Wilma F. Tromp

Comparison of two instruments measuring carotid-femoral pulse wave velocity: Vicorder versus SphygmoCor

Background The carotid-femoral pulse wave velocity (PWVcf) is used as an indicator of arterial stiffness. It is often measured using applanation tonometry, for instance with the SphygmoCor. In young children, this method is difficult to perform. Therefore, techniques are needed that are less dependent on patient compliance. The Vicorder device uses the oscillometric technique to measure the PWVcf and is thought to be less time consuming and less dependent on operator skills. Objective To compare the PWVcf measured by an extensively used device (SphygmoCor) and the Vicorder in adults initially. Methods Thirty-eight healthy volunteers (20 men, mean age 48 ± 13.1 years) participated in this cross-sectional study. The PWVcf was assessed twice using the SphygmoCor and the Vicorder by a single investigator during one visit. Intra-rater reproducibility of each instrument and comparison between the two instruments were assessed by the Bland–Altman method. Results The mean difference (95% confidence interval) between repeated measurements was 0.09 (−0.20 to 0.38) m/s and 0.24 (−0.55 to 1.03) m/s, for the SphygmoCor and Vicorder, respectively. The Limits of Agreement (LoA) were −1.53 to 1.71 m/s and −4.24 to 4.72 m/s, for the SphygmoCor and Vicorder, respectively. The mean PWVcf measured by the Vicorder was 0.58 (−0.20 to 1.35) m/s higher than the PWVcf measured by the SphygmoCor. The LoA between the two instruments were −3.50 to 4.66 m/s. Conclusion The LoA of both instruments exceed a value of 1.5 m/s. The LoA of the Vicorder PWVcf measurements are considered too wide for using this technique reliably in adults or in children.

Important differences in management policies for children with end-stage renal disease in the Netherlands and Belgium--report from the RICH-Q study.

BACKGROUND The low prevalence of childhood end-stage renal disease and the small centre sizes have been a barrier for clinical studies and the development of evidence-based guidelines for chronic renal replacement therapy (cRRT) in children. Few data exist on the quality of care for these patients and the applicability of existing guidelines. The aim of this study is to quantify variation in treatment policies and actually delivered care in nine centres that deliver cRRT for children. METHODS We surveyed treatment policies in all nine centres in the Netherlands and Belgium and compared them with the actually provided therapies and with recommendations from available guidelines. Data on treatment policies were gathered by questionnaires; actually provided care and outcomes were registered prospectively from 2007 to 2010. RESULTS Data on policies and actual patient care were obtained from all nine centres. We found relevant differences between centres in treatment policies on various topics, e.g. estimated glomerular filtration rate threshold as an indication for initiation of cRRT, preferred initial mode of cRRT, peritoneal dialysis catheter care, haemodialysis frequency and vascular access. Discrepancies were seen between stated treatment policies and actual performed therapies. For the majority of policies, no evidence-based guidelines are available. CONCLUSIONS Health care disparities exist due to large and unwanted variation in treatment policies between hospitals providing cRRT for children. Delivered care does not live up to stated policies, for which clear and internationally accepted guidelines are lacking.

Fewer pre-emptive renal transplantations and more rejections in immigrant children compared to native Dutch and Belgian children

BACKGROUND In the Netherlands and Belgium, an increasing number of children who have end-stage renal disease (ESRD) are of non-Western origin. We analysed renal transplantation practices and outcome for immigrant ESRD children as compared to native children in both countries. METHODS All Dutch and Belgian children aged <19 years who received their first renal transplantation between 1 September 2007 and 1 January 2011 were included. Therapy characteristics and outcomes were registered prospectively on a 3-monthly basis. Immigrants were defined as children of whom one or both parents had been born outside Western European countries. Multivariable Cox regression analysis was used to quantify the hazard ratio for acute rejection. RESULTS One hundred and nineteen first renal transplant recipients were included, of which 41 (34%) were immigrants. Median [range] follow-up time of transplantation was 18 [2-28] months. Compared to native children, immigrants had pre-emptive transplantations (15 versus 32%, P = 0.040) and transplantations with a kidney from a living donor less often (24 versus 59%, P < 0.001). Survival analysis in 96 children with at least 3 months of follow-up showed an increased risk for acute rejection in immigrants adjusted for donor source, duration of dialysis and number of HLA mismatches on the DR locus [hazard ratio (95% confidence interval) 2.5 (1.1-5.9)]. CONCLUSIONS Immigrant children receive fewer pre-emptive and living donor transplantations compared to native children. After transplantation, immigrant children are at higher risk for acute rejection irrespective of the mode of transplantation.

