New Opportunities for Funding Dialysis-Dependent Undocumented Individuals

PubMed Central

2017-01-01

The cost of dialysis for the estimated 6500 dialysis-dependent undocumented individuals with kidney failure in the United States is high, the quality of dialysis care they receive is poor, and their treatment varies regionally. Some regions use state and matched federal funds to cover regularly scheduled dialysis treatments, while others provide treatment only in emergent life-threatening conditions. Nephrologists caring for patients who receive emergent dialysis are tasked with the difficult moral dilemma of determining “who gets dialysis that day.” Without a path to citizenship and by exclusion from the federal marketplace exchanges, undocumented individuals have limited options for their treatment. A novel opportunity to provide scheduled dialysis for this population is through the purchase of insurance off the exchange. Plans purchased off the exchange must still abide by the 2014 provision of the Patient Protection and Affordable Care Act, which prohibits insurance companies from denying coverage based on a preexisting health condition. In 2015 and 2016, >100 patients previously receiving only emergent dialysis at the two largest safety-net hospital systems in Texas obtained off-the-exchange commercial health insurance plans. These undocumented patients now receive scheduled dialysis treatments, which has improved their care and quality of life, as well as decompressed the overburdened hospital systems. The long-term sustainability of this option is not known. Socially responsive and visionary policymakers allowing the move into this bold, new direction deserve special appreciation. PMID:27577244

Black yeasts-like fungi isolated from dialysis water in hemodialysis units.

PubMed

Figel, Izabel Cristina; Marangoni, Paulo Roberto Dantas; Tralamazza, Sabina Moser; Vicente, Vânia Aparecida; Dalzoto, Patrícia do Rocio; do Nascimento, Mariana Machado Fidelis; de Hoog, G Sybren; Pimentel, Ida Chapaval

2013-06-01

Hemodialysis in patients with chronic renal failure promotes the removal of toxic substances, water, and minerals from the body and often takes place in specialized clinics. Microbial contamination of dialysis fluid is a serious problem in therapy. One of the sources of contamination is the water used to prepare the dialysate. In Brazil, legislation regulating the microbiological quality of water for dialysis does not cover waterborne microbes such as Pseudomonas, mycobacteria, and fungi. The aim of the present study was to quantify, isolate, and identify fungi present in water systems in six hemodialysis units in Curitiba, Paraná state, Brazil. Fungi were analyzed by surface plating and membrane filtration. Isolates were identified by morphology, while the dematiaceous fungi were identified by sequencing the rDNA ITS region. It was found that 66 % of the samples presented fungi, while black fungi were present in 46 % of all samples. Twenty-eight isolates from treated water for dialysis and dialysate were identified by sequencing and were found to be Exophiala pisciphila, E. cancerae, E. equina, and Rhinocladiella similis. The presence of dematiaceous fungi may pose a risk for debilitated hospitalized patients.

Conceptual framework for holistic dialysis management based on key performance indicators.

PubMed

Liu, Hu-Chen; Itoh, Kenji

2013-10-01

This paper develops a theoretical framework of holistic hospital management based on performance indicators that can be applied to dialysis hospitals, clinics or departments in Japan. Selection of a key indicator set and its validity tests were performed primarily by a questionnaire survey to dialysis experts as well as their statements obtained through interviews. The expert questionnaire asked respondents to rate the degree of "usefulness" for each of 66 indicators on a three-point scale (19 responses collected). Applying the theoretical framework, we selected a minimum set of key performance indicators for dialysis management that can be used in the Japanese context. The indicator set comprised 27 indicators and items that will be collected through three surveys: patient satisfaction, employee satisfaction, and safety culture. The indicators were confirmed by expert judgment from viewpoints of face, content and construct validity as well as their usefulness. This paper established a theoretical framework of performance measurement for holistic dialysis management from primary healthcare stakeholders' perspectives. In this framework, performance indicators were largely divided into healthcare outcomes and performance shaping factors. Indicators of the former type may be applied for the detection of operational problems or weaknesses in a dialysis hospital, clinic or department, while latent causes of each problem can be more effectively addressed by the latter type of indicators in terms of process, structure and culture/climate within the organization. © 2013 The Authors. Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis.

Impact of modality choice on rates of hospitalization in patients eligible for both peritoneal dialysis and hemodialysis.

PubMed

Quinn, Robert R; Ravani, Pietro; Zhang, Xin; Garg, Amit X; Blake, Peter G; Austin, Peter C; Zacharias, James M; Johnson, John F; Pandeya, Sanjay; Verrelli, Mauro; Oliver, Matthew J

2014-01-01

Hospitalization rates are a relevant consideration when choosing or recommending a dialysis modality. Previous comparisons of peritoneal dialysis (PD) and hemodialysis (HD) have not been restricted to individuals who were eligible for both therapies. ♢ We conducted a multicenter prospective cohort study of people 18 years of age and older who were eligible for both PD and HD, and who started outpatient dialysis between 2007 and 2010 in four Canadian dialysis programs. Zero-inflated negative binomial models, adjusted for baseline patient characteristics, were used to examine the association between modality choice and rates of hospitalization. ♢ The study enrolled 314 patients. A trend in the HD group toward higher rates of hospitalization, observed in the primary analysis, became significant when modality was treated as a time-varying exposure or when the population was restricted to elective outpatient starts in patients with at least 4 months of pre-dialysis care. Cardiovascular disease, infectious complications, and elective surgery were the most common reasons for hospital admission; only 23% of hospital stays were directly related to complications of dialysis or kidney disease. ♢ Efforts to promote PD utilization are unlikely to result in increased rates of hospitalization, and efforts to reduce hospital admissions should focus on potentially avoidable causes of cardiovascular disease and infectious complications.

Impact of Modality Choice on Rates of Hospitalization in Patients Eligible for Both Peritoneal Dialysis and Hemodialysis

PubMed Central

Quinn, Robert R.; Ravani, Pietro; Zhang, Xin; Garg, Amit X.; Blake, Peter G.; Austin, Peter C.; Zacharias, James M.; Johnson, John F.; Pandeya, Sanjay; Verrelli, Mauro; Oliver, Matthew J.

2014-01-01

♦ Background: Hospitalization rates are a relevant consideration when choosing or recommending a dialysis modality. Previous comparisons of peritoneal dialysis (PD) and hemodialysis (HD) have not been restricted to individuals who were eligible for both therapies. ♦ Methods: We conducted a multicenter prospective cohort study of people 18 years of age and older who were eligible for both PD and HD, and who started outpatient dialysis between 2007 and 2010 in four Canadian dialysis programs. Zero-inflated negative binomial models, adjusted for baseline patient characteristics, were used to examine the association between modality choice and rates of hospitalization. ♦ Results: The study enrolled 314 patients. A trend in the HD group toward higher rates of hospitalization, observed in the primary analysis, became significant when modality was treated as a time-varying exposure or when the population was restricted to elective outpatient starts in patients with at least 4 months of pre-dialysis care. Cardiovascular disease, infectious complications, and elective surgery were the most common reasons for hospital admission; only 23% of hospital stays were directly related to complications of dialysis or kidney disease. ♦ Conclusions: Efforts to promote PD utilization are unlikely to result in increased rates of hospitalization, and efforts to reduce hospital admissions should focus on potentially avoidable causes of cardiovascular disease and infectious complications. PMID:24525596

Decreasing dialysis catheter rates by creating a multidisciplinary dialysis access program.

PubMed

Rosenberry, Patricia M; Niederhaus, Silke V; Schweitzer, Eugene J; Leeser, David B

2018-03-01

Centers for Medicare and Medicaid Services have determined that chronic dialysis units should have <12% of their patients utilizing central venous catheters for hemodialysis treatments. On the Eastern Shore of Maryland, the central venous catheter rates in the dialysis units averaged >45%. A multidisciplinary program was established with goals of decreasing catheter rates in order to decrease central line-associated bloodstream infections, decrease mortality associated with central line-associated bloodstream infection, decrease hospital days, and provide savings to the healthcare system. We collected the catheter rates within three dialysis centers served over a 5-year period. Using published data surrounding the incidence and related costs of central line-associated bloodstream infection and mortality per catheter day, the number of central line-associated bloodstream infection events, the costs, and the related mortality could be determined prior to and after the initiation of the dialysis access program. An organized dialysis access program resulted in a 82% decrease in the number of central venous catheter days which lead to a concurrent reduction in central line-associated bloodstream infection and deaths. As a result of creating an access program, central venous catheter rates decreased from an average rate of 45% to 8%. The cost savings related to the program was calculated to be over US$5 million. The decrease in the number of mortalities is estimated to be between 13 and 27 patients. We conclude that a formalized access program decreases catheter rates, central line-associated bloodstream infection, and the resultant hospitalizations, mortality, and costs. Areas with high hemodialysis catheter rates should develop access programs to better serve their patient population.

[Cost analysis of dialysis treatment at the Odense University Hospital and the Sønderborg Hospital].

PubMed

Maschoreck, T R; Sørensen, M C; Andresen, M; Høgsberg, I M; Rasmussen, P; Søgaard, J

1998-12-14

The major purpose of this paper is to investigate the treatment costs of dialysis treatment by modality. In this study Odense University Hospital (OUH) and Sønderborg Hospital were chosen as cases. The costs of haemodialysis (HD) treatment are estimated to DKK 341-392,000 per patient during the first year, and DKK 328-379,000 per year the following years. The costs of continuous ambulatory peritoneal dialysis (CAPD) treatment are estimated to DKK 262-291,000 per patient during the first year, and DKK 251-277,000 per year the following years. The costs of CCPD (peritoneal dialysis with the aid of a machine), treatment are estimated to DKK 312-325,000 per patient during the first year, and DKK 296-308,000 per year the following years. The treatment costs of HD are lower than expected, while the treatment costs of PD are higher than expected. As a result of this the differences in treatment costs (HD versus PD) are much lower than expected, DKK 130,000 at the most.

The Changing Landscape of Home Dialysis in the United States

PubMed Central

Rivara, Matthew B.; Mehrotra, Rajnish

2015-01-01

Purpose of review To discuss the changing landscape of home dialysis in the United States over the past decade, including recent research on clinical outcomes in patient undergoing peritoneal dialysis (PD) and home hemodialysis (HHD), and to describe the impact of recent payment reforms for patients with end stage renal disease (ESRD). Recent findings Accumulating evidence supports that clinical outcomes for patients treated with PD or HHD are as good as or better than for patients treated with conventional in-center hemodialysis (ICHD). The recent implementation of the Medicare expanded prospective payment system (PPS) for the care of ESRD patients has resulted in substantial growth in the utilization of PD in the United States. Utilization of HHD has also grown, but the contribution of the expanded PPS to this growth is less certain. Summary Home dialysis, including PD and HHD represent important alternatives to ICHD that are effective and patient-centered. Over the coming decade, growth in the number of ESRD patient treated with home dialysis modalities should prompt further comparative and cost effectiveness research, increased attention to racial and ethnic disparities, and investments in home dialysis education for both patients and providers. PMID:25197946

Algorithm for optimal dialysis access timing.

PubMed

Heaf, J G

2007-02-01

Acute initiation of dialysis is associated with increased morbidity due to access and uremia complications. It is frequent despite early referral and regular out-patient control. We studied factors associated with end-stage renal disease (ESRD) progression in order to optimize the timing of dialysis access (DA). In a retrospective longitudinal study (Study 1), the biochemical and clinical course of 255 dialysis and 64 predialysis patients was registered to determine factors associated with dialysis-free survival (DFS). On the basis of these results an algorithm was developed to predict timely DA, defined as >6 weeks and <26 weeks before dialysis initiation, with too late placement weighted twice as harmful as too early. The algorithm was validated in a prospective study (Study 2) of 150 dialysis and 28 predialysis patients. Acute dialysis was associated with increased 90-day hospitalization (17.9 vs. 9.0 days) and mortality (14% vs. 6%). P-creatinine and p-urea were poor indicators of DFS. At any level of p-creatinine, DFS was shorter with lower creatinine clearance and vice versa. Patients with systemic renal disease had a significantly shorter DFS than primary renal disease, due to faster GFR loss and earlier dialysis initiation. Short DFS was seen with hypoalbuminemia and cachexia; these patients were recommended early DA. The following algorithm was used to time DA (units: 1iM and ml/min/1.73 m2): P-Creatinine - 50 x GFR + (100 if Systemic Renal Disease) >200. Use of the algorithm was associated with earlier dialysis placement and a fall in acute dialysis requirements from 50% to 23%. The incidence of too early DA was unchanged (7% vs. 9%), and was due to algorithm non-application. The algorithm failed to predict imminent dialysis in 10% of cases, primarily due to acute exacerbation of stable uremia. Dialysis initiation was advanced by approximately one month. A predialysis program based on early dialysis planning and GFR-based DA timing may reduce the

[Census 2004 of the Italian Renal and Dialysis Units. Emilia-Romagna, Toscana].

