The augmented nurse care management intervention resulted in reduced hospitalizations in late-stage CKD and there were suggestions of improved end-stage kidney disease preparation. Given suboptimal outcomes in late-stage CKD, care management interventions could potentially improve patient outcomes.

No abstract

BackgroundLate-stage chronic kidney disease (LS-CKD) can be defined by glomerular filtration rate (GFR) 0–30 mL/min. It is a period of risk for medication discrepancies because of frequent hospitalizations, fragmented medical care, inadequate communication and polypharmacy. In this study, we sought to characterize medication discrepancies in LS-CKD.MethodsWe analyzed all patients enrolled in Northwell Health’s Healthy Transitions in LS-CKD program. All patients had estimated GFR 0–30 mL/min, not on dialysis. Medications were reviewed by a nurse at a home visit. Patients’ medication usage and practice were compared with nephrologists’ medication lists, and discrepancies were characterized. Patients were categorized as having either no discrepancies or one or more. Associations between patient characteristics and number of medication discrepancies were evaluated by chi-square or Fisher’s exact test for categorical variables, and two-sample t-test or Wilcoxon text for continuous variables.ResultsSeven hundred and thirteen patients with a median age of 70 (interquartile range 58–79) years were studied. There were 392 patients (55.0% of the study population) with at least one medication discrepancy. The therapeutic classes of medications with most frequently occurring medication discrepancies were cardiovascular, vitamins, bone and mineral disease agents, diuretics, analgesics and diabetes medications. In multivariable analysis, factors associated with higher risk of discrepancies were congestive heart failure [odds ratio (OR) 2.13; 95% confidence interval (CI) 1.44–3.16; P = 0.0002] and number of medications (OR 1.29; 95% CI 1.21–1.37; P < 0.0001).ConclusionsMedication discrepancies are common in LS-CKD, affect the majority of patients and include high-risk medication classes. Congestive heart failure and total number of medications are independently associated with greater risk for multiple drug discrepancies. The frequency of medication discrepancies indicates a need for great care in medication management of these patients.

Rationale & Objective The accuracy of glycated hemoglobin (HbA 1c ) level for assessment of glycemic control in patients with chronic kidney disease (CKD) is uncertain. This study assessed the accuracy of HbA 1c level using continuous glucose monitoring. Study Design Diagnostic test study of HbA 1c and serum fructosamine. The continuous glucose monitor was worn for 14 days. Glucose was measured every 15 minutes (up to 1,344 measurements). Average glucose concentration was calculated for each patient from the patient’s continuous glucose monitor measurements. Linear regression was applied to estimate the relationship between average glucose concentration and HbA 1c and serum fructosamine levels. The influence of patient characteristics on the relationship between HbA 1c and average glucose concentrations was examined in a multivariate regression model. Setting & Participants Patients with type 2 diabetes and CKD (estimated glomerular filtration rate, 7-45 mL/min, not receiving dialysis) seen in an academic nephrology clinic. Tests Analyzed The accuracy of HbA 1c level for assessment of chronic glycemia. A secondary objective was to study serum fructosamine levels. Outcomes The degree of correlation between continuous glucose monitoring–derived average glucose concentration and HbA 1c level; serum fructosamine level was studied as a secondary outcome. Results 80 patients wore the continuous glucose monitor for a mean of 12.7 ± 2.9 days. Average glucose concentration of all patients was 151.5 ± 55.7 mg/dL. Mean HbA 1c level was 7.2% ± 1.5%. HbA 1c level was highly correlated with average glucose concentration, described by the equation: average glucose concentration = 30.48 × HbA 1c − 68.48; r = 0.82; P < 0.001. Serum fructosamine level was also significantly correlated with average glucose concentration; r = 0.55; P < 0.001. The strong correlation between average glucose concentration and HbA 1c level was not affected by the severity of CKD, whereas the performance of serum fructosamine level, in contrast, degraded among patients with more severe CKD. Limitations Relatively small sample size. Conclusions HbA 1c is an accurate measure of glycemic status among patients with CKD and type 2 diabetes. This relationship appears to hold true among patients with more severe CKD.