease patients frequently involves many diagnostic and interventional procedures. Most of these procedures are currently performed by radiologists, vascular surgeons, and general surgeons. This has caused fragmented medical care, which has led many nephrologists to introduce a new paradigm, often referred as interventional nephrology (IN). The aim of this study was to establish the extent of involvement of the Brazilian nephrology community with regard to specific IN procedures. From October 2004 to February 2005, questionnaires were sent by e-mail to all 2500 nephrologists throughout Brazil. The enrollment questionnaire was composed of five sections, with questions about renal biopsy, specific training in ultrasonography, peritoneal dialysis access (insertion of peritoneal catheters guided or not by peritoneoscopy), hemodialysis vascular access (ability to place tunneled catheters, construction of arteriovenous fistulas, and other vascular access procedures), and the nephrologist's interest in being trained in IN. A total of 239 nephrologists answered the questionnaire. Only 18% of Brazilian nephrologists perform kidney biopsy guided by ultrasonography assisted by a radiologist. On the other hand, 42% of them reported that this procedure was done without any image support. Most of the respondents (85%) indicated that they were not formally trained to perform renal ultrasonography. When asked about peritoneal dialysis catheter placement, 66% of the respondents reported that they referred their patients to a surgeon for this procedure. The insertion of peritoneal dialysis catheters guided by peritoneoscopy was reported by 3% of the respondents. Similar to the results for peritoneal dialysis catheter placement, the majority of the respondents (77%) indicated no training in the insertion of tunneled catheters for temporary hemodialysis. Regarding the interest of nephrologists to participate in an IN program, the great majority (87%) responded that they would like to be trained in these procedures. Most nephrologists are not trained in IN procedures. Therefore, in Brazil, it will be necessary to develop training centers for IN that will allow nephrologists to optimize nephrology care.

Arteriovenous Shunt, Surgical↗
PubMed2002

The history of nephrology in the Talmudic corpus.

The kidneys, the bladder and nephrology in general were discussed in the Talmudic literature from their anatomical, pathological and philological aspects. The Sages' deliberations were based on the Biblical texts. The characteristic phraseology of the scriptures uses the kidneys as symbols of the human emotions, contrary to the heart, which is regarded as the location of wisdom. The kidney is considered to be the individual's seat of their deepest desires--perhaps because it is an "internal" organ, well hidden, surrounded by a capsule and by a layer of perinephric fat. The Talmudic corpus considers the kidneys to be the origin of secret counsels--"the kidneys advise". An injury to the kidneys is used symbolically as an example of a cruel and serious injury. The sages were concerned with nephrological problems such as a diseased kidney of small size, fluid and pus in the kidney, injuries, perforations and more. Fascinating advice is given regarding micturition, its timing, characteristics and significance. The Halakhah is concerned with the kidneys during the examination of an animal after slaughter for the fitness for its ritual consumption. The paper presents various nephrological diseases from the Talmudic corpus. Among them are, for example, "Tzemirtha"--urolithiasis; "Hydrakon"--hydronephrosis; "Suskhinta"--urinary retention; "Tzinit"--podagra, gout, and "Yerakon"--icterus. A survey of some Talmudic personalities will exemplify the existence of these conditions.

Animals↗
PubMed1985

Evaluation of recent research grant applications to the National Institutes of Health in the area of pediatric nephrology.

To assess the National Institutes of Health extramural activity in the area of pediatric nephrology research, the rate of submission of grant applications to the National Institutes of Health and available indicators of the quality of these applications were analyzed. This was accomplished by utilizing the grant application files of the Division of Research Grants' Statistics and Analysis Branch with the help of the Reports, Analysis and Presentation Section. Applications reviewed during the period 1980-1983 (May 1980 to January 1984 Council dates) were evaluated, and data from the 10 Study Sections most frequently involved with the review of nephrology applications were tabulated. Results showed that the number of pediatric nephrology applications submitted was quite low, whereas the approval rate was good for those that were submitted.

Evaluation Studies as Topic↗
PubMed1986

Nephrology in the United States from Osler to the artificial kidney.