PubMed

Lusenti, T; Santoro, A; Cappelli, G; Cagnoli, L; Moriconi, L; Rindi, P; Lippi, A; Alloatti, S

2006-01-01

The 2004 SIN census of the Italian nephrology and dialysis centres showed many interesting data about the epidemiology and the organization in the Regions of Emilia-Romagna (ER) and Tuscany (T). A) Epidemiology: incidence of dialysis patients 169 pmp (patients per million population) in ER, 147 ppm in T; prevalence of dialysis patients 639 pmp and 665 pmp, respectively; prevalence of transplanted patients 325 ppm in ER and 233 pmp in T; gross mortality of dialysis patients 16.3% and 13.4%, respectively; B) Type of vascular access in prevalently dialysis patients: arteriovenous fistula 83% and 78%; central venous catheter 13% and 12%; vascular graft 5% and 9%. C) Structural resources: nephrology beds 44 mp (per million population) and 50 mp; dialysis places 157 and 146 mp. D) Personnel resources : renal physicians 29 and 41 mp; renal nurses 171 and 202 mp ; each renal physician cares for 22 and 16 dialysis patients, and each renal nurse takes care of 3.7 and 3.3 dialysis patients. E) Activity: hospital admissions 1572, 1769 pmp; renal biopsies 115 and 166 pmp.

Consolidation in the Dialysis Industry, Patient Choice, and Local Market Competition

PubMed Central

Zheng, Yuanchao; Winkelmayer, Wolfgang C.; Bhattacharya, Jay; Chertow, Glenn M.

2017-01-01

The Medicare program insures >80% of patients with ESRD in the United States. An emphasis on reducing outpatient dialysis costs has motivated consolidation among dialysis providers, with two for-profit corporations now providing dialysis for >70% of patients. It is unknown whether industry consolidation has affected patients’ ability to choose among competing dialysis providers. We identified patients receiving in-center hemodialysis at the start of 2001 and 2011 from the national ESRD registry and ascertained dialysis facility ownership. For each hospital service area, we determined the maximum distance within which 90% of patients traveled to receive dialysis in 2001. We compared the numbers of competing dialysis providers within that same distance between 2001 and 2011. Additionally, we examined the Herfindahl–Hirschman Index, a metric of market concentration ranging from near zero (perfect competition) to one (monopoly) for each hospital service area. Between 2001 and 2011, the number of different uniquely owned competing providers decreased 8%. However, increased facility entry into markets to meet rising demand for care offset the effect of provider consolidation on the number of choices available to patients. The number of dialysis facilities in the United States increased by 54%, and patients experienced an average 10% increase in the number of competing proximate facilities from which they could choose to receive dialysis (P<0.001). Local markets were highly concentrated in both 2001 and 2011 (mean Herfindahl–Hirschman Index =0.46; SD=0.2 for both years), but overall market concentration did not materially change. In summary, a decade of consolidation in the United States dialysis industry did not (on average) limit patient choice or result in more concentrated local markets. However, because dialysis markets remained highly concentrated, it will be important to understand whether market competition affects prices paid by private insurers, access to

Influenza and pneumococcal vaccinations in dialysis patients in a London district general hospital.

PubMed

Wilmore, Stephanie M S; Philip, Keir E; Cambiano, Valentina; Bretherton, Christopher P; Harborne, Josephine E; Sharma, Aditi; Jayasena, Shyama D

2014-02-01

Patients on dialysis mount reduced immune responses compared with the general population. The Department of Health advises that these patients receive influenza and pneumococcal vaccinations at regular intervals-once yearly and every five years, respectively. This article investigates the uptake of these vaccinations in this patient population and seeks to examine factors that may influence vaccination status such as patient's language and presence of a general practitioner (GP) electronic vaccination reminder system. It also explores preferred site of vaccination for patients and GPs as these are primary care vaccinations yet patients have more frequent contact with their dialysis unit than their GP, blurring the boundaries between primary and specialized care. This is a retrospective study of all patients registered as dialysing at the North Middlesex University Hospital NHS Trust (NMUH) in September 2011. Information was obtained through GP letters, GP and patient questionnaires. Of 154 patients, 133 were included in the data analysis. Nineteen per cent were up-to-date with both vaccinations and 67% with their influenza vaccination. Fifty per cent had received the influenza vaccination in the last two consecutive years. Thirty per cent were not up-to-date with either vaccination. There was no evidence of a difference in uptake in 2009 (P = 0.7564) and in 2010 (P = 0.7435) among those who could and could not speak English. Twenty-five per cent of GPs and 58.6% of patients preferred vaccination to occur in the dialysis unit. Unfortunately a high number of GPs did not provide information on whether they used an electronic vaccination reminder but the analysis from the information provided by the few respondents did not reveal any correlation between the presence of an electronic reminder and vaccination status. Most dialysis patients were not up-to-date with both vaccinations. They were, however, more up-to-date with their influenza than their pneumococcal

Influenza and pneumococcal vaccinations in dialysis patients in a London district general hospital

PubMed Central

Wilmore, Stephanie M.S.; Philip, Keir E.; Cambiano, Valentina; Bretherton, Christopher P.; Harborne, Josephine E.; Sharma, Aditi; Jayasena, Shyama D.

2014-01-01

Background Patients on dialysis mount reduced immune responses compared with the general population. The Department of Health advises that these patients receive influenza and pneumococcal vaccinations at regular intervals—once yearly and every five years, respectively. This article investigates the uptake of these vaccinations in this patient population and seeks to examine factors that may influence vaccination status such as patient's language and presence of a general practitioner (GP) electronic vaccination reminder system. It also explores preferred site of vaccination for patients and GPs as these are primary care vaccinations yet patients have more frequent contact with their dialysis unit than their GP, blurring the boundaries between primary and specialized care. Methods This is a retrospective study of all patients registered as dialysing at the North Middlesex University Hospital NHS Trust (NMUH) in September 2011. Information was obtained through GP letters, GP and patient questionnaires. Results Of 154 patients, 133 were included in the data analysis. Nineteen per cent were up-to-date with both vaccinations and 67% with their influenza vaccination. Fifty per cent had received the influenza vaccination in the last two consecutive years. Thirty per cent were not up-to-date with either vaccination. There was no evidence of a difference in uptake in 2009 (P = 0.7564) and in 2010 (P = 0.7435) among those who could and could not speak English. Twenty-five per cent of GPs and 58.6% of patients preferred vaccination to occur in the dialysis unit. Unfortunately a high number of GPs did not provide information on whether they used an electronic vaccination reminder but the analysis from the information provided by the few respondents did not reveal any correlation between the presence of an electronic reminder and vaccination status. Conclusion Most dialysis patients were not up-to-date with both vaccinations. They were, however, more up-to-date with their

The interview with a patient on dialysis: feeling, emotions and fears.

PubMed

Brunori, Francesco; Dozio, Beatrice; Colzani, Sara; Pozzi, Marco; Pisano, Lucia; Galassi, Andrea; Santorelli, Gennaro; Auricchio, Sara; Busnelli, Luisa; Di Carlo, Angela; Viganò, Monica; Calabrese, Valentina; Mariani, Laura; Mossa, Monica; Longoni, Stefania; Scanziani, Renzo

2016-01-01

This study has been performed in the Nephrology and Dialysis Unit, in Desio Hospital, Italy. The aim of this study is to evaluate, starting from research questions, which information is given to patient in the pre-dialysis colloquia for his/her chosen dialysis methods. Moreover, the study evaluated feelings, emotions and fears since the announcement of the necessity of dialysis treatment. The objective of the study was reached through the interview with patients on dialysis. The fact-finding survey was based on the tools of social research, as the semi-structured interview. Instead of using the questionnaire, even though it make it easier to collect larger set of data, the Authors decided to interview patients in person, since the interview allows direct patient contact and to build a relationship of trust with the interviewer, in order to allow patient explain better his/her feeling.

Adherence barriers to chronic dialysis in the United States.

PubMed

Chan, Kevin E; Thadhani, Ravi I; Maddux, Franklin W

2014-11-01

Hemodialysis patients often do not attend their scheduled treatment session. We investigated factors associated with missed appointments and whether such nonadherence poses significant harm to patients and increases overall health care utilization in an observational analysis of 44 million hemodialysis treatments for 182,536 patients with ESRD in the United States. We assessed the risk of hospitalization, emergency room visit, or intensive-coronary care unit (ICU-CCU) admission in the 2 days after a missed treatment relative to the risk for patients who received hemodialysis. Over the 5-year study period, the average missed treatment rate was 7.1 days per patient-year. In covariate adjusted logistic regression, the risk of hospitalization (odds ratio [OR], 3.98; 95% confidence interval [95% CI], 3.93 to 4.04), emergency room visit (OR, 2.00; 95% CI, 1.87 to 2.14), or ICU-CCU admission (OR, 3.89; 95% CI, 3.81 to 3.96) increased significantly after a missed treatment. Overall, 0.9 missed treatment days per year associated with suboptimal transportation to dialysis, inclement weather, holidays, psychiatric illness, pain, and gastrointestinal upset. These barriers also associated with excess hospitalization (5.6 more events per patient-year), emergency room visits (1.1 more visits), and ICU-CCU admissions (0.8 more admissions). In conclusion, poor adherence to hemodialysis treatments may be a substantial roadblock to achieving better patient outcomes. Addressing systemic and patient barriers that impede access to hemodialysis care may decrease missed appointments and reduce patient morbidity. Copyright © 2014 by the American Society of Nephrology.

Adherence Barriers to Chronic Dialysis in the United States

PubMed Central

Thadhani, Ravi I.; Maddux, Franklin W.

2014-01-01

Hemodialysis patients often do not attend their scheduled treatment session. We investigated factors associated with missed appointments and whether such nonadherence poses significant harm to patients and increases overall health care utilization in an observational analysis of 44 million hemodialysis treatments for 182,536 patients with ESRD in the United States. We assessed the risk of hospitalization, emergency room visit, or intensive-coronary care unit (ICU-CCU) admission in the 2 days after a missed treatment relative to the risk for patients who received hemodialysis. Over the 5-year study period, the average missed treatment rate was 7.1 days per patient-year. In covariate adjusted logistic regression, the risk of hospitalization (odds ratio [OR], 3.98; 95% confidence interval [95% CI], 3.93 to 4.04), emergency room visit (OR, 2.00; 95% CI, 1.87 to 2.14), or ICU-CCU admission (OR, 3.89; 95% CI, 3.81 to 3.96) increased significantly after a missed treatment. Overall, 0.9 missed treatment days per year associated with suboptimal transportation to dialysis, inclement weather, holidays, psychiatric illness, pain, and gastrointestinal upset. These barriers also associated with excess hospitalization (5.6 more events per patient-year), emergency room visits (1.1 more visits), and ICU-CCU admissions (0.8 more admissions). In conclusion, poor adherence to hemodialysis treatments may be a substantial roadblock to achieving better patient outcomes. Addressing systemic and patient barriers that impede access to hemodialysis care may decrease missed appointments and reduce patient morbidity. PMID:24762400

Consolidation in the Dialysis Industry, Patient Choice, and Local Market Competition.

