Nwamaka D. Eneanya

Health literacy and education as mediators of racial disparities in patient activation within an elderly patient cohort

The Patient Activation Measure (PAM) assesses facets of patient engagement to identify proactive health behaviors and is an important predictor of health outcomes. Health literacy and education are also important for patient participation and successful navigation of the health care system. Because health literacy, education, and patient activation are associated with racial disparities, we sought to investigate whether health literacy and education would mediate racial differences in patient activation. Participants were 265 older adults who participated in a computer-based exercise interventional study. Health literacy was assessed using the Test of Functional Health Literacy in Adults (TOFHLA). Of 210 eligible participants, 72% self-identified as Black and 28% as White. In adjusted analyses, education and health literacy each significantly reduced racial differences in patient activation. These findings are especially important when considering emerging data on the significance of patient activation and new strategies to increase patient engagement.

Racial Disparities in End-of-Life Communication and Preferences among Chronic Kidney Disease Patients

Background: Previous studies on end-of-life (EOL) care among patients with chronic kidney disease (CKD) have been largely limited to White hemodialysis patients. In this study, we sought to explore racial variability in EOL communication, care preferences and advance care planning (ACP) among patients with advanced CKD prior to decisions regarding the initiation of dialysis. Methods: We performed a cross-sectional study between 2013 and 2015 of Black and White patients with stage IV or V CKD (per the Modified Diet in Renal Disease estimation of GFR <30 ml/min/1.73 m2) from 2 academic centers in Boston. We assessed experiences with EOL communication, ACP, EOL care preferences, hospice knowledge, spiritual/religious and cultural beliefs, and distrust of providers. Results: Among 152 participants, 41% were Black. Black patients were younger, had less education, and lower income than White patients (all p < 0.01). Black patients also had less knowledge of hospice compared to White patients (17 vs. 61%, p < 0.01). A small fraction of patients (8%) reported having EOL discussions with their nephrologists and the majority had no advance directives. In multivariable analyses, Blacks were more likely to have not communicated EOL preferences (adjusted OR 2.70, 95% CI 1.08-6.76) and more likely to prefer life-extending treatments (adjusted OR 3.06, 95% CI 1.23-7.60) versus Whites. Conclusions: As Black and White patients with advanced CKD differ in areas of EOL communication, preferences, and hospice knowledge, future efforts should aim to improve patient understanding and promote informed decision-making.

Prognosis of Patients with Cirrhosis and AKI Who Initiate RRT

BACKGROUND AND OBJECTIVES Literature on the prognosis of patients with cirrhosis who require RRT for AKI is sparse and is confounded by liver transplant eligibility. An update on outcomes in the nonlisted subgroup is needed. Our objective was to compare outcomes in this group between those diagnosed with hepatorenal syndrome and acute tubular necrosis, stratifying by liver transplant listing status. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Retrospective cohort study of patients with cirrhosis acutely initiated on hemodialysis or continuous RRT at five hospitals, including one liver transplant center. Multivariable regression and survival analysis were performed. RESULTS Four hundred seventy-two subjects were analyzed (341 not listed and 131 listed for liver transplant). Among nonlisted subjects, 15% (51 of 341) were alive at 6 months after initiating RRT. Median survival was 21 (interquartile range [IQR], 8, 70) days for those diagnosed with hepatorenal syndrome and 12 (IQR, 3, 43) days for those diagnosed with acute tubular necrosis (P=0.25). Among listed subjects, 48% (63 of 131) received a liver transplant. Median transplant-free survival was 15 (IQR, 5, 37) days for those diagnosed with hepatorenal syndrome and 14 (IQR, 4, 31) days for those diagnosed with acute tubular necrosis (P=0.60). When stratified by transplant listing, with adjusted Cox models we did not detect a difference in the risk of death between hepatorenal syndrome and acute tubular necrosis (hazard ratio [HR], 0.81; 95% confidence interval [95% CI], 0.59 to 1.11, among those not listed; HR, 0.73; 95% CI, 0.44 to 1.19, among those listed). CONCLUSIONS Cause of AKI was not significantly associated with mortality in patients with cirrhosis who required RRT. Among those not listed for liver transplant, mortality rates were extremely high in patients both with hepatorenal syndrome and acute tubular necrosis. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_11_09_CJASNPodcast_18_1_A.mp3.

