Professional Documents
Culture Documents
GFW 359
GFW 359
GFW 359
|| 40. An WS, Kim SE, Kim KH et al. Associations between oxidized LDL to LDL
in vascular calcification in patients on hemodialysis. Kidney Int 2005; 67: || ratio, HDL and vascular calcification in the feet of hemodialysis patients. J
1532–1538 || Korean Med Sci 2009; 24 (Suppl): S115–S120
31. Block GA, Raggi P, Bellasi A et al. Mortality effect of coronary calcification || 41. Sun L, Zou L, Chen M et al. Meta-analysis of statin therapy in maintenance
and phosphate binder choice in incident hemodialysis patients. Kidney Int
|| dialysis patients. Ren Fail 2015; 37: 1149–1156
||
2007; 71: 438–441 || 42. M€arz W, Genser B, Drechsler C et al. Atorvastatin and low-density lipopro-
32. Schwarz U, Buzello M, Ritz E et al. Morphology of coronary atherosclerotic || tein cholesterol in type 2 diabetes mellitus patients on hemodialysis. Clin J
lesions in patients with end-stage renal failure. Nephrol Dial Transplant || Am Soc Nephrol 2011; 6: 1316–1325
2000; 15: 218–223
|| 43. Yazbek DC, de Carvalho AB, Barros CS et al. Cardiovascular disease in early
||
33. Floege J, Kim J, Ireland E et al. Serum iPTH, calcium and phosphate, and || kidney transplantation: comparison between living and deceased donor
the risk of mortality in a European haemodialysis population. Nephrol Dial || recipients. Transplant Proc 2012; 44: 3001–3006
Transplant 2011; 26: 1948–1955 || 44. Kim HG, Song SW, Kim TY et al. Risk factors for progression of aortic arch
34. Floege J, Gillespie IA, Kronenberg F et al. Development and validation of a
|| calcification in patients on maintenance hemodialysis and peritoneal dialy-
||
predictive mortality risk score from a European hemodialysis cohort. || sis. Hemodial Int 2011; 15: 460–467
Kidney Int 2015; 87: 996–1008 || 45. Roberts WC, Taylor MA, Shirani J. Cardiac findings at necropsy in patients
35. Palmer SC, Craig JC, Navaneethan SD et al. Benefits and harms of statin || with chronic kidney disease maintained on chronic hemodialysis. Medicine
||
therapy for persons with chronic kidney disease: a systematic review and || 2012; 91: 165–178
meta-analysis. Ann Intern Med 2012; 157: 263–275 || 46. Pruijm M, Schmidtko J, Aho A et al. High prevalence of anti-
36. Steinberg D. The LDL modification hypothesis of atherogenesis: an update. || apolipoprotein/A-1 autoantibodies in maintenance hemodialysis and associ-
J Lipid Res 2009; 50 (Suppl): S376–S381
|| ation with dialysis vintage. Ther Apher Dial 2012; 16: 588–594
||
37. Samouilidou EC, Karpouza AP, Kostopoulos V et al. Lipid abnormalities || 47. Herrington W, Haynes R, Staplin N et al. Evidence for the prevention and
and oxidized LDL in chronic kidney disease patients on hemodialysis and || treatment of stroke in dialysis patients. Semin Dial 2015; 28: 35–47
peritoneal dialysis. Ren Fail 2012; 34: 160–164 || 48. Findlay MD, Thomson PC, Fulton RL et al. Risk factors of ischemic stroke
38. Johnson-Davis KL, Fernelius C, Eliason NB et al. Blood enzymes and oxida-
|| and subsequent outcome in patients receiving hemodialysis. Stroke 2015; 46:
||
tive stress in chronic kidney disease: a cross sectional study. Ann Clin Lab || 2477–2481
Sci 2011; 41: 331–339 ||
39. Pawlak K, Mysliwiec M, Pawlak D. Oxidized low-density lipoprotein || Received: 1.3.2016; Editorial decision: 6.9.2016
(oxLDL) plasma levels and oxLDL to LDL ratio—are they real oxidative
||
||
stress markers in dialyzed patients? Life Sci 2013; 92: 253–258 ||
||
usual care on the proportion of patients using ACEI/ARBs [14, || BP target. Three studies [21, 22, 24] reported the proportion
21]. The proportion of patients using ACEI/ARBs did not differ || of patients achieving a prespecified BP target (130/80 or 140/80
between computer-assisted interventions and usual care
|| mmHg). The proportion was similar for education-based com-
||
[pooled OR 1.00 (95% CI 0.83–1.21)] (Figure 2) (I2 ¼ 0.0%, P- || pared with computer-assisted interventions [pooled OR 1.11
value ¼ 0.60). Three studies [21, 22, 24] provided data sufficient
|| (95% CI 0.90–1.37)] (Figure 3), with no evidence of heterogene-
||
to compare ACEI/ARB use between education-based and || ity across studies included (I2 ¼ 0.0%, P ¼ 0.86).