PubMed

Erickson, Kevin F; Zheng, Yuanchao; Winkelmayer, Wolfgang C; Ho, Vivian; Bhattacharya, Jay; Chertow, Glenn M

2017-03-07

The Medicare program insures >80% of patients with ESRD in the United States. An emphasis on reducing outpatient dialysis costs has motivated consolidation among dialysis providers, with two for-profit corporations now providing dialysis for >70% of patients. It is unknown whether industry consolidation has affected patients' ability to choose among competing dialysis providers. We identified patients receiving in-center hemodialysis at the start of 2001 and 2011 from the national ESRD registry and ascertained dialysis facility ownership. For each hospital service area, we determined the maximum distance within which 90% of patients traveled to receive dialysis in 2001. We compared the numbers of competing dialysis providers within that same distance between 2001 and 2011. Additionally, we examined the Herfindahl-Hirschman Index, a metric of market concentration ranging from near zero (perfect competition) to one (monopoly) for each hospital service area. Between 2001 and 2011, the number of different uniquely owned competing providers decreased 8%. However, increased facility entry into markets to meet rising demand for care offset the effect of provider consolidation on the number of choices available to patients. The number of dialysis facilities in the United States increased by 54%, and patients experienced an average 10% increase in the number of competing proximate facilities from which they could choose to receive dialysis ( P <0.001). Local markets were highly concentrated in both 2001 and 2011 (mean Herfindahl-Hirschman Index =0.46; SD=0.2 for both years), but overall market concentration did not materially change. In summary, a decade of consolidation in the United States dialysis industry did not (on average) limit patient choice or result in more concentrated local markets. However, because dialysis markets remained highly concentrated, it will be important to understand whether market competition affects prices paid by private insurers, access to

Performance measures for a dialysis setting.

PubMed

Gu, Xiuzhu; Itoh, Kenji

2018-03-01

This study from Japan extracted performance measures for dialysis unit management and investigated their characteristics from professional views. Two surveys were conducted using self-administered questionnaires, in which dialysis managers/staff were asked to rate the usefulness of 44 performance indicators. A total of 255 managers and 2,097 staff responded. Eight performance measures were elicited from dialysis manager and staff responses: these were safety, operational efficiency, quality of working life, financial effectiveness, employee development, mortality, patient/employee satisfaction and patient-centred health care. These performance measures were almost compatible with those extracted in overall healthcare settings in a previous study. Internal reliability, content and construct validity of the performance measures for the dialysis setting were ensured to some extent. As a general trend, both dialysis managers and staff perceived performance measures as highly useful, especially for safety, mortality, operational efficiency and patient/employee satisfaction, but showed relatively low concerns for patient-centred health care and employee development. However, dialysis managers' usefulness perceptions were significantly higher than staff. Important guidelines for designing a holistic hospital/clinic management system were yielded. Performance measures must be balanced for outcomes and performance shaping factors (PSF); a common set of performance measures could be applied to all the healthcare settings, although performance indicators of each measure should be composed based on the application field and setting; in addition, sound causal relationships between PSF and outcome measures/indicators should be explored for further improvement. © 2017 European Dialysis and Transplant Nurses Association/European Renal Care Association.

How Should Disaster Base Hospitals Prepare for Dialysis Therapy after Earthquakes? Introduction of Double Water Piping Circuits Provided by Well Water System

PubMed Central

Ohta, Nobutaka

2016-01-01

After earthquakes, continuing dialysis for patients with ESRD and patients suffering from crush syndrome is the serious problem. In this paper, we analyzed the failure of the provision of dialysis services observed in recent disasters and discussed how to prepare for disasters to continue dialysis therapy. Japan has frequently experienced devastating earthquakes. A lot of dialysis centers could not continue dialysis treatment owing to damage caused by these earthquakes. The survey by Japanese Society for Dialysis Treatment (JSDT) after the Great East Japan Earthquake in 2011 showed that failure of lifelines such as electric power and water supply was the leading cause of the malfunction of dialysis treatment. Our hospital is located in Shizuoka Prefecture, where one of the biggest earthquakes is predicted to occur in the near future. In addition to reconstructing earthquake-resistant buildings and facilities, we therefore have adopted double electric and water lifelines by introducing emergency generators and well water supply systems. It is very important to inform politicians, bureaucrats, and local water departments that dialysis treatment, a life sustaining therapy for patients with end stage renal diseases, requires a large amount of water. We cannot prevent an earthquake but can curb the extent of a disaster by preparing for earthquakes. PMID:27999820

How Should Disaster Base Hospitals Prepare for Dialysis Therapy after Earthquakes? Introduction of Double Water Piping Circuits Provided by Well Water System.

PubMed

Ikegaya, Naoki; Seki, George; Ohta, Nobutaka

2016-01-01

After earthquakes, continuing dialysis for patients with ESRD and patients suffering from crush syndrome is the serious problem. In this paper, we analyzed the failure of the provision of dialysis services observed in recent disasters and discussed how to prepare for disasters to continue dialysis therapy. Japan has frequently experienced devastating earthquakes. A lot of dialysis centers could not continue dialysis treatment owing to damage caused by these earthquakes. The survey by Japanese Society for Dialysis Treatment (JSDT) after the Great East Japan Earthquake in 2011 showed that failure of lifelines such as electric power and water supply was the leading cause of the malfunction of dialysis treatment. Our hospital is located in Shizuoka Prefecture, where one of the biggest earthquakes is predicted to occur in the near future. In addition to reconstructing earthquake-resistant buildings and facilities, we therefore have adopted double electric and water lifelines by introducing emergency generators and well water supply systems. It is very important to inform politicians, bureaucrats, and local water departments that dialysis treatment, a life sustaining therapy for patients with end stage renal diseases, requires a large amount of water. We cannot prevent an earthquake but can curb the extent of a disaster by preparing for earthquakes.

Economic Evaluation of Urgent-Start Peritoneal Dialysis Versus Urgent-Start Hemodialysis in the United States

PubMed Central

Liu, Frank Xiaoqing; Ghaffari, Arshia; Dhatt, Harman; Kumar, Vijay; Balsera, Cristina; Wallace, Eric; Khairullah, Quresh; Lesher, Beth; Gao, Xin; Henderson, Heather; LaFleur, Paula; Delgado, Edna M.; Alvarez, Melissa M.; Hartley, Janett; McClernon, Marilyn; Walton, Surrey; Guest, Steven

2014-01-01

Abstract Patients presenting late in the course of kidney disease who require urgent initiation of dialysis have traditionally received temporary vascular catheters followed by hemodialysis. Recent changes in Medicare payment policy for dialysis in the USA incentivized the use of peritoneal dialysis (PD). Consequently, the use of more expeditious PD for late-presenting patients (urgent-start PD) has received new attention. Urgent-start PD has been shown to be safe and effective, and offers a mechanism for increasing PD utilization. However, there has been no assessment of the dialysis-related costs over the first 90 days of care. The objective of this study was to characterize the costs associated with urgent-start PD, urgent-start hemodialysis (HD), or a dual approach (urgent-start HD followed by urgent-start PD) over the first 90 days of treatment from a provider perspective. A survey of practitioners from 5 clinics known to use urgent-start PD was conducted to provide inputs for a cost model representing typical patients. Model inputs were obtained from the survey, literature review, and available cost data. Sensitivity analyses were also conducted. The estimated per patient cost over the first 90 days for urgent-start PD was $16,398. Dialysis access represented 15% of total costs, dialysis services 48%, and initial hospitalization 37%. For urgent-start HD, total per patient costs were $19,352, and dialysis access accounted for 27%, dialysis services 42%, and initial hospitalization 31%. The estimated cost for dual patients was $19,400. Urgent-start PD may offer a cost saving approach for the initiation of dialysis in eligible patients requiring an urgent-start to dialysis. PMID:25526471

Reexploring Differences among For-Profit and Nonprofit Dialysis Providers

PubMed Central

Lee, Donald K K; Chertow, Glenn M; Zenios, Stefanos A

2010-01-01

Objective To determine whether profit status is associated with differences in hospital days per patient, an outcome that may also be influenced by provider financial goals. Data Sources United States Renal Data System Standard Analysis Files and Centers for Medicare and Medicaid Services cost reports. Design We compared the number of hospital days per patient per year across for-profit and nonprofit dialysis facilities during 2003. To address possible referral bias in the assignment of patients to dialysis facilities, we used an instrumental variable regression method and adjusted for selected patient-specific factors, facility characteristics such as size and chain affiliation, as well as metrics of market competition. Data Extraction Methods All patients who received in-center hemodialysis at any time in 2003 and for whom Medicare was the primary payer were included (N=170,130; roughly two-thirds of the U.S. hemodialysis population). Patients dialyzed at hospital-based facilities and patients with no dialysis facilities within 30 miles of their residence were excluded. Results Overall, adjusted hospital days per patient were 17±5 percent lower in nonprofit facilities. The difference between nonprofit and for-profit facilities persisted with the correction for referral bias. There was no association between hospital days per patient per year and chain affiliation, but larger facilities had inferior outcomes (facilities with 73 or more patients had a 14±1.7 percent increase in hospital days relative to facilities with 35 or fewer patients). Differences in outcomes among for-profit and nonprofit facilities translated to 1,600 patient-years in hospital that could be averted each year if the hospital utilization rates in for-profit facilities were to decrease to the level of their nonprofit counterparts. Conclusions Hospital days per patient-year were statistically and clinically significantly lower among nonprofit dialysis providers. These findings suggest that

Reexploring differences among for-profit and nonprofit dialysis providers.

PubMed

Lee, Donald K K; Chertow, Glenn M; Zenios, Stefanos A

2010-06-01

To determine whether profit status is associated with differences in hospital days per patient, an outcome that may also be influenced by provider financial goals. United States Renal Data System Standard Analysis Files and Centers for Medicare and Medicaid Services cost reports. We compared the number of hospital days per patient per year across for-profit and nonprofit dialysis facilities during 2003. To address possible referral bias in the assignment of patients to dialysis facilities, we used an instrumental variable regression method and adjusted for selected patient-specific factors, facility characteristics such as size and chain affiliation, as well as metrics of market competition. All patients who received in-center hemodialysis at any time in 2003 and for whom Medicare was the primary payer were included (N=170,130; roughly two-thirds of the U.S. hemodialysis population). Patients dialyzed at hospital-based facilities and patients with no dialysis facilities within 30 miles of their residence were excluded. Overall, adjusted hospital days per patient were 17+/-5 percent lower in nonprofit facilities. The difference between nonprofit and for-profit facilities persisted with the correction for referral bias. There was no association between hospital days per patient per year and chain affiliation, but larger facilities had inferior outcomes (facilities with 73 or more patients had a 14+/-1.7 percent increase in hospital days relative to facilities with 35 or fewer patients). Differences in outcomes among for-profit and nonprofit facilities translated to 1,600 patient-years in hospital that could be averted each year if the hospital utilization rates in for-profit facilities were to decrease to the level of their nonprofit counterparts. Hospital days per patient-year were statistically and clinically significantly lower among nonprofit dialysis providers. These findings suggest that the indirect incentives in Medicare's current payment system may provide

Natural disasters and dialysis care in the Asia-Pacific.

PubMed

Gray, Nicholas A; Wolley, Martin; Liew, Adrian; Nakayama, Masaaki

2015-12-01

The impact of natural disasters on the provision of dialysis services has received increased attention in the last decade following Hurricane Katrina devastating New Orleans in 2005. The Asia-Pacific is particularly vulnerable to earthquakes, tsunami, typhoons (also known as cyclones and hurricanes) or storms and flooding. These events can seriously interrupt provision of haemodialysis with adverse effects for patients including missed dialysis, increased hospitalization and post-traumatic stress disorder. Furthermore, haemodialysis patients may need to relocate and experience prolonged periods of displacement from family and social supports. In contrast to haemodialysis, most literature suggests peritoneal dialysis in a disaster situation is more easily managed and supported. It has become apparent that dialysis units and patients should be prepared for a disaster event and that appropriate planning will result in reduced confusion and adverse outcomes should a disaster occur. Numerous resources are now available to guide dialysis units, patients and staff in preparation for a possible disaster. This article will examine the disaster experiences of dialysis units in the Asia-Pacific, the impact on patients and staff, methods employed to manage during the disaster and suggested plans for reducing the impact of future disasters. © 2015 Asian Pacific Society of Nephrology.

The Perception of Art among Patients and Staff on a Renal Dialysis Unit.

