Rory McQuillan

Neuropsychiatric complications of chronic kidney disease

Evidence is emerging that cognitive impairment, delirium and depression are very common in patients with renal disease. All of these conditions are associated with prolonged hospitalization and an increased risk of mortality. A good understanding of these conditions is key to their prevention, early intervention and management. This Review summarizes the clinical features of various forms of cognitive dysfunction that occur in individuals with renal disease and describes the evidence for the high burden of disease in such patients.

A Randomized Controlled Trial Comparing Mupirocin and Polysporin Triple Ointments in Peritoneal Dialysis Patients: The MP3 Study

BACKGROUND AND OBJECTIVES Infectious complications remain a significant cause of peritoneal dialysis (PD) technique failure. Topical ointments seem to reduce peritonitis; however, concerns over resistance have led to a quest for alternative agents. This study examined the effectiveness of applying topical Polysporin Triple ointment (P(3)) against mupirocin in a multi-centered, double-blind, randomized controlled trial. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS PD patients routinely applied either P(3) or mupirocin ointment to their exit site. Patients were followed for 18 months or until death or catheter removal. The primary study outcome was a composite endpoint of exit-site infection (ESI), tunnel infection, or peritonitis. RESULTS Seventy-five of 201 randomized patients experienced a primary outcome event (51 peritonitis episodes, 24 ESIs). No difference was seen in the time to first event for P(3) (13.2 months; 95% confidence interval, 11.9-14.5) and mupirocin (14.0 months; 95% confidence interval, 12.7-15.4) (P=0.41). Twice as many patients reported redness at the exit site in the P(3) group (14 versus 6, P=0.10). Over the complete study period, a higher rate per year of fungal ESIs was seen in patients using P(3) (0.07 versus 0.01; P=0.02) with a corresponding increase in fungal peritonitis (0.04 versus 0.00, respectively; P<0.05). CONCLUSIONS This study shows that P(3) is not superior to mupirocin in the prophylaxis of PD-related infections. Colonization of the exit site with fungal organisms is of concern and warrants further study. As such, the use of P(3) over mupirocin is not advocated in the prophylaxis of PD-related infections.

Modifiable Risk Factors for Early Mortality on Hemodialysis

Data of incident hemodialysis patients from 2001 to 2007 were abstracted from The Renal Disease Registry (TRDR) from central Ontario, Canada and followed until December 2008 to determine 90-day mortality rates for incident hemodialysis patients. Modifiable risk factors of early mortality were determined by a Cox model. In total, 876 of 4807 incident patients died during their first year on dialysis; 304 (34.7%) deaths occurred within the first 90 days of dialysis initiation. The majority of deaths were attributed to a cardiovascular event or infection and more likely occurred in older patients and those with cardiovascular co-morbidities. Of potentially modifiable risk factors, low body mass index (<18.5), a surrogate for malnutrition, was a strong predictor of early mortality [adjusted hazard ratio (HR) 4.22 (CI: 3.12–5.17)]. Also, central venous catheter use was associated with a 2.40 fold increase risk of death (CI: 1.4–3.90). Patients who attended a multidisciplinary pre-dialysis clinic were less likely to die (HR: 0.60, CI: 0.47–0.78). The first 90 days after initiation of dialysis is a period of especially high risk of death. We have identified potentially modifiable risk factors in vascular access type, pre-dialysis care and nutritional status.