||
computer-assisted interventions; similarly, the proportion of ||
patients using ACEI/ARBs did not differ [pooled OR 1.12 (95% || Proteinuria assessment. Two [22, 24] studies provided suf-
||
CI 0.77–1.64)] (Figure 2) with no evidence of heterogeneity in || ficient information to compare the effects of education-based
the magnitude of effect across the included studies (I2 ¼ 0.0%, P || interventions with computer-assisted interventions on the pro-
||
¼ 0.87). portion of patients having a proteinuria measurement (binary
116
Author (year) Country Inclusion criteria Intervention (category) Comparator Unit of Total no. Mean Patient Outcomes reported Timeline
of origin randomization of patients patient gender
(no. of age (% male)
clusters) (years)
Cortés-Sanabria Mexico Primary health care 6-months education based on Usual care Clinic 94 (2) 62.0 43.5 Clinical competence of 6-months intervention;
et al. (2008) units, patients with type theory-practice model physicians; BP; BMI; smok- outcomes assessed at
2 diabetes and CKD ing cessation; alcohol cessa- enrollment, 6- and
tion; glucose; cholesterol; 12-month time points
albuminuria; eGFR; use of
antihypertensives, antidia-
betics, statins, NSAID use
Abdel-Kader USA CKD patients (eGFR Two 15-min education Two 15-min Physician 248 (30) 65.3 37.7 EMR order for nephrology 12-month interven-
et al. (2011) <45 mL/min/1.73 m2) sessions (education related) þ education sessions practice consultation; Albuminuria tion; outcomes
in the 12 months prior real-time automated EMR (education related) or proteinuria; ACEI/ARB, assessed 1 year before
to their visit and had alerts (EMR related) for NSAID use; documentation and 1 year after
never been evaluated by patients with eGFR of CKD; achievement of (exceptions ACEI/
a nephrologist <45 mL/min/1.73 m2 target BP; BP; eGFR; Hb; ARB assessed at onset
bicarbonate; calcium; and after
phosphorus; PTH
Drawz et al. USA Primary care clinics, Access to web-based CKD Lecture on CKD Patients 781 (N/A) 71.0 95.2 PTH measurement; 12-month interven-
(2012) CKD patients (eGFR registry (EMR related) þ guidelines achievement of target BP; tion; outcomes
<60 mL/min/1.73 m2 lecture on CKD guidelines (education related) phosphorous; proteinuria; assessed 1 year before
based on two readings (education related) Hb measurement; use of and 1 year after
between 90–730 days ACEI/ARB, diuretica
previous
Manns et al. Canada Primary care practices, Enhanced eGFR laboratory Standard eGFR Clinic 5444 (90) 78.1 44.8 ACEI/ARB prescription; 12-month interven-
(2012) elderly (>66 years old) prompt (EMR related) laboratory prompt cholesterol lowering medi- tion; outcomes
CKD patients defined (usual care) cation; new class antihyper- assessed within 1 year
by eGFR <60 mL/min/ tensive medication; of first prompt
1.73 m2 with diabetes or nephrologist consultation;
proteinuria albuminuria measurement;
Lipid measurement; Hb
A1C measurement
de Lusignana UK Primary care clinics, Audit-based education Usual care Clinic 504 207 (93) 75.0 33.9 Reduction in SBP over time; 2-year intervention;
et al. (2013) CKD patients (eGFR (education related) involved incident cases of cardiovas- outcomes assessed
<60/mL/min/1.73 m2) feedback and training at data cular disease; eGFR between earliest and
based on two readings quality workshops, printed latest measurements
at least 90 days apart aids, target patient lists.