PubMed

Corrigan, C; Peterson, L; McVeigh, C; Lavin, P J; Mellotte, G J; Wall, C; Baker Kerrigan, A; Barnes, L; O'Neill, D; Moss, H

2017-10-10

This study investigated the purpose and effectiveness of giving outpatients an opportunity to engage in art activities while receiving dialysis treatment. A mixed method study was conducted. 21 semi-structured interviews were conducted with outpatients attending the dialysis unit and 13 surveys of clinicians were completed. The principle reasons to partake in the art activity programme included: to pass time, to relieve boredom, to be creative, to try something new, distraction from concerns, to stay positive and to achieve something new. Patients who did not participate in the programme pass their time primarily by watching TV or sleeping. All staff who partook in the survey were satisfied with the programme and wanted it to continue. Our findings indicate that the creative arts programme is viewed positively by staff and patients alike, and might be useful in other hospital departments. Further in depth qualitative research would be useful to interrogate the potential effect of engagement in art on positive mental health and quality of life for patients with chronic conditions.

Impact of dialysis practice patterns on outcomes in acute kidney injury in Intensive Care Unit.

PubMed

Annigeri, Rajeev A; Nandeesh, Venkatappa; Karuniya, Ramanathan; Rajalakshmi, Sasikumar; Venkataraman, Ramesh; Ramakrishnan, Nagarajan

2016-01-01

Recent advances in dialysis therapy have made an impact on the clinical practice of renal replacement therapy (RRT) in acute kidney injury (AKI) in Intensive Care Unit (ICU). We studied the impact of RRT practice changes on outcomes in AKI in ICU over a period of 8 years. AKI patients requiring RRT in ICU referred to a nephrologist during two different periods (period-1: Between May 2004 and May 2007, n = 69; period-2: Between August 2008 and May 2011, n = 93) were studied. The major changes in the dialysis practice during the period-2, compared to period-1 were introduction of prolonged intermittent RRT (PIRRT), early dialysis for metabolic acidosis, early initiation of RRT for anuria and positive fluid balance and use of bicarbonate-based fluids for continuous RRT (CRRT) instead of lactate buffer. The primary study outcome was 28-day hospital mortality. The mean age was 53.8 ± 16.1 years and 72.6% were male. Introduction of PIRRT resulted in 37% reduction in utilization of CRRT during period-2 (from 85.5% to 53.7%). The overall mortality was high (68%) but was significantly reduced during period-2 compared to period-1 (59% vs. 79.7%, P = 0.006). Metabolic acidosis but not the mode of RRT, was the significant factor which influenced mortality. Adaption of PIRRT resulted in 37% reduction of utilization of CRRT. The mortality rate was significantly reduced during the period of adaption of PIRRT, possibly due to early initiation of RRT in the latter period for indications such as anuria and metabolic acidosis.

Delivery of high-tech home care by hospital-based nursing units in Quebec: clinical and technical challenges.

PubMed

Lehoux, Pascale; Richard, L; Pineault, R; Saint-Arnaud, J

2006-03-01

The role that hospital-based nurses should play in the delivery of high-tech home care, and how they should be supported in that role, are topics that remain understudied. Our research objective was to document how hospital-based nursing teams perceive and deal with the clinical and technical challenges associated with the provision of high-tech home care. Four home care interventions were selected: antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis and oxygen therapy. A self-administered survey was sent to all hospital-based units providing these interventions in the province of Quebec, Canada (n = 154; response rate: 70.8%). We used descriptive statistical analyses to derive mean values for scores on either a five- or a six-level Likert scale. Despite variation across the four interventions, our results indicate that while nursing teams believe these interventions increase patients' autonomy, they also recognize that they generate anxiety and impose constraints on patients' lives. Nurses must increase efforts to deal with both clinical and technical challenges and help patients overcome the barriers to appropriate use of home care technologies. While nursing teams generally perceive high-tech home care as beneficial, they still experience significant technical and clinical challenges. Some of these challenges could be addressed by strengthening professional training initiatives, while others require broader home care policy interventions.

Conserving water in and applying solar power to haemodialysis: 'green dialysis' through wiser resource utilization.

PubMed

Agar, John W M

2010-06-01

Natural resources are under worldwide pressure, water and sustainable energy being the paramount issues. Haemodialysis, a water-voracious and energy-hungry healthcare procedure, thoughtlessly wastes water and leaves a heavy carbon footprint. In our service, 100 000 L/week of previously discarded reverse osmosis reject water--water which satisfies all World Health Organisation criteria for potable (drinking) water--no longer drains to waste but is captured for reuse. Reject water from the hospital-based dialysis unit provides autoclave steam for instrument sterilization, ward toilet flushing, janitor stations and garden maintenance. Satellite centre reject water is tanker-trucked to community sporting fields, schools and aged-care gardens. Home-based nocturnal dialysis patient reuse reject water for home domestic utilities, gardens and animal watering. Although these and other potential water reuse practices should be mandated through legislation for all dialysis services, this is yet to occur. In addition, we now are piloting the use of solar power for the reverse osmosis plant and the dialysis machines in our home dialysis training service. If previously attempted, these have yet to be reported. After measuring the power requirements of both dialytic processes and modelling the projected costs, a programme has begun to solar power all dialysis-related equipment in a three-station home haemodialysis training unit. Income-generation with the national electricity grid via a grid-share and reimbursement arrangement predicts a revenue stream back to the dialysis service. Dialysis services must no longer ignore the non-medical aspects of their programmes but plan, trial, implement and embrace 'green dialysis' resource management practices.

Analysis of the costs of dialysis and the effects of an incentive mechanism for low-cost dialysis modalities.

PubMed

Cleemput, Irina; De Laet, Chris

2013-05-01

Treatment costs of end-stage renal disease with dialysis are high and vary between dialysis modalities. Public healthcare payers aim at stimulating the use of less expensive dialysis modalities, with maintenance of healthcare quality. This study examines the effects of Belgian financial incentive mechanisms for the use of low-cost dialysis treatments. First, the costs of different dialysis modalities were calculated from the hospital's perspective. Data were obtained through a hospital survey. The balance between costs and revenues was simulated for an average Belgian dialysis programme. Incremental profits were calculated in function of the proportion of patients on alternative dialysis modalities. Hospital haemodialysis is the most expensive modality per patient year, followed by peritoneal dialysis and finally satellite haemodialysis. Under current reimbursement rules mean profits of a dialysis programme are maximal if about 28% of patients are treated with a low-cost dialysis modality. This is only slightly lower than the observed percentage in Belgian dialysis centres in the same period. In Belgium, the financial incentives for the use of low-cost dialysis modalities only had a modest impact due to the continuing profits that could be generated by high-cost dialysis. Profit neutrality is crucial for the success of any financial incentive mechanism for low-cost dialysis modalities. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Impact of dialysis practice patterns on outcomes in acute kidney injury in Intensive Care Unit

PubMed Central

Annigeri, Rajeev A.; Nandeesh, Venkatappa; Karuniya, Ramanathan; Rajalakshmi, Sasikumar; Venkataraman, Ramesh; Ramakrishnan, Nagarajan

2016-01-01

Aim: Recent advances in dialysis therapy have made an impact on the clinical practice of renal replacement therapy (RRT) in acute kidney injury (AKI) in Intensive Care Unit (ICU). We studied the impact of RRT practice changes on outcomes in AKI in ICU over a period of 8 years. Subjects and Methods: AKI patients requiring RRT in ICU referred to a nephrologist during two different periods (period-1: Between May 2004 and May 2007, n = 69; period-2: Between August 2008 and May 2011, n = 93) were studied. The major changes in the dialysis practice during the period-2, compared to period-1 were introduction of prolonged intermittent RRT (PIRRT), early dialysis for metabolic acidosis, early initiation of RRT for anuria and positive fluid balance and use of bicarbonate-based fluids for continuous RRT (CRRT) instead of lactate buffer. The primary study outcome was 28-day hospital mortality. Results: The mean age was 53.8 ± 16.1 years and 72.6% were male. Introduction of PIRRT resulted in 37% reduction in utilization of CRRT during period-2 (from 85.5% to 53.7%). The overall mortality was high (68%) but was significantly reduced during period-2 compared to period-1 (59% vs. 79.7%, P = 0.006). Metabolic acidosis but not the mode of RRT, was the significant factor which influenced mortality. Conclusions: Adaption of PIRRT resulted in 37% reduction of utilization of CRRT. The mortality rate was significantly reduced during the period of adaption of PIRRT, possibly due to early initiation of RRT in the latter period for indications such as anuria and metabolic acidosis. PMID:26955212

Disinfection of the hospital water supply: a hidden risk to dialysis patients

PubMed Central

2009-01-01

Water suitable for drinking is unsuited for use in the preparation of haemodialysis fluid and undergoes additional treatment. The primary component of the additional treatment is reverse osmosis, which does not remove low-molecular-weight contaminants, and the water treatment system must contain carbon beds or filters to ensure effective removal of such contaminants. The recent article by Bek and colleagues highlights an unrecognised issue with respect to chemicals that may be added to the water within hospitals to ensure that the distribution network is free of pathogens (for example, Legionella, pseudomonas, and mycobacteria) and underlines the need for personnel responsible for dialysis in a renal or intensive care setting to be aware of any potential effects that disinfection of the hospital water treatment system may have on the product water used in the preparation of dialysis fluid. Such awareness requires communication and the sharing of information between clinical and facilities staff. PMID:20053299

Serum Magnesium Levels and Hospitalization and Mortality in Incident Peritoneal Dialysis Patients: A Cohort Study

PubMed Central

Yang, Xiao; Soohoo, Melissa; Streja, Elani; Rivara, Matthew B.; Obi, Yoshitsugu; Adams, Scott V.; Kalantar-Zadeh, Kamyar; Mehrotra, Rajnish

2016-01-01

Background Prior studies have shown the association of low serum magnesium with adverse health outcomes in patients undergoing hemodialysis. There is a paucity of such studies in patients undergoing peritoneal dialysis (PD). Study Design Cohort Study. Setting & Participants 10,692 patients treated with PD January 1, 2007–December 31, 2011 in facilities operated by a single large dialysis organization in the United States. Predictor Baseline serum magnesium levels, examined as five categories (<1.8, 1.8–<2.0, 2.0–<2.2 [reference], 2.2–<2.4, and ≥2.4 mg/dL). Outcomes Time to first hospitalization and time to death using competing risks regression models. Results The distribution of baseline serum magnesium levels in the cohort were < 1.8 mg/dl: 1928 (18%); 1.8–<2.0 mg/dl: 2204 (21%); 2.0–<2.2 mg/dl: 2765 (26%); 2.2–<2.4 mg/dl: 1765 (16%); and ≥ 2.4 mg/dl: 2030 (19%). Of the 10,692 patients, 6465 (60%) were hospitalized at least once and 1392 (13%) died during follow-up (median, 13; IQR, 7–23 months). Baseline serum magnesium <1.8 mg/dL was associated with higher risk for hospitalization and all-cause mortality after adjustment for demographic and clinical characteristics (adjusted HRs of 1.23 [95% CI, 1.14–1.33] and 1.21 [95% CI, 1.03–1.42], respectively). The higher risk for hospitalization persisted upon adjustment for laboratory variables while that for all-cause mortality was attenuated to a non-significant level. The greatest risk for hospitalization was in patients with low serum albumin (< 3.5 g/dl; p for interaction < 0.001). Limitations Possibility of residual confounding by unmeasured variables cannot be excluded. Conclusions Lower serum magnesium levels may be associated with higher risk of hospitalization in incident PD patients, particularly among those with hypoalbuminemia. Additional studies are needed to confirm these findings and investigate whether correction of hypomagnesemia reduces these risks. PMID:27261330

Disaster preparedness of dialysis patients for Hurricanes Gustav and Ike 2008.