An Interdisciplinary Approach to Dialysis Decision-Making in the CKD Patient With Depression

Depression and depressive symptoms are common in advanced kidney disease and are associated with poor outcomes. For those with CKD not on dialysis, depression may influence how patients cope and prepare for their disease and its management, including decisions about dialysis treatment. Patient self-reported scales exist to better identify depression; how to incorporate these scales into clinical practice and assist with treatment decision-making is less clear. We present a case-based discussion of depressive symptoms in patients with advanced kidney disease not on dialysis. We highlight the contribution of underlying somatic and psychosocial factors in the assessment and management of depression. We further define the role of the interdisciplinary care team, including palliative care and hospice medicine, to assist with symptom management and end-of-life care for CKD patients with depression.

Health Literacy Mediates Racial Disparities in Cardiopulmonary Resuscitation Knowledge among Chronic Kidney Disease Patients

Abstract:Black patients with chronic kidney disease (CKD) receive more cardiopulmonary resuscitation (CPR) than other racial groups, and knowledge of CPR influences preferences for care. As limited health literacy disproportionately affects Blacks and contributes to disparities in end-of-life (EOL) care, we investigated whether health literacy mediates racial disparities in CPR knowledge. Black and White adult patients with advanced CKD completed CPR knowledge surveys. Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine. Among 149 patients, Black patients were more likely to have limited health literacy and lower mean CPR knowledge scores than White patients. In adjusted analyses, health literacy mediated racial differences in CPR knowledge. Knowledge of CPR is lower among Black compared with White CKD patients and health literacy is a mediator of this difference. Future CPR educational interventions should target health literacy barriers to improve informed decision-making and decrease racial disparities at the end of life.

Characterization and Correction of Olfactory Deficits in Kidney Disease

Patients with CKD suffer from food aversion, anorexia, and malnutrition. Although olfaction has a significant role in determining food flavor, our understanding of olfactory impairment and of the olfaction-nutrition axis in patients with kidney disease is limited. We quantified odor identification, odor threshold, and subjective odor perception in a cohort (n=161) comprising 36 participants with CKD, 100 participants with ESRD, and 25 controls. We investigated olfaction-nutrition associations in these participants and examined a novel intervention to improve olfaction in ESRD. The mean odor identification score was lower in patients with CKD (75.6%±13.1%; P=0.02) and ESRD (66.8%±15.1%; P<0.001) than in controls (83.6%±11.4%). Patients with ESRD exhibited higher odor threshold than the remaining participants exhibited. All groups had similar scores for subjective smell assessment. In multivariable adjusted analyses, kidney disease associated with increased odds of odor identification deficits (odds ratio, 4.80; 95% confidence interval, 1.94 to 11.89). A reduction in odor identification score was associated with higher subjective global assessment score and lower serum total cholesterol, LDL cholesterol, and albumin concentrations. We found no associations between odor threshold and nutritional parameters. In a proof of concept, 6-week, open-label clinical trial, intranasal theophylline (an epithelial membrane transport and proton secretion activator) increased odor identification score in five out of seven (71%) patients with ESRD. In conclusion, patients with kidney disease have olfactory deficits that may influence their nutritional status. Our preliminary results regarding olfactory improvement using intranasal theophylline warrant confirmation in a randomized controlled trial.

Palliative and end-of-life care in nephrology: moving from observations to interventions

Purpose of review In comparison with patients who have other serious illnesses, patients with advanced kidney disease have a higher rate of intensive care utilization at the end of life and receive palliative care less frequently. Consensus and clinical practice guidelines have therefore recommended the incorporation of palliative care earlier in the disease trajectory. This review summarizes recent literature on this aspect of care and will highlight future directions for patient-centered care within palliative nephrology. Recent findings Patients with advanced kidney disease and their families frequently do not engage effectively with their clinicians to make informed treatment decisions or plan for care at the end of life. Furthermore, racial and ethnic minority patients continue to receive a lower rate of palliative care services compared to other racial groups. Interventions that promote better palliative care communication and education among nephrology clinicians, patients and their families are becoming increasingly more common in nephrology. Summary Overall, improved understanding of the unique care needs of patients with advanced and end-stage kidney disease provides a solid foundation to improve palliative and end-of-life care delivery among diverse populations in nephrology.

Case Records of the Massachusetts General Hospital. Case 35-2015: A 72-Year-Old Woman with Proteinuria and a Kidney Mass.

A 72-year-old woman presented with flank pain, proteinuria, and a new kidney mass. Magnetic resonance imaging of the kidney revealed a complex, solid mass (3 cm x 2.9 cm x 2.9 cm) in the lower pole of the right kidney. Diagnostic tests were performed.

Case 35-2015

A 72-year-old woman presented with flank pain, proteinuria, and a new kidney mass. Magnetic resonance imaging of the kidney revealed a complex, solid mass (3 cm x 2.9 cm x 2.9 cm) in the lower pole of the right kidney. Diagnostic tests were performed.