Modern knowledge of renal physiology, kidney disease, and the body fluids in American medicine was established largely by Donald D. Van Slyke, Thomas Addis, John P. Peters, Homer W. Smith, and Alfred Newton Richards. Only two of these men were physicians, and through this group future nephrology was shaped by a dominant interest in metabolic problems and pathophysiology. Acute renal failure emerged as a new syndrome during World War II and fostered interest in hemodialysis and renal biopsy. Dialysis, when applied to chronic renal failure, eventually spawned an army of renal clinicians; and biopsy provided a specialist's nosology of what had once enjoyed the unity of "Bright's disease." A society and subspecialty board came late to nephrology and have been directed largely by renal academicians of the metabolic tradition. Nephrology is in the 1980s a bipartite subspecialty, its senior leaders still cherishing the metabolic-physiologic tradition, and a growing army of dialysis practitioners mostly looking after patients with chronic and acute renal failure.

Acute Kidney Injury↗
PubMed1999

History of women in nephrology (1918 to 1960).

Little has been written concerning the role of women in nephrology in America during the first half of the twentieth century. However, the records show that women scientists made substantial contributions to nephrology and definitely were involved in research efforts at a number of prestigious academic institutions that had interests focused on kidney function in health and disease. Here, we describe the contributions of some of these pioneering women scientists to whom nephrology shall always be indebted.

Female↗
PubMedDate not supplied

An evidence-based nephrology column in the JN.

Evidence-based medicine (EBM) combines clinical experience with the best available patient-centred medical knowledge. EBM is not restricted to randomised trials and meta-analyses. It involves finding the best studies (the best "external evidence") to answer the clinical questions we face in everyday clinical practice. This is a challenging framework where medical decisions absolutely cannot be based on a superficial or automatic approach to patient care. Interest in this approach is growing fast. The EB Nephrology Section of the Journal of Nephrology aims to help readers to update and extend their knowledge of the foundations, the tools and the products of EBM, with specific applications in the field of clinical nephrology.

Evidence-Based Medicine↗
PubMed2000

The political economy of nephrology.

An issue of Seminars devoted to "The Economics of Nephrology" requires consideration not only of the narrow economic issues affecting the specialty but also the public policies that establish its economic parameters. Some economic issues involve only the balancing of costs and revenues in a dialysis unit. Others turn on the ESRD policies of Medicare. Still others hinge on action by the US Congress and, by definition, are political in character. In nephrology, economics are intertwined with politics, hence the political economy of nephrology.

Humans↗
PubMed2001

[Contribution of clinical epidemiology to evidence-based nephrology].

Improvement of modern medicine does not make day-to-day practice of nephrology easier. Decision-making remains difficult, often requiring numerical, probabilistic approach. Contribution of clinical epidemiology to evidence-based nephrology is not limited to randomised-controlled trial. The concept of natural history: spontaneous evolution without treatment, has been developed in epidemiology to describe diagnosis and prognosis of diseases. For example, in IgA nephropathy, it allowed to measure the prognostic significance of gross hematuria or to design classification of end-stage renal failure. Epidemiologic studies needs appropriate designs, representative samples and correct methods of analysis. Like other medical research, epidemiology has some important methodological limits that must be taking into account. Practising evidence-based nephrology improves confidence in management decisions.

Epidemiology↗
PubMed2001

Identification and measurement of nurse sensitive outcomes in pediatric nephrology nursing.

Patient outcomes are increasingly the focus of research and are seen as primary indicators of nursing care quality. The identification and measurement of nurse-sensitive outcomes that actually reflect nursing care are more difficult than it seems. Many of the outcomes currently in use for nephrology patients are global in scope and influenced by many health professionals as well as patients and families. Further, outcomes appropriate for adult nephrology patients may need modification for pediatric patients or may not work at all. This article explores issues related to identifying outcomes related to the nursing care of pediatric nephrology patients, reviews selected outcomes, and describes measurement strategies.

Age Factors↗
PubMedDate not supplied

Improvement in clinical outcome by early nephrology referral in type II diabetics on maintenance peritoneal dialysis.