PubMed

Kleinpeter, Myra A

2009-01-01

Hurricanes Katrina and Rita resulted in massive devastation of the Gulf Coast at Mississippi, Louisiana, and Texas during 2005. Because of those disasters, dialysis providers, nephrologists, and dialysis patients used disaster planning activities to work to mitigate the morbidity and mortality associated with the 2005 hurricane season for future events affecting dialysis patients. As Hurricane Gustav approached, anniversary events for Hurricane Katrina were postponed because of evacuation orders for nearly the entire Louisiana Gulf Coast. As part of the hurricane preparation, dialysis units reviewed the disaster plans of patients, and patients made preparation for evacuation. Upon evacuation, many patients returned to the dialysis units that had provided services during their exile from Hurricane Katrina; other patients went to other locations as part of their evacuation plan. Patients uniformly reported positive experiences with dialysis providers in their temporary evacuation communities, provided that those communities did not experience the effects of Hurricane Gustav. With the exception of evacuees to Baton Rouge, patients continued to receive their treatments uninterrupted. Because of extensive damage in the Baton Rouge area, resulting in widespread power losses and delayed restoration of power to hospitals and other health care facilities, some patients missed one treatment. However, as a result of compliance with disaster fluid and dietary recommendations, no adverse outcomes occurred. In most instances, patients were able to return to their home dialysis unit or a nearby unit to continue dialysis treatments within 4 - 5 days of Hurricane Gustav. Hurricane Ike struck the Texas Gulf Coast near Galveston, resulting in devastation of that area similar to the devastation seen in New Orleans after Katrina. The storm surge along the Louisiana Gulf Coast resulted in flooding that temporarily closed coastal dialysis units. Patients were prepared and experienced

Challenges of ECG monitoring and ECG interpretation in dialysis units.

PubMed

Poulikakos, Dimitrios; Malik, Marek

Patients on hemodialysis (HD) suffer from high cardiovascular morbidity and mortality due to high rates of coronary artery disease and arrhythmias. Electrocardiography (ECG) is often performed in the dialysis units as part of routine clinical assessment. However, fluid and electrolyte changes have been shown to affect all ECG morphologies and intervals. ECG interpretation thus depends on the time of the recording in relation to the HD session. In addition, arrhythmias during HD are common, and dialysis-related ECG artifacts mimicking arrhythmias have been reported. Studies using advanced ECG analyses have examined the impact of the HD procedure on selected repolarization descriptors and heart rate variability indices. Despite the challenges related to the impact of the fluctuant fluid and electrolyte status on conventional and advanced ECG parameters, further research in ECG monitoring during dialysis has the potential to provide clinically meaningful and practically useful information for diagnostic and risk stratification purposes. Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.

[Auto-dialysis: an 11-year experience of a hemodialysis center in France].

PubMed

Montagnac, R; Schillinger, F

1996-03-30

Report 11 years of experience with self-managed hemodialysis in patients medically apt for extra-hospital dialysis and living close enough to small outpatient hemodialysis units to become totally self-sufficient. Among the 276 patients with chronic renal failure managed at the hemodialysis center at the Troyes hospital during the 11-year study period from 1984 through 1994, self-managed hemodialysis at small outpatient units was initiated in 127 (46%). None of these 127 patients required medical assistance or specific care during dialysis sessions. At initial hospital admission, only 60/127 (47%) were totally self-sufficient: 52 (41%) were later graft recipients; and 21 (16.5%) had to return to the hospital for a medical or surgical condition incompatible with extra-hospital care but all of these 21 patients remained self-sufficient. Extra-hospital hemodialysis in units close to the patients residence offers patients a better quality of life, even when medical assistance is required. All patients who require hemodialysis can thus be treated at lower cost without compromising quality of treatment. Perfect self-sufficiency may not be a goal in itself, but self-managed hemodialysis can be a very useful technique for patients without major medical problems. Continuing contact with the organizing hemodialysis center guarantees the safety of the system.

Dialysis Cannot be Dosed

PubMed Central

Meyer, Timothy W.; Sirich, Tammy L.; Hostetter, Thomas H.

2014-01-01

Adequate dialysis is difficult to define because we have not identified the toxic solutes that contribute most to uremic illness. Dialysis prescriptions therefore cannot be adjusted to control the levels of these solutes. The current solution to this problem is to define an adequate dose of dialysis on the basis of fraction of urea removed from the body. This has provided a practical guide to treatment as the dialysis population has grown over the past 25 years. Indeed, a lower limit to Kt/Vurea (or the related urea reduction ratio) is now established as a quality indicator by the Centers for Medicare and Medicaid for chronic hemodialysis patients in the United States. For the present, this urea-based standard provides a useful tool to avoid grossly inadequate dialysis. Dialysis dosing, however, based on measurement of a single, relatively nontoxic solute can provide only a very limited guide toward improved treatment. Prescriptions which have similar effects on the index solute can have widely different effects on other solutes. The dose concept discourages attempts to increase the removal of such solutes independent of the index solute. The dose concept further assumes that important solutes are produced at a constant rate relative to body size, and discourages attempts to augment dialysis treatment by reducing solute production. Identification of toxic solutes would provide a more rational basis for the prescription of dialysis and ultimately for improved treatment of patients with renal failure. PMID:21929590

Serum Magnesium Levels and Hospitalization and Mortality in Incident Peritoneal Dialysis Patients: A Cohort Study.

PubMed

Yang, Xiao; Soohoo, Melissa; Streja, Elani; Rivara, Matthew B; Obi, Yoshitsugu; Adams, Scott V; Kalantar-Zadeh, Kamyar; Mehrotra, Rajnish

2016-10-01

Prior studies have shown the association of low serum magnesium levels with adverse health outcomes in patients undergoing hemodialysis. There is a paucity of such studies in patients undergoing peritoneal dialysis (PD). Cohort study. 10,692 patients treated with PD from January 1, 2007, through December 31, 2011, in facilities operated by a single large dialysis organization in the United States. Baseline serum magnesium levels, examined as 5 categories (<1.8, 1.8-<2.0, 2.0-<2.2 [reference], 2.2-<2.4, and ≥2.4mg/dL). Time to first hospitalization and time to death using competing-risks regression models. The distribution of baseline serum magnesium levels in the cohort was <1.8mg/dL, 1,928 (18%); 1.8 to <2.0mg/dL, 2,204 (21%); 2.0 to <2.2mg/dL, 2,765 (26%); 2.2 to <2.4mg/dL, 1,765 (16%); and ≥2.4mg/dL, 2,030 (19%). Of 10,692 patients, 6,465 (60%) were hospitalized at least once and 1,392 (13%) died during follow-up (median, 13; IQR, 7-23 months). Baseline serum magnesium level < 1.8mg/dL was associated with higher risk for hospitalization and all-cause mortality after adjustment for demographic and clinical characteristics (adjusted HRs of 1.23 [95% CI, 1.14-1.33] and 1.21 [95% CI, 1.03-1.42], respectively). The higher risk for hospitalization persisted upon adjustment for laboratory variables, whereas that for all-cause mortality was attenuated to a nonsignificant level. The greatest risk for hospitalization was in patients with low serum albumin levels (<3.5g/dL; P for interaction < 0.001). Possibility of residual confounding by unmeasured variables cannot be excluded. Lower serum magnesium levels may be associated with higher risk for hospitalization in incident PD patients, particularly those with hypoalbuminemia. Additional studies are needed to confirm these findings and investigate whether correction of hypomagnesemia reduces these risks. Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Captivating a captive audience: a quality improvement project increasing participation in intradialytic exercise across five renal dialysis units

PubMed Central

Egas-Kitchener, Sara; Whibley, Daniel; Fynmore, Tom; Jones, Gareth D.

2017-01-01

Abstract Background Benefits of exercise on dialysis (EOD) are well established, however, uptake in our local satellite haemodialysis units is low. The implications of the status quo are risks to treatment efficiency, equity and patient centredness in managing personal health risks. The current study aimed to identify and address barriers to exercise participation while on dialysis by substantiating local EOD risks, assigning context, implementing changes and evaluating their impact. Our primary objective was to increase the uptake of EOD across our five dialysis units. Methods Semi-structured interview and questionnaire data from patients and nursing staff were used to inform a root-cause analysis of barriers to exercise participation while on dialysis. Intervention was subsequently designed and implemented by a senior physiotherapist. It consisted of patient and nursing staff education, equipment modification and introduction of patient motivation schemes. Results Staff knowledge, patient motivation and equipment problems were the main barriers to EOD. A significant increase in the uptake of EOD from 23.3% pre-intervention to 74.3% post-intervention was achieved [χ2 (1, N = 174) = 44.18, P < 0.001]. Conclusions Barriers to EOD are challenging, but there is evidence that patients wish to participate and would benefit from doing so. The input of a physiotherapist in the dialysis units had a significant positive effect on the uptake of EOD. National guidelines should encourage dialysis units to include professional exercise provision in future service planning. PMID:28852491

Searching for the optimal renal prescription. Fresenius, Kaiser Permanente team up to offer new options in dialysis care.

PubMed

Neumann, M E

1999-01-01

The goals are simple: Improve well-being of the dialysis patient and reduce hospitalizations. The tools are diverse: Ultrapure dialysate. On-line blood monitoring. Biocompatible membranes. No reuse. Daily, in-center dialysis and possibly nocturnal dialysis at home. Reimbursement: Full-risk capitation, With Medicare and commercial payor rates varying on a patient-by-patient basis. Create an incubator with approximately 1,000 end-stage renal disease patients, treated at both capitated payment-exclusive dialysis units and mingled in at traditional fee-for-service clinics. Establish a team of nurses and renal care staff to direct the care plan, and put the program in place. After the first year, analyze the data and see if the end--hopefully, improved outcomes and resulting reduced hospitalizations--justifies the means--the higher cost for "optimal technologies."

Impacts on dialysis therapy.

PubMed

Passon, S; Uthoff, S; Jäckle-Meyer, I

1998-01-01

Improvement of clinical outcome of dialysis therapy is a task for everybody working in a dialysis unit. Here we consider dialysis conditions such as choice of treatment parameters and composition of dialysis fluid which may influence clinical outcome of dialysis therapy. Providing 'adequate' dialysis is the aim of the daily work of a dialysis nurse. Haemodialysis parameters with potential impact on dialysis adequacy are discussed with respect to quantification and optimisation. Every year, each patient comes in contact with 20,000 I dialysis fluid during HD treatment. The composition of the fluid, its physical and microbiological quality and their impact on clinical outcome are considered. The function of PD fluid is different from that of an HD fluid thus additional aspects have to be considered regarding its composition. Information is given how the composition and biocompatibility of PD solutions impact the dialysis therapy and how individual patient needs are considered.

Increasing home dialysis knowledge through a web-based e-learning program.

PubMed

Bennett, Paul N; Jaeschke, Sadie; Sinclair, Peter M; Kerr, Peter G; Holt, Steve; Schoch, Monica; Fortnum, Debbie; Ockerby, Cherene; Kent, Bridie

2014-06-01

There has been a global decline in the uptake of home-based dialysis therapies in the past 20 years. The ability to provide appropriate information to potential patients in this area may be confounded by a lack of knowledge of home dialysis options. The aim of this study was to develop a web-based education package for health professionals to increase knowledge and positive perceptions of home-based dialysis options. A three-module e-learning package concerning home dialysis was developed under the auspices of the home dialysis first project. These modules were tested on 88 undergraduate health professionals. Changes in attitudes and knowledge of home dialysis were measured using custom designed surveys administered electronically to students who completed the modules. Matched pre and post responses to the survey items were compared using Wilcoxon signed rank tests. The pre survey indicated clear deficits in existing knowledge of home dialysis options. In particular, when asked if haemodialysis could be performed at home, 22% of participants responded 'definitely no' and a further 24% responded 'probably no'. Upon completion of the e-learning, post survey responses indicated statistically significant improvements (P < 0.001) in eight of the nine items. When asked if the e-learning had increased their knowledge about home dialysis, 99% of participants responded 'definitely yes'. A suite of web-based education modules can successfully deliver significant improvements in awareness and knowledge around home dialysis therapies. © 2014 Asian Pacific Society of Nephrology.