Guidelines and prompts
(EMR related) involved
academic detailing, printed
information including CKD
guidelines, and access to an
information website
Outcomes reported in studies included continuous variables, expressed as means, and categorical variables, expressed as numbers or proportions.
KDOQI, Kidney Disease Outcomes Quality Initiative; N/A, not applicable; BP, blood pressure; Hb, hemoglobin; TG, triglyceride; SCr, serum creatinine; SBP, systolic blood pressure; PTH, parathyroid hormone; ACEI/ARB, angiotensin-converting
enzyme inhibitor or angiotensin receptor blocker; EMR, electronic medical record; NSAID, nonsteroidal anti-inflammatory drug; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate.
a
Outcomes reported as ORs.
L. Galbraith et al.
Table 2. Risk of bias assessment of included trials using the Cochrane Collaboration Tool for Assessing Risk of Bias
FIGURE 2: Forest plot of studies reporting the odds of ACEI/ARB use in CKD patients between computer-assisted CDM interventions and
usual care and education-based and computer-assisted CDM interventions using random effects analysis.
measure). The proportion of patients with a proteinuria assess- intervention types [WMD 0.32 mL/min/ 1.73 m2 (95% CI
||
ment did not differ [pooled OR 0.87 (95% CI 0.41–1.84)] || 2.37–1.73)], with no evidence of heterogeneity (I2 ¼ 0.0%, P
(Figure 3), with moderate heterogeneity across the included || ¼ 0.89) (Figure 4).
||
studies (I2 ¼ 63.7%, P ¼ 0.09). ||
||
|| Publication bias. Publication bias could not be assessed due
Mean change in SBP. The mean difference in SBP postinter- || to inconsistency of data reporting in the included studies.
||
vention between the education-based and computer-assisted ||
interventions was included as an outcome in two [21, 24] stud- ||
||
ies identified. The mean difference in SBP did not differ ||
|| DISCUSSION
[weighted mean difference (WMD) 0.59 mmHg (95% CI
||
2.80–1.61)] across the interventions, with no evidence of het- || Our systematic review assessing CDM interventions targeting
erogeneity across the included studies (I2 ¼ 0.0%, P ¼ 0.76) ||
|| primary care providers who care for CKD patients in the com-
(Figure 4). || munity identified a critical lack of studies, with only five rele-
||
|| vant RCTs and with only four eligible for inclusion in the meta-
Mean change in eGFR. Two studies [21, 24] reported the || analysis. When compared with usual care, computer-assisted
||
mean change in eGFR for patients within the education-based || interventions had no effect on ACEI/ARB use among CKD
interventions compared with computer-assisted interventions. || patients. A head-to-head comparison of education-based versus
||
There was no difference in the mean eGFR between the computer-assisted CDM interventions also found no effect on
FIGURE 4: Forest plot of studies comparing education-based to computer-assisted CDM interventions on the mean weighted difference of
SBP and eGFR in CKD patients using random effects analysis.
any of the patient outcomes or processes of care. However, these assessment and care for these patients. Unfortunately, evi-
||
findings are limited by the considerable lack of evidence for all || dence suggests that many physicians are unfamiliar with the
CDM intervention types targeting primary care providers man- || CKD guidelines, resulting in a significant barrier to uptake
||
aging patients with CKD. || in practice [25–27]. Moreover, dissemination and implemen-
The Kidney Disease: Improving Global Outcomes || tation of guidelines into practice alone is insufficient to
||
(KDIGO) clinical practice guidelines for evaluation and || overcome the challenges of daily management of CKD [9],
management of CKD patients were developed to standardize || as patients with CKD often have numerous comorbid
||