Quasi-Experimental designs for quality improvement research

Presentation Quality Improvement (QI) research may be defined as “the design, development and evaluation of complex interventions aimed at the re-design of health care systems to produce improved outcomes”. The challenge of QI lies in bridging the gap between knowing what needs to happen at an individual patient level and implementing this at a systems level. The inherent complexity of systems poses challenges in terms of implementation, but also presents the researcher with circumstances for which conventional research methods may not prove useful. Explanatory trials are designed to answer the question “does this intervention work under ideal circumstances?” Patient and system variability are typically rigorously controlled. Pragmatic trials seek to answer how well an intervention works in usual practice [1]. It is important to contend with variation (e.g., in patient volume or complexity) and not control for it. Consider the analogy of water sampled from a pond versus a river [2]. If one takes random samples of water from a still pool of water one can draw inference about the pond as aw hole, as it is relatively static and unchanging. This is the principle we are using in attempting to extrapolate the findings of a randomized controlled trial to a population. The real world however, behaves far more like a river where the water changes from second to second, influenced by innumerable complex interacting factors such as the season, rain, construction. In QI research it is important to understand the changing nature of the river (i.e. causes of system variation) in order to be able to predict how to make an intervention work under all the conditions in which it will be expected to perform. QI research should focus therefore on robust, sequential experimentation. Too often, quality improvement investigators seek to proceed to clinical trials before sufficient exploration, investigation, and understanding of the complex system and its interactions have been achieved. Campbell et al present a trajectory for QI research required to build requisite knowledge [3]. The design and testing of complex interventions in care delivery proceeds through a series of planned stages. One begins by developing a concept or theory and then progresses to designing a prototype. Next, an intervention is piloted on a small scale before performing a detailed test and finally disseminating the ideas generated. A variety of study designs may be used as learning proceeds across this trajectory of understanding. Research methods that address issues of internal validity without randomization of individuals are referred to as “quasi-experimental” designs and include time-series, equivalent time series, multiple baseline and factorial design.

How to Begin a Quality Improvement Project

Quality improvement involves a combined effort among health care staff and stakeholders to diagnose and treat problems in the health care system. However, health care professionals often lack training in quality improvement methods, which makes it challenging to participate in improvement efforts. This article familiarizes health care professionals with how to begin a quality improvement project. The initial steps involve forming an improvement team that possesses expertise in the quality of care problem, leadership, and change management. Stakeholder mapping and analysis are useful tools at this stage, and these are reviewed to help identify individuals who might have a vested interest in the project. Physician engagement is a particularly important component of project success, and the knowledge that patients/caregivers can offer as members of a quality improvement team should not be overlooked. After a team is formed, an improvement framework helps to organize the scientific process of system change. Common quality improvement frameworks include Six Sigma, Lean, and the Model for Improvement. These models are contrasted, with a focus on the Model for Improvement, because it is widely used and applicable to a variety of quality of care problems without advanced training. It involves three steps: setting aims to focus improvement, choosing a balanced set of measures to determine if improvement occurs, and testing new ideas to change the current process. These new ideas are evaluated using Plan-Do-Study-Act cycles, where knowledge is gained by testing changes and reflecting on their effect. To show the real world utility of the quality improvement methods discussed, they are applied to a hypothetical quality improvement initiative that aims to promote home dialysis (home hemodialysis and peritoneal dialysis). This provides an example that kidney health care professionals can use to begin their own quality improvement projects.

How to Sustain Change and Support Continuous Quality Improvement

To achieve sustainable change, quality improvement initiatives must become the new way of working rather than something added on to routine clinical care. However, most organizational change is not maintained. In this next article in this Moving Points in Nephrology feature on quality improvement, we provide health care professionals with strategies to sustain and support quality improvement. Threats to sustainability may be identified both at the beginning of a project and when it is ready for implementation. The National Health Service Sustainability Model is reviewed as one example to help identify issues that affect long-term success of quality improvement projects. Tools to help sustain improvement include process control boards, performance boards, standard work, and improvement huddles. Process control and performance boards are methods to communicate improvement results to staff and leadership. Standard work is a written or visual outline of current best practices for a task and provides a framework to ensure that changes that have improved patient care are consistently and reliably applied to every patient encounter. Improvement huddles are short, regular meetings among staff to anticipate problems, review performance, and support a culture of improvement. Many of these tools rely on principles of visual management, which are systems transparent and simple so that every staff member can rapidly distinguish normal from abnormal working conditions. Even when quality improvement methods are properly applied, the success of a project still depends on contextual factors. Context refers to aspects of the local setting in which the project operates. Context affects resources, leadership support, data infrastructure, team motivation, and team performance. For these reasons, the same project may thrive in a supportive context and fail in a different context. To demonstrate the practical applications of these quality improvement principles, these principles are applied to a hypothetical quality improvement initiative that aims to promote home dialysis (home hemodialysis and peritoneal dialysis).