An instrumental variable approach finds no associated harm or benefit from early dialysis initiation in the United States

PubMed Central

Scialla, Julia J.; Liu, Jiannong; Crews, Deidra C.; Guo, Haifeng; Bandeen-Roche, Karen; Ephraim, Patti L.; Tangri, Navdeep; Sozio, Stephen M.; Shafi, Tariq; Miskulin, Dana C.; Michels, Wieneke M.; Jaar, Bernard G.; Wu, Albert W.; Powe, Neil R.; Boulware, L. Ebony

2014-01-01

The estimated glomerular filtration rate (eGFR) at dialysis initiation has been rising. Observational studies suggest harm, but may be confounded by unmeasured factors. As instrumental variable methods may be less biased we performed a retrospective cohort study of 310,932 patients starting dialysis between 2006 to 2008 and registered in the United States Renal Data System in order to describe geographic variation in eGFR at dialysis initiation and determine its association with mortality. Patients were grouped into 804 health service areas by zip code. Individual eGFR at dialysis initiation averaged 10.8 ml/min/1.73m2 but varied geographically. Only 11% of the variation in mean health service areas-level eGFR at dialysis initiation was accounted for by patient characteristics. We calculated demographic-adjusted mean eGFR at dialysis initiation in the health service areas using the 2006 and 2007 incident cohort as our instrument and estimated the association between individual eGFR at dialysis initiation and mortality in the 2008 incident cohort using the 2 stage residual inclusion method. Among 89,547 patients starting dialysis in 2008 with eGFR 5 to 20 ml/min/1.73m2, eGFR at initiation was not associated with mortality over a median of 15.5 months [hazard ratio 1.025 per 1 ml/min/1.73m2 for eGFR 5 to 14 ml/min/1.73m2; and 0.973 per 1 ml/min/1.73m2 for eGFR 14 to 20 ml/min/1.73m2]. Thus, there was no associated harm or benefit from early dialysis initiation in the United States. PMID:24786707

The Evolving Ethics of Dialysis in the United States: A Principlist Bioethics Approach

PubMed Central

Mehrotra, Rajnish; Tonelli, Mark R.; Lam, Daniel Y.

2016-01-01

Throughout the history of dialysis, four bioethical principles — beneficence, nonmaleficence, autonomy and justice — have been weighted differently based upon changing forces of technologic innovation, resource limitation, and societal values. In the 1960s, a committee of lay people in Seattle attempted to fairly distribute a limited number of maintenance hemodialysis stations guided by considerations of justice. As technology advanced and dialysis was funded under an amendment to the Social Security Act in 1972, focus shifted to providing dialysis for all in need while balancing the burdens of treatment and quality of life, supported by the concepts of beneficence and nonmaleficence. At the end of the last century, the importance of patient preferences and personal values became paramount in medical decisions, reflecting a focus on the principle of autonomy. More recently, greater recognition that health care financial resources are limited makes fair allocation more pressing, again highlighting the importance of distributive justice. The varying application and prioritization of these four principles to both policy and clinical decisions in the United States over the last 50 years makes the history of hemodialysis an instructive platform for understanding principlist bioethics. As medical technology evolves in a landscape of changing personal and societal values, a comprehensive understanding of an ethical framework for evaluating appropriate use of medical interventions enables the clinician to systematically negotiate and optimize difficult ethical situations. PMID:26912540

National Trends in Emergency Room Visits of Dialysis Patients for Adverse Drug Reactions.

PubMed

Chan, Lili; Saha, Aparna; Poojary, Priti; Chauhan, Kinsuk; Naik, Nidhi; Coca, Steven; Garimella, Pranav S; Nadkarni, Girish N

2018-06-12

Various medications are cleared by the kidneys, therefore patients with impaired renal function, especially dialysis patients are at risk for adverse drug events (ADEs). There are limited studies on ADEs in maintenance dialysis patients. We utilized a nationally representative database, the Nationwide Emergency Department Sample, from 2008 to 2013, to compare emergency department (ED) visits for dialysis and propensity matched non-dialysis patients. Log binomial regression was used to calculate relative risk of hospital admission and logistic regression to calculate ORs for in-hospital mortality while adjusting for patient and hospital characteristics. While ED visits for ADEs decreased in both groups, they were over 10-fold higher in dialysis patients than non-dialysis patients (65.8-88.5 per 1,000 patients vs. 4.6-5.4 per 1,000 patients respectively, p < 0.001). The top medication category associated with ED visits for ADEs in dialysis patients is agents primarily affecting blood constituents, which has increased. After propensity matching, patient admission was higher in dialysis patients than non-dialysis patients, (88 vs. 76%, p < 0.001). Dialysis was associated with a 3% increase in risk of admission and 3 times the odds of in-hospital mortality (adjusted OR 3, 95% CI 2.7-2.3.3). ED visits for ADEs are substantially higher in dialysis patients than non-dialysis patients. In dialysis patients, ADEs associated with agents primarily affecting blood constituents are on the rise. ED visits for ADEs in dialysis patients have higher inpatient admissions and in-hospital mortality. Further studies are needed to identify and implement measures aimed at reducing ADEs in dialysis patients. © 2018 S. Karger AG, Basel.

Prevalence-Based Targets Underestimate Home Dialysis Program Activity and Requirements for Growth.

PubMed

Bevilacqua, Micheli U; Er, Lee; Copland, Michael A; Singh, R Suneet; Jamal, Abeed; Dunne, Órla Marie; Brumby, Catherine; Levin, Adeera

2018-01-01

Many renal programs have targets to increase home dialysis prevalence. Data from a large Canadian home dialysis program were analyzed to determine if home dialysis prevalence accurately reflects program activity and whether prevalence-based assessments adequately reflect the work required for program growth. Data from home dialysis programs in British Columbia, Canada, were analyzed from 2005 to 2015. Prevalence data were compared to dialysis activity data including intakes and exits to describe program turnover. Using current attrition rates, recruitment rates needed to increase home dialysis prevalence proportions were identified. We analyzed 7,746 patient-years of peritoneal dialysis (PD) and 1,362 patient-years of home hemodialysis (HHD). The proportion of patients on home dialysis increased by 3.34% over the ten years examined, while the number of prevalent home dialysis patients increased 2.65% per year and the number of patients receiving home dialysis at any time in the year increased 4.04% per year. For every 1 patient net home dialysis growth, 13.6 new patients were recruited. Patient turnover included higher rates of transplantation in home dialysis than facility-based HD. Overall, the proportion dialyzing at home increased from 29.3 to 32.6%. There is high patient turnover in home dialysis such that program prevalence is an incomplete marker of total program activity. This turnover includes high rates of transplantation, which is a desirable interaction that affects home dialysis prevalence. The shortcomings of this commonly used metric are important for renal programs to consider, and better understanding of the activities that support home dialysis and the complex trajectories that home dialysis patients follow is needed. Copyright © 2018 International Society for Peritoneal Dialysis.

Fatigue experienced by patients receiving maintenance dialysis in hemodialysis units.

PubMed

Letchmi, Santhna; Das, Srijit; Halim, Hasliza; Zakariah, Farid Azizul; Hassan, Hamidah; Mat, Samsiah; Packiavathy, Ruth

2011-03-01

The fatigue that is observed in patients who are undergoing dialysis is usually associated with an impaired quality of life. The present cross-sectional study was conducted from January to April 2009 in three hemodialysis units in Kuala Lumpur, Malaysia. In this study, the Multidimensional Fatigue Inventory and Depression Anxiety and Stress Score 21 were used to determine the level of fatigue, depression, anxiety, and stress of patients who were undergoing dialysis. The data were obtained from a calculated sample of 116 and a total of 103 respondents participated in the study. A total of 56 (54.4%) and 47 (45.6%) respondents experienced a high level and a low level of fatigue, respectively. There was a significant relationship between the duration of treatment and the level of fatigue. The respondents who had been receiving treatment for > 2 years experienced more fatigue, compared to the respondents who had been undergoing hemodialysis for > 2 years. There was a significant difference in relation to the age of the participants regarding the level of fatigue. No significant relationship between the sex of the participants, anemia, depression, anxiety, stress, and the level of fatigue was observed. Special attention needs to be paid to both the younger and older adults who are receiving treatment. In addition, proper planning is needed for the patients regarding their daily activities in order to reduce fatigue. Nurses who work in hemodialysis units are recommended to provide exercise classes or group therapy in order to boost the energy levels among patients who are undergoing dialysis. Health professionals should provide appropriate treatment for patients who are experiencing fatigue in order to prevent any other complications that could arise. © 2011 Blackwell Publishing Asia Pty Ltd.

Conflict when making decisions about dialysis modality.

PubMed

Chen, Nien-Hsin; Lin, Yu-Ping; Liang, Shu-Yuan; Tung, Heng-Hsin; Tsay, Shiow-Luan; Wang, Tsae-Jyy

2018-01-01

To explore decisional conflict and its influencing factors on choosing dialysis modality in patients with end-stage renal diseases. The influencing factors investigated include demographics, predialysis education, dialysis knowledge, decision self-efficacy and social support. Making dialysis modality decisions can be challenging for patients with end-stage renal diseases; there are pros and cons to both haemodialysis and peritoneal dialysis. Patients are often uncertain as to which one will be the best alternative for them. This decisional conflict increases the likelihood of making a decision that is not based on the patient's values or preferences and may result in undesirable postdecisional consequences. Addressing factors predisposing patients to decisional conflict helps to facilitate informed decision-making and then to improve healthcare quality. A predictive correlational cross-sectional study design was used. Seventy patients were recruited from the outpatient dialysis clinics of two general hospitals in Taiwan. Data were collected with study questionnaires, including questions on demographics, dialysis modality and predialysis education, the Dialysis Knowledge Scale, the Decision Self-Efficacy scale, the Social Support Scale, and the Decisional Conflict Scale. The mean score on the Decisional Conflict Scale was 29.26 (SD = 22.18). Decision self-efficacy, dialysis modality, predialysis education, professional support and dialysis knowledge together explained 76.4% of the variance in decisional conflict. Individuals who had lower decision self-efficacy, did not receive predialysis education on both haemodialysis and peritoneal dialysis, had lower dialysis knowledge and perceived lower professional support reported higher decisional conflict on choosing dialysis modality. When providing decisional support to predialysis stage patients, practitioners need to increase patients' decision self-efficacy, provide both haemodialysis and peritoneal dialysis

Comparison of outcomes for veterans receiving dialysis care from VA and non-VA providers.

PubMed

Wang, Virginia; Maciejewski, Matthew L; Patel, Uptal D; Stechuchak, Karen M; Hynes, Denise M; Weinberger, Morris

2013-01-18

Demand for dialysis treatment exceeds its supply within the Veterans Health Administration (VA), requiring VA to outsource dialysis care by purchasing private sector dialysis for veterans on a fee-for-service basis. It is unclear whether outcomes are similar for veterans receiving dialysis from VA versus non-VA providers. We assessed the extent of chronic dialysis treatment utilization and differences in all-cause hospitalizations and mortality between veterans receiving dialysis from VA versus VA-outsourced providers. We constructed a retrospective cohort of veterans in 2 VA regions who received chronic dialysis treatment financed by VA between January 2007 and December 2008. From VA administrative data, we identified veterans who received outpatient dialysis in (1) VA, (2) VA-outsourced settings, or (3) both ("dual") settings. In adjusted analyses, we used two-part and logistic regression to examine associations between dialysis setting and all-cause hospitalization and mortality one-year from veterans' baseline dialysis date. Of 1,388 veterans, 27% received dialysis exclusively in VA, 47% in VA-outsourced settings, and 25% in dual settings. Overall, half (48%) were hospitalized and 12% died. In adjusted analysis, veterans in VA-outsourced settings incurred fewer hospitalizations and shorter hospital stays than users of VA due to favorable selection. Dual-system dialysis patients had lower one-year mortality than veterans receiving VA dialysis. VA expenditures for "buying" outsourced dialysis are high and increasing relative to "making" dialysis treatment within its own system. Outcomes comparisons inform future make-or-buy decisions and suggest the need for VA to consider veterans' access to care, long-term VA savings, and optimal patient outcomes in its placement decisions for dialysis services.

GUIDING PRINCIPLES FOR GOOD PRACTICES IN HOSPITAL-BASED HEALTH TECHNOLOGY ASSESSMENT UNITS.