OBJECTIVES: To evaluate the influence of early nephrology referral on clinical outcome in type II diabetes mellitus patients on maintenance peritoneal dialysis (PD). DESIGN: This is a retrospective study in a single University Hospital in Taiwan. PATIENTS: This study analyzed the type II diabetic patients entering our PD program from February 1988 to June 2000. Patients that were presented to a nephrologist more than 6 months before starting dialysis were defined as early referrals (ER). Patients were considered late referrals (LR) if they were transferred to the nephrology department within 6 months before initial dialysis. MAIN OUTCOME MEASURES: Patient survival and technique survival curves were derived from Kaplan-Meier analysis and were compared using the Cox-Mantel log rank test. Covariates were analyzed with Cox proportional hazards model. RESULTS: 52 type II diabetic patients were enrolled in this study: 16 in the ER group and 36 in the LR group. Patient survival was better in the ER group than in the LR group [relative risks [exp(coef)] 0.42; 95% confidence interval 0.152-0.666; p < 0.05]. The improved survival in the ER group was independent of age at dialysis, good glycemic control, and residual renal function, as indicated in the multivariate analysis with stepwise regression by Cox proportional hazards model. The ER group was also associated with better technique survival. CONCLUSIONS: These results suggest that early nephrology referral before initiating dialysis is associated with improved long-term clinical outcome in type II diabetics on maintenance PD.

Aged↗
PubMedDate not supplied

[Critical appraisal of systematic reviews of randomised trials in nephrology: theory and practice for interpreting level I evidence].

INTRODUCTION: Systematic reviews represent the primary level of evidence (level I evidence) and an excellent answer to causality questions. They should be based upon high quality standards and the critical appraisal of such study design is fundamental. METHODS: In this review we introduce the primary indicators of quality and guide our readers through the process of critical appraisal of systematic reviews. RESULTS: The main criteria in critically appraising systematic reviews in nephrology are the adequate presentation of a research question, adequate selection of studies, comprehensiveness of search strategies, the quality assessment of included studies, the fact that all procedures have been performed independently by at least 2 investigators, the exploration of heterogeneity, the type of results and their applicability. In nephrology we still lack a large number of systematic reviews because of the lack of randomised trials. CONCLUSIONS: Preparing a large number of systematic reviews is an important challenge for the nephrology community. This community should prepare more randomised trials to answer intervention questions and should make an effort to synthesise the evidence in the form of systematic reviews. It is essential that available systematic reviews be critically appraised and their results implemented in the clinical practice whenever they are based on high methodological standards.

Nephrology↗
PubMed1992

[Molecular biological approaches in nephrology].

Recent explosive advances in molecular biological techniques have greatly expanded their applications, and they are now widely employed in nephrology. Main applications of molecular biological techniques in the field of nephrology are 1) molecular cloning of genes coding important proteins, 2) analysis of gene expressions, 3) approach using transgenic animals, 4) molecular genetic approach for inheritable diseases such as adult polycystic kidney disease. These techniques are now considered to be one of the most important and powerful tools in the field of nephrology.

Animals↗
PubMed2005

[Extra-hospital nephrology: a challenge for our near future].

The Spanish nephrology is one of the medical specialties that have experienced a greater development in the last years. Defined initially as an activity in the hospital and consolidated in this sense, at the present time the "Libro Blanco of the Spanish Nephrology" makes a call of attention on the necessity of a change of welfare direction. The attention was called on the little development of the prevention activities and the delay in the arrival of the patient to the Service of Nephrology, which causes a worsening of his pathology. In order to approach us this reality it is necessary to give priority to the attendance of the patient out of the hospital and to guarantee a logical continuity between welfare levels. The welfare initiatives that have been carried out in the Spanish territory are scarce and still insufficient. The progressive increase in the incidence and prevalence of the ERD associated with a bad evolution and elevated costs is converting ERD in an important problem of public health, that requires specific plans of detection and prevention. The improvement of the coordination between general practioners and nephrologists is necessary. Multiple papers show a delayed reference of the patients with renal disease to the nephrologists. The initiatives of coordination between both levels should be centered in studies epidemiologists that clarify the real meaning of the renal pathology and in educating the GP on the early reference to the nephrologist of the patients with renal failure.

Family Practice↗