The significance of tubuloreticular inclusions as a marker of systemic stimulation by interferons in a case of focal and segmental glomerulosclerosis associated with cytomegalovirus (CMV) infection

The identification of large numbers of tubuloreticular inclusions (TRIs) in renal biopsies may be useful to raise diagnostic suspicion for certain clinical entities, particularly autoimmune diseases and viral infections. We report a case of a 65-year-old female with a 2-week history of malaise, massive proteinuria and lower extremity edema of acute onset. A renal biopsy was performed and the diagnosis of non-human immunodeficiency virus (HIV) tip-located, early focal segmental glomerulosclerosis (FSGS) was established. The electron microscopy examination was remarkable for the presence of diffuse foot process effacement and frequent TRIs in the endothelial cells of the glomerular capillary loops, endothelium of arterioles and cytoplasm of fibroblasts in the interstitium, highly suggestive of an underlying etiology. Patient clinical and laboratory workup revealed the absence of an autoimmune disease but the presence of a subclinical cytomegalovirus (CMV) infection. Therefore, we highlight that the identification of TRIs is a useful indicator of systemic interferon activity. In the present case, the unusual location of numerous TRIs was associated with a subclinical CMV infection in an immunocompetent patient.

Targeted Deprescribing in an Outpatient Hemodialysis Unit: A Quality Improvement Study to Decrease Polypharmacy

BACKGROUND Polypharmacy in hemodialysis patients can result in adverse patient outcomes. Deprescribing tools can reduce polypharmacy, yet no method exists for an outpatient hemodialysis population. DESIGN Quality improvement study. SETTING & PARTICIPANTS 240 patients in a tertiary-care outpatient hemodialysis unit. QUALITY IMPROVEMENT PLAN We aimed to: (1) develop a deprescribing tool for target medications with poor evidence for efficacy and safety, (2) determine its effectiveness in decreasing polypharmacy, and (3) monitor patient safety and satisfaction. OUTCOMES The primary outcome was the proportion of target medications completely deprescribed after 4 weeks. Secondary outcomes were the proportion of target medications completely deprescribed after 6 months, average number of medications per patient before and after deprescription, and proportion of successful deprescriptions for each target medication. MEASUREMENTS Number of medications deprescribed at 4 weeks and 6 months. Patient safety and satisfaction were monitored using drug-specific monitoring parameters. RESULTS A deprescribing tool for specific medications was developed and implemented in the hemodialysis unit. 5 medication classes were selected: quinine, diuretics, α1-blockers, proton pump inhibitors, and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins). All 240 patients in the unit were screened using the deprescribing tool. There were 171 of 240 (71%) patients prescribed at least 1 of the 5 target medications, and after applying the tool, 35 of 40 (88%) eligible patients had the medications deprescribed. There were 31 of 40 (78%) target medications completely deprescribed. 6 months after the study, only 5 of 31 (16%) medications discontinued were represcribed. At the end of the study, 57% of patients were taking fewer medications than at baseline. No adverse events were observed. LIMITATIONS Single-center study that relied on patient self-reporting of medication use and adherence to our recommendations. CONCLUSIONS Deprescribing tools can be applied successfully in an outpatient hemodialysis unit to reduce polypharmacy while maintaining patient safety and satisfaction.

How to Diagnose Solutions to a Quality of Care Problem

To change a particular quality of care outcome within a system, quality improvement initiatives must first understand the causes contributing to the outcome. After the causes of a particular outcome are known, changes can be made to address these causes and change the outcome. Using the example of home dialysis (home hemodialysis and peritoneal dialysis), this article within this Moving Points feature on quality improvement will provide health care professionals with the tools necessary to analyze the steps contributing to certain outcomes in health care quality and develop ideas that will ultimately lead to their resolution. The tools used to identify the main contributors to a quality of care outcome will be described, including cause and effect diagrams, Pareto analysis, and process mapping. We will also review common change concepts and brainstorming activities to identify effective change ideas. These methods will be applied to our home dialysis quality improvement project, providing a practical example that other kidney health care professionals can replicate at their local centers.

The Intuitive Case for β-blockers in Patients with ESRD

Sudden cardiac death (SCD) is common in dialysis patients accounting for up to 25% of all‐cause mortality. Unlike in the general population, occlusive coronary artery disease is implicated in a minority of these deaths. Activation of the sympathetic nervous system is prevalent in the dialysis population and may underlie this high rate of SCD. β‐blockers reduce SCD in the general population and, given their mode of action, β‐blockers would seem to be an ideal class of agents to prevent SCD in dialysis patients. In this review, we will explore the etiology of SCD in dialysis patients and discuss the evidence supporting the use of β‐blockers in patients with ESRD. We will also examine potential impediments to the use β‐blocker in the dialysis population and outline directions for future trials in this area.