PubMed

Sampietro-Colom, Laura; Lach, Krzysztof; Pasternack, Iris; Wasserfallen, Jean-Blaise; Cicchetti, Americo; Marchetti, Marco; Kidholm, Kristian; Arentz-Hansen, Helene; Rosenmöller, Magdalene; Wild, Claudia; Kahveci, Rabia; Ulst, Margus

2015-01-01

Health technology assessment (HTA) carried out for policy decision making has well-established principles unlike hospital-based HTA (HB-HTA), which differs from the former in the context characteristics and ways of operation. This study proposes principles for good practices in HB-HTA units. A framework for good practice criteria was built inspired by the EFQM excellence business model and information from six literature reviews, 107 face-to-face interviews, forty case studies, large-scale survey, focus group, Delphi survey, as well as local and international validation. In total, 385 people from twenty countries have participated in defining the principles for good practices in HB-HTA units. Fifteen guiding principles for good practices in HB-HTA units are grouped in four dimensions. Dimension 1 deals with principles of the assessment process aimed at providing contextualized information for hospital decision makers. Dimension 2 describes leadership, strategy and partnerships of HB-HTA units which govern and facilitate the assessment process. Dimension 3 focuses on adequate resources that ensure the operation of HB-HTA units. Dimension 4 deals with measuring the short- and long-term impact of the overall performance of HB-HTA units. Finally, nine core guiding principles were selected as essential requirements for HB-HTA units based on the expertise of the HB-HTA units participating in the project. Guiding principles for good practices set up a benchmark for HB-HTA because they represent the ideal performance of HB-HTA units; nevertheless, when performing HTA at hospital level, context also matters; therefore, they should be adapted to ensure their applicability in the local context.

Inpatient Dialysis Unit Project Development: Redesigning Acute Hemodialysis Care.

PubMed

Day, Jennifer

2017-01-01

Executive leaders of an acute care hospital performed a market and financial analysis, and created a business plan to establish an inpatient hemodialysis unit operated by the hospital to provide safe, high-quality, evidence-based care to the population of individuals experiencing end stage renal disease (ESRD) within the community. The business plan included a SWOT (Strengths - Weaknesses - Opportunities - Threats) analysis to assess advantages of the hospital providing inpatient hemodialysis services versus outsourcing the services with a contracted agency. The results of the project were a newly constructed tandem hemodialysis room and an operational plan with clearly defined key performance indicators, process improvement initiatives, and financial goals. This article provides an overview of essential components of a business plan to guide the establishment of an inpatient hemodialysis unit. Copyright© by the American Nephrology Nurses Association.

The role of leader behaviors in hospital-based emergency departments' unit performance and employee work satisfaction.

PubMed

Lin, Blossom Yen-Ju; Hsu, Chung-Ping C; Juan, Chi-Wen; Lin, Cheng-Chieh; Lin, Hung-Jung; Chen, Jih-Chang

2011-01-01

The role of the leader of a medical unit has evolved over time to expand from simply a medical role to a more managerial one. This study aimed to explore how the behavior of a hospital-based emergency department's (ED's) leader might be related to ED unit performance and ED employees' work satisfaction. One hundred and twelve hospital-based EDs in Taiwan were studied: 10 in medical centers, 32 in regional hospitals, and 70 in district hospitals. Three instruments were designed to assess leader behaviors, unit performance and employee satisfaction in these hospital-based EDs. A mail survey revealed that task-oriented leader behavior was positively related to ED unit performance. Both task- and employee-oriented leader behaviors were found to be positively related to ED nurses' work satisfaction. However, leader behaviors were not shown to be related to ED physicians' work satisfaction at a statistically significant level. Some ED organizational characteristics, however, namely departmentalization and hospital accreditation level, were found to be related to ED physicians' work satisfaction. Copyright © 2010 Elsevier Ltd. All rights reserved.

Comparison of outcomes for veterans receiving dialysis care from VA and non-VA providers

PubMed Central

2013-01-01

Background Demand for dialysis treatment exceeds its supply within the Veterans Health Administration (VA), requiring VA to outsource dialysis care by purchasing private sector dialysis for veterans on a fee-for-service basis. It is unclear whether outcomes are similar for veterans receiving dialysis from VA versus non-VA providers. We assessed the extent of chronic dialysis treatment utilization and differences in all-cause hospitalizations and mortality between veterans receiving dialysis from VA versus VA-outsourced providers. Methods We constructed a retrospective cohort of veterans in 2 VA regions who received chronic dialysis treatment financed by VA between January 2007 and December 2008. From VA administrative data, we identified veterans who received outpatient dialysis in (1) VA, (2) VA-outsourced settings, or (3) both (“dual”) settings. In adjusted analyses, we used two-part and logistic regression to examine associations between dialysis setting and all-cause hospitalization and mortality one-year from veterans’ baseline dialysis date. Results Of 1,388 veterans, 27% received dialysis exclusively in VA, 47% in VA-outsourced settings, and 25% in dual settings. Overall, half (48%) were hospitalized and 12% died. In adjusted analysis, veterans in VA-outsourced settings incurred fewer hospitalizations and shorter hospital stays than users of VA due to favorable selection. Dual-system dialysis patients had lower one-year mortality than veterans receiving VA dialysis. Conclusions VA expenditures for “buying” outsourced dialysis are high and increasing relative to “making” dialysis treatment within its own system. Outcomes comparisons inform future make-or-buy decisions and suggest the need for VA to consider veterans’ access to care, long-term VA savings, and optimal patient outcomes in its placement decisions for dialysis services. PMID:23327632

Rationale for a home dialysis virtual ward: design and implementation.

PubMed

Schachter, Michael E; Bargman, Joanne M; Copland, Michael; Hladunewich, Michelle; Tennankore, Karthik K; Levin, Adeera; Oliver, Matthew; Pauly, Robert P; Perl, Jeffrey; Zimmerman, Deborah; Chan, Christopher T

2014-02-14

Home-based renal replacement therapy (RRT) [peritoneal dialysis (PD) and home hemodialysis (HHD)] offers independent quality of life and clinical advantages compared to conventional in-center hemodialysis. However, follow-up may be less complete for home dialysis patients following a change in care settings such as post hospitalization. We aim to implement a Home Dialysis Virtual Ward (HDVW) strategy, which is targeted to minimize gaps of care. The HDVW Pilot Study will enroll consecutive PD and HHD patients who fulfilled any one of our inclusion criteria: 1. following discharge from hospital, 2. after interventional procedure(s), 3. prescription of anti-microbial agents, or 4. following completion of home dialysis training. Clinician-led telephone interviews are performed weekly for 2 weeks until VW discharge. Case-mix (modified Charlson Comorbidity Index), symptoms (the modified Edmonton Symptom Assessment Scale) and patient satisfaction are assessed serially. The number of VW interventions relating to eight pre-specified domains will be measured. Adverse events such as re-hospitalization and health-services utilization will be ascertained through telephone follow-up after discharge from the VW at 2, 4, 12 weeks. The VW re-hospitalization rate will be compared with a contemporary cohort (matched for age, gender, renal replacement therapy and co-morbidities). Our protocol has been approved by research ethics board (UHN: 12-5397-AE). Written informed consent for participation in the study will be obtained from participants. This report serves as a blueprint for the design and implementation of a novel health service delivery model for home dialysis patients. The major goal of the HDVW initiative is to provide appropriate and effective supports to medically complex patients in a targeted window of vulnerability. (NCT01912001).

Early Dialysis and Adverse Outcomes After Hurricane Sandy.

PubMed

Lurie, Nicole; Finne, Kristen; Worrall, Chris; Jauregui, Maria; Thaweethai, Tanayott; Margolis, Gregg; Kelman, Jeffrey

2015-09-01

Hemodialysis patients have historically experienced diminished access to care and increased adverse outcomes after natural disasters. Although "early dialysis" in advance of a storm is promoted as a best practice, evidence for its effectiveness as a protective measure is lacking. Building on prior work, we examined the relationship between the receipt of dialysis ahead of schedule before the storm (also known as early dialysis) and adverse outcomes of patients with end-stage renal disease in the areas most affected by Hurricane Sandy. Retrospective cohort analysis, using claims data from the Centers for Medicare & Medicaid Services Datalink Project. Patients receiving long-term hemodialysis in New York City and the state of New Jersey, the areas most affected by Hurricane Sandy. Receipt of early dialysis compared to their usual treatment pattern in the week prior to the storm. Emergency department (ED) visits, hospitalizations, and 30-day mortality following the storm. Of 13,836 study patients, 8,256 (60%) received early dialysis. In unadjusted logistic regression models, patients who received early dialysis were found to have lower odds of ED visits (OR, 0.75; 95% CI, 0.63-0.89; P=0.001) and hospitalizations (OR, 0.77; 95% CI, 0.65-0.92; P=0.004) in the week of the storm and similar odds of 30-day mortality (OR, 0.80; 95% CI, 0.58-1.09; P=0.2). In adjusted multivariable logistic regression models, receipt of early dialysis was associated with lower odds of ED visits (OR, 0.80; 95% CI, 0.67-0.96; P=0.01) and hospitalizations (OR, 0.79; 95% CI, 0.66-0.94; P=0.01) in the week of the storm and 30-day mortality (OR, 0.72; 95% CI, 0.52-0.997; P=0.048). Inability to determine which patients were offered early dialysis and declined and whether important unmeasured patient characteristics are associated with receipt of early dialysis. Patients who received early dialysis had significantly lower odds of having an ED visit and hospitalization in the week of the storm and of

Infection-Related Hospitalizations in Older Patients With End-Stage Renal Disease

PubMed Central

Dalrymple, Lorien S.; Johansen, Kirsten L.; Chertow, Glenn M.; Cheng, Su-Chun; Grimes, Barbara; Gold, Ellen B.; Kaysen, George A.

2010-01-01

Background Infection is an important cause of hospitalization and death in patients receiving dialysis. Few studies have examined the full range of infections experienced by dialysis patients. The purpose of this study was to examine the types, rates and risk factors for infection among older persons starting dialysis. Study Design Retrospective observational cohort study. Setting and Participants The cohort was assembled from the United States Renal Data System and included patients aged 65 to 100 years who initiated dialysis between 1/1/00 and 12/31/02. Exclusions included prior kidney transplant, unknown dialysis modality, or death, loss to follow-up, or transplant during the first 90 days of dialysis. Patients were followed until death, transplant, or study end 12/31/04. Predictors Baseline demographics, co-morbidities, serum albumin and hemoglobin. Outcomes and Measurements Infection-related hospitalizations were ascertained using discharge ICD-9-CM codes. Hospitalization rates were calculated for each type of infection. The Wei-Lin-Weissfeld Model was used to examine risk factors for up to 4 infection-related events. Results 119,858 patients were included, 7,401 of whom were on peritoneal dialysis. During a median follow-up of 1.9 years, infection-related diagnoses were observed in approximately 35% of all hospitalizations. Approximately 50% of patients had at least one infection-related hospitalization. Rates (per 100 person-years) of pulmonary, soft tissue, and genitourinary infections ranged from 8.3 to 10.3 in patients on peritoneal dialysis and 10.2 to 15.3 in patients on hemodialysis. Risk factors for infection included older age, female sex, diabetes, heart failure, pulmonary disease, and low serum albumin. Limitations Use of ICD-9-CM codes, reliance on Medicare claims to capture hospitalizations, use of the Medical Evidence Form to ascertain co-morbidities, absence of data on dialysis access. Conclusion Infection-related hospitalization is frequent in

Management of chronic kidney disease and dialysis in homeless persons.

PubMed

Podymow, Tiina; Turnbull, Jeff

2013-05-01

End-stage renal disease and dialysis are complicated illnesses to manage in homeless persons, who often suffer medical comorbidities, psychiatric disease, cognitive impairment and addictions; descriptions of this population and management strategies are lacking. A retrospective review of dialysis patients who were homeless or unstably housed was undertaken at an urban academic Canadian center from 2001 to 2011. Electronic hospital records were analyzed for demographic, housing, medical, and psychiatric history, dialysis history, adherence to treatment, and outcomes. Two detailed cases of homeless patients with chronic kidney disease are presented. Eleven homeless dialysis patients with a mean age of 52.7±12.3 years, mostly men and mostly from minority groups were dialyzed for 41.1±29.2 months. Most resided permanently in shelters, eventually obtained fistula access, and were adherent to dialysis schedules. Patients were often nonadherent to pre-dialysis management, resulting in emergency starts. Many barriers to care for homeless persons with end-stage kidney disease and on dialysis are identified, and management strategies are highlighted. Adherence is optimized with shelter-based health care and intensive team-oriented case management.

