In living kidney donation, transplant professionals consider the rights of a living kidney donor and recipient to keep their personal health information confidential and the need to disclose this information to the other for informed consent. In incompatible kidney exchange, personal health information from multiple living donors and recipients may affect decision making and outcomes.
We conducted a survey to understand and compare the preferences of potential donors (n = 43), potential recipients (n = 73), and health professionals (n = 41) toward sharing personal health information (in total 157 individuals).
When considering traditional live-donor transplantation, donors and recipients generally agreed that a recipient's health information should be shared with the donor (86 and 80%, respectively) and that a donor's information should be shared with the recipient (97 and 89%, respectively). When considering incompatible kidney exchange, donors and recipients generally agreed that a recipient's information should be shared with all donors and recipients involved in the transplant (85 and 85%, respectively) and that a donor's information should also be shared with all involved (95 and 90%, respectively). These results were contrary to attitudes expressed by transplant professionals, who frequently disagreed about whether such information should be shared.
Future policies and practice could facilitate greater sharing of personal health information in living kidney donation. This requires a consideration of which information is relevant, how to put it in context, and a plan to obtain consent from all concerned.
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To evaluate the relationship between the social determinants of health (SDH) and glycemic control in a large pediatric type 1 diabetes (T1D) population.
Deprivation Indices (DI) were used to ascertain population-level measures of socioeconomic status, family structure, and ethnicity in patients with T1D followed at The Hospital for Sick Children August 2010-2011 (n = 854). DI quintile scores were determined for individual patients based on de-identified postal codes, and linked to mean patient A1Cs as a measure of glycemic control. We compared mean A1C between the most and least deprived DI quintiles. Associations were estimated controlling for age and sex, and repeated for insulin pump use.
The T1D population evaluated in this study was most concentrated in the least and most deprived quintiles of the Material DI. A1C levels were highest in patients with the greatest degree of deprivation (fifth vs first quintile) on the Material DI (9.2% vs 8.3%, P
Buttonhole (constant-site) cannulation (BHC) continues to gain popularity with home and in-center dialysis programs worldwide. However, long-term safety data are lacking. This paper reports the authors' single-center experience with Staphylococcus aureus bacteremia (SAB) and the efficacy of topical mupirocin prophylaxis (MP).
This study was a retrospective prepost comparison of SAB rates after establishing MP. Fifty-six consecutive patients on home nocturnal hemodialysis via arteriovenous fistulae, mean age 51.5 +/- 10.6 years, 38% women, and vintage 44.5 +/- 34.5 months were observed for a total of 93.4 (pre-MP) and 193.5 (post-MP) patient-years.
Ten episodes of SAB were observed, with metastatic complications in four cases, including pneumonia (n = 2), septic arthritis, and a fatal C3 epidural abscess. When analyzed by observation period, the odds ratio (OR) for SAB before versus after the introduction of MP was 6.4 [95% confidence interval (CI) = 1.3 to 32.3; P = 0.02]. Two SAB episodes occurred after the MP started. Both patients had discontinued the MP for 3 weeks (nonadherent) preceding infection; hence, no SAB episodes were observed on treatment. In an as-treated analysis, the OR for SAB in the absence of MP was 35.3 (95% CI = 2.0 to 626.7; P = 0.01).
BHC is associated with a significant risk of SAB with metastatic complications. In this prepost comparison of SAB rates, no infections were observed with MP. While awaiting more definitive studies, this simple intervention should be considered for patients using BHC.
Prevalent central venous catheter (CVC) rates among hemodialysis (HD) patients in Canada remain high. In October 2006, we implemented a three-step multidisciplinary quality improvement project in our in-centre HD unit. The primary objective was to convert 50% of suitable patients to arteriovenous fistulas (AVFs) or arteriovenous grafts (AVGs). DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENT: We undertook a case-crossover evaluation of the efficacy of a three-step conversion strategy. In step one, all medically suitable in-centre HD patients were assessed for arteriovenous (AV) access creation. In step two, patients were scheduled for preoperative vascular mapping and referred to the vascular surgeon. In step three, patients who refused conversion were asked to sign a waiver indicating that their decision to continue with a CVC was against medical advice.
At the start of the project in October 2006, there were a total of 284 patients on HD in our in-centre unit and 108 patients were catheter-dependent (38%). Of these, 53 patients were deemed suitable for conversion from a CVC to AVF or AVG; 26/53 (49%) patients agreed to conversion and 27/53 (51%) refused conversion. For the patients in the conversion group, 63% had been followed in chronic kidney disease (CKD) clinic and 37% initiated dialysis acutely; compared to 57% and 43% respectively in the refusal group. The difference was not statistically significant (p = 0.62 by Chi-square test), suggesting that there may be other factors affecting a patient's decision other than predialysis nephrology care. Of interest, 19/27 (70%) of patients who refused conversion signed the waiver and 8/27 (30%) refused to sign the waiver. None of the patients, when confronted with the waiver, agreed to conversion. Based on analysis of the main findings from our study, patients were most concerned about insertion of needles, pain and the appearance of their AV accesses. While 22 patients have successfully converted, resulting in a conversion rate of 41.5%, the percentage of catheter-dependent patients increased from 38% to 46% during the project period. Factors that likely contribute to the increase in point-prevalence CVC rates during the project period include a high rate of patient refusal, a high rate of patients deemed to be medically unsuitable, AV access failure during the project period, and most common was a failure to create AV access among incident HD patients who were followed in our centre through the late stages of chronic kidney disease (CKD). Successful conversion was defined as removal of CVC and use ofAVaccess for HD at the end of the study period (December, 2010).
Long-term CVC use in Canada and the unwillingness of medically suitable patients to convert to more optimal forms of vascular access are linked problems with potentially grave consequences. We need to develop a better understanding of the patients' perspective and possible psychological factors affecting patients' decisions if we are to have an impact on the high CVC use of Canadian prevalent HD patients.