Quality and consistency of clinical practice guidelines for the management of children on chronic dialysis

BACKGROUND Clinical practice guidelines aim to improve the quality of care, yet for users of guidelines it is often not clear how these guidelines were developed and whether the recommendations are robust. We aimed to identify all current published guidelines for the management of children on chronic dialysis, assess the quality of their development and evaluate consistency among their recommendations. METHODS We searched Medline (1948 to January 2012), and relevant websites of guideline development programmes. Three reviewers appraised all 17 identified guidelines with the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. RESULTS The guidelines were developed by five different professional associations. The overall mean AGREE II score from seven Kidney Disease Outcomes Quality Initiatives (KDOQI) guidelines was considered sufficient (mean scores 64-75%), and from all other 10 guidelines poor (29-44%). Five out of seven KDOQI guidelines scored weak on applicability. We found important inconsistencies between recommendations concerning initiation of renal replacement therapy, management of haemoglobin level and the use of mupirocin to prevent exit-site infections. CONCLUSIONS While the recently developed KDOQI guidelines meet the modern quality standards, advice for implementation of these recommendations is lacking. There is an urgent need for international collaboration and coordination to ensure that the management of children on chronic dialysis is informed by relevant and high-quality evidence.

Children of non-Western origin with end-stage renal disease in the Netherlands, Belgium and a part of Germany have impaired health-related quality of life compared with Western children

BACKGROUND Many children with end-stage renal disease (ESRD) living in Western Europe are of non-Western European origin. They have unfavourable somatic outcomes compared with ESRD children of Western origin. In this study, we compared the Health-related Quality of Life (HRQoL) of both groups. METHODS All children (5-18 years) with ESRD included in the RICH-Q project (Renal Insufficiency therapy in Children-Quality assessment and improvement) or their parents were asked to complete the generic version of the Paediatric Quality-of-Life Inventory 4.0 (PedsQL). RICH-Q comprises the Netherlands, Belgium and a part of Germany. Children were considered to be of non-Western origin if they or at least one parent was born outside Western-European countries. Impaired HRQoL for children with ESRD of Western or non-Western origin was defined as a PedsQL score less than fifth percentile for healthy Dutch children of Western or non-Western origin, respectively. RESULTS Of the 259 eligible children, 230 agreed to participate. One hundred and seventy-four children responded (response rate 67%) and 55 (32%) were of non-Western origin. Overall, 31 (56%) of the ESRD children of non-Western origin, and 58 (49%) of Western origin had an impaired total HRQoL score. Total HRQoL scores of children with ESRD of Western origin and non-Western origin were comparable, but scores on emotional functioning and school functioning were lower in non-Western origin (P=0.004 and 0.01, respectively). The adjusted odds ratios (95% confidence interval) for ESRD children of non-Western origin to have impaired emotional functioning and school functioning, compared with Western origin, were 3.3(1.5-7.1) and 2.2(1.1-4.2), respectively. CONCLUSION Children with ESRD of non-Western origin in three Western countries were found to be at risk for impaired HRQoL on emotional and school functioning. These children warrant special attention.

Lessons learned from efforts to improve the quality of care in children with end-stage renal disease in the Netherlands and Belgium

Quality improvement research strives to bridge the gap between ideal and actual care.1 Many paediatric diseases are rare, and thus there is insufficient evidence to define ‘ideal care’. Low prevalences and generally small patient numbers in centres in which children with rare diseases are treated create considerable barriers for clinical studies and for the development of evidence based guidelines. As a consequence, most existing guidelines are derived from studies in adults and lack any paediatric evidence.2 Here we focus on paediatric end-stage renal disease (ESRD) as an example of a clinical field in which these challenges are encountered.