Impact of facility size and profit status on intermediate outcomes in chronic dialysis patients.

PubMed

Frankenfield, D L; Sugarman, J R; Presley, R J; Helgerson, S D; Rocco, M V

2000-08-01

Little information is available regarding the influence of dialysis facility size or profit status on intermediate outcomes in chronic dialysis patients. We have combined data from the Health Care Financing Administration (HCFA) Core Indicators Project; the end-stage renal disease (ESRD) facility survey; and the HCFA On-Line Survey, Certification, and Reporting System to analyze trends in this area. For hemodialysis patients, larger facilities were more likely than smaller facilities to perform dialysis on patients who were younger than 65 years of age, black, or undergoing dialysis 2 years or more (P < 0.001). Nonprofit facilities were more likely to perform dialysis on patients with diabetes mellitus as a cause of ESRD and less likely to perform dialysis on patients with hypertension as a cause of ESRD compared with for-profit units (P < 0.05). By multivariate analysis, larger facility size was modestly associated with a greater Kt/V value and urea reduction ratio, but not with hematocrit or serum albumin values. Facility profit status was not associated with these intermediate outcomes. For peritoneal dialysis patients, there were no significant differences in patient demographics based on facility size. More patients in nonprofit units had been undergoing dialysis 2 or more years than patients in for-profit units (P < 0.05). By univariate analysis, patients in larger facilities were more likely to have an adequacy measure performed than patients from smaller facilities (P < 0.05). There were few substantial differences in intermediate outcomes in chronic dialysis patients based on facility size or profit status.

Dialysis Facility and Patient Characteristics Associated with Utilization of Home Dialysis

PubMed Central

Walker, David R.; Inglese, Gary W.; Sloand, James A.

2010-01-01

Background and objectives: Nonmedical factors influencing utilization of home dialysis at the facility level are poorly quantified. Home dialysis is comparably effective and safe but less expensive to society and Medicare than in-center hemodialysis. Elimination of modifiable practice variation unrelated to medical factors could contribute to improvements in patient outcomes and use of scarce resources. Design, setting, participants, & measurements: Prevalent dialysis patient data by facility were collected from the 2007 ESRD Network’s annual reports. Facility characteristic data were collected from Medicare’s Dialysis Facility Compare file. A multivariate regression model was used to evaluate associations between the use of home dialysis and facility characteristics. Results: The utilization of home dialysis was positively associated with facility size, percent patients employed full- or part-time, younger population, and years a facility was Medicare certified. Variables negatively associated include an increased number of hemodialysis patients per hemodialysis station, chain association, rural location, more densely populated zip code, a late dialysis work shift, and greater percent of black patients within a zip code. Conclusions: Improved understanding of factors affecting the frequency of use of home dialysis may help explain practice variations across the United States that result in an imbalanced use of medical resources within the ESRD population. In turn, this may improve the delivery of healthcare and extend the ability of an increasingly overburdened medical financing system to survive. PMID:20634324

Dialysis facility and patient characteristics associated with utilization of home dialysis.

PubMed

Walker, David R; Inglese, Gary W; Sloand, James A; Just, Paul M

2010-09-01

Nonmedical factors influencing utilization of home dialysis at the facility level are poorly quantified. Home dialysis is comparably effective and safe but less expensive to society and Medicare than in-center hemodialysis. Elimination of modifiable practice variation unrelated to medical factors could contribute to improvements in patient outcomes and use of scarce resources. Prevalent dialysis patient data by facility were collected from the 2007 ESRD Network's annual reports. Facility characteristic data were collected from Medicare's Dialysis Facility Compare file. A multivariate regression model was used to evaluate associations between the use of home dialysis and facility characteristics. The utilization of home dialysis was positively associated with facility size, percent patients employed full- or part-time, younger population, and years a facility was Medicare certified. Variables negatively associated include an increased number of hemodialysis patients per hemodialysis station, chain association, rural location, more densely populated zip code, a late dialysis work shift, and greater percent of black patients within a zip code. Improved understanding of factors affecting the frequency of use of home dialysis may help explain practice variations across the United States that result in an imbalanced use of medical resources within the ESRD population. In turn, this may improve the delivery of healthcare and extend the ability of an increasingly overburdened medical financing system to survive.

Comparison of cost-utility between automated peritoneal dialysis and continuous ambulatory peritoneal dialysis.

PubMed

Cortés-Sanabria, Laura; Paredes-Ceseña, Carlos A; Herrera-Llamas, Rebeca M; Cruz-Bueno, Yolanda; Soto-Molina, Herman; Pazarín, Leonardo; Cortés, Margarita; Martínez-Ramírez, Héctor R

2013-11-01

The use of automated peritoneal dialysis (APD) is increasing compared to continuous ambulatory peritoneal dialysis (CAPD). Surprisingly, little data about health benefits and cost of APD exist, and virtually no information comparing the cost-utility between CAPD and APD is available. We undertook this study to evaluate and compare the health-related quality of life (HRQOL) and cost-utility indexes in patients on CAPD vs. This was a prospective cohort of patients initiating dialysis (2008-2009). Two questionnaires were self-administered: European Research Questionnaire Quality of Life (EQ-5D) and Kidney Disease Quality of Life (short form, KDQOL-SF, Rand, Santa Monica, CA). Direct medical costs (DMC) were determined from the health provider perspective including the following medical resource utilization: outpatient clinic/emergency care, dialysis procedures, medications, laboratory tests, hospitalization, and surgery. Cost-utility indexes were calculated dividing total mean cost by indicators of the HRQOL. One hundred twenty-three patients were evaluated: 77 on CAPD and 46 on APD. Results of the EQ-5D and KDQOL-SF questionnaires were significantly better in APD compared to the CAPD group. Main costs in both APD and CAPD were attributed to hospitalization and dialysis procedures followed by medication and surgery. Outpatient clinic visits and laboratory tests were significantly more costly in CAPD than in APD, whereas dialysis procedures were more expensive in the latter. Cost-utility indexes were significantly better in APD compared to CAPD. A significant cost-utility advantage of APD vs. CAPD was observed. The annual DMC per-patient were not different between groups but the HRQOL was better in the APD compared to the CAPD group. Copyright © 2013 IMSS. Published by Elsevier Inc. All rights reserved.

Assessment of management policies and practices for occupational exposure to bloodborne pathogens in dialysis facilities.

PubMed

Mbaeyi, Chukwuma; Panlilio, Adelisa L; Hobbs, Cynthia; Patel, Priti R; Kuhar, David T

2012-10-01

Occupational exposure management is an important element in preventing the transmission of bloodborne pathogens in health care settings. In 2008, the US Centers for Disease Control and Prevention conducted a survey to assess procedures for managing occupational bloodborne pathogen exposures in outpatient dialysis facilities in the United States. A cross-sectional survey of randomly selected outpatient dialysis facilities. 339 outpatient dialysis facilities drawn from the 2006 US end-stage renal disease database. Hospital affiliation (free-standing vs hospital-based facilities), profit status (for-profit vs not-for-profit facilities), and number of health care personnel (≥100 vs <100 health care personnel). Exposures to hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV); provision of HBV and HIV postexposure prophylaxis. We calculated the proportion of facilities reporting occupational bloodborne pathogen exposures and offering occupational exposure management services. We analyzed bloodborne pathogen exposures and provision of postexposure prophylaxis by facility type. Nearly all respondents (99.7%) had written policies and 95% provided occupational exposure management services to health care personnel during the daytime on weekdays, but services were provided infrequently during other periods of the week. Approximately 10%-15% of facilities reported having HIV, HBV, or HCV exposures in health care personnel in the 12 months prior to the survey, but inconsistencies were noted in procedures for managing such exposures. Despite 86% of facilities providing HIV prophylaxis for exposed health care personnel, only 37% designated a primary HIV postexposure prophylaxis regimen. For-profit and free-standing facilities reported fewer exposures, but did not as reliably offer HBV prophylaxis or have a primary HIV postexposure prophylaxis regimen relative to not-for-profit and hospital-based facilities. The survey response rate was low

Urgent-Start Peritoneal Dialysis: A Chance for a New Beginning

PubMed Central

Arramreddy, Rohini; Zheng, Sijie; Saxena, Anjali B.; Liebman, Scott E.; Wong, Leslie

2014-01-01

Peritoneal dialysis (PD) remains greatly underutilized in the United States despite the widespread preference of home modalities among nephrologists and patients. A hemodialysis-centric model of end-stage renal disease care has perpetuated for decades due to a complex set of factors, including late end-stage renal disease referrals and patients who present to the hospital requiring urgent renal replacement therapy. In such situations, PD rarely is a consideration and patients are dialyzed through a central venous catheter, a practice associated with high infection and mortality rates. Recently, the term urgent-start PD has gained momentum across the nephrology community and has begun to change this status quo. It allows for expedited placement of a PD catheter and initiation of PD therapy within days. Several published case reports, abstracts, and poster presentations at national meetings have documented the initial success of urgent-start PD programs. From a wide experiential base, we discuss the multifaceted issues related to urgent-start PD implementation, methods to overcome barriers to therapy, and the potential impact of this technique to change the existing dialysis paradigm. PMID:24246221

Efficiency of U.S. Dialysis Centers: An Updated Examination of Facility Characteristics That Influence Production of Dialysis Treatments

PubMed Central

Shreay, Sanatan; Ma, Martin; McCluskey, Jill; Mittelhammer, Ron C; Gitlin, Matthew; Stephens, J Mark

2014-01-01

Objective To explore the relative efficiency of dialysis facilities in the United States and identify factors that are associated with efficiency in the production of dialysis treatments. Data Sources/Study Setting Medicare cost report data from 4,343 free-standing dialysis facilities in the United States that offered in-center hemodialysis in 2010. Study Design A cross-sectional, facility-level retrospective database analysis, utilizing data envelopment analysis (DEA) to estimate facility efficiency. Data Collection/Extraction Methods Treatment data and cost and labor inputs of dialysis treatments were obtained from 2010 Medicare Renal Cost Reports. Demographic data were obtained from the 2010 U.S. Census. Principal Findings Only 26.6 percent of facilities were technically efficient. Neither the intensity of market competition nor the profit status of the facility had a significant effect on efficiency. Facilities that were members of large chains were less likely to be efficient. Cost and labor savings due to changes in drug protocols had little effect on overall dialysis center efficiency. Conclusions The majority of free-standing dialysis facilities in the United States were functioning in a technically inefficient manner. As payment systems increasingly employ capitation and bundling provisions, these institutions will need to evaluate their efficiency to remain competitive. PMID:24237043

Dialysis treatment in patients with rheumatoid arthritis.

PubMed

Hezemans, R L; Krediet, R T; Arisz, L

1995-07-01

The results of dialysis treatment in 24 rheumatoid arthritis patients, 20 chronic rheumatoid arthritis (RA) and 4 juvenile rheumatoid arthritis (JRA), were analysed. Presence of secondary amyloidosis, renal function, morbidity and survival were examined. Amyloidosis was present in 13 patients. Especially among amyloidosis patients, renal function declined rapidly in the last year before dialysis started. On average, 63 days per patient-year were spent in the hospital, 58% was dialysis-related, mainly due to vascular access problems. Hospitalization was even more widespread in amyloidosis patients (79 days, 72% dialysis-related). Median survival in RA patients with amyloidosis was 11 months; in RA patients without amyloidosis this was 29 months. Two-year survival was only 1 out of 10 for the RA amyloidosis patients; for the RA non-amyloidosis patients this was 5 out of 6 (p < 0.01). Cardiovascular causes of death were most frequent. In conclusion, high morbidity and low survival make RA patients with amyloidosis a high-risk group on renal replacement therapy.

Falls and fall-related injuries in older dialysis patients.

PubMed

Cook, Wendy L; Tomlinson, George; Donaldson, Meghan; Markowitz, Samuel N; Naglie, Gary; Sobolev, Boris; Jassal, Sarbjit V

2006-11-01

Dialysis patients are increasingly older and more disabled. In community-dwelling seniors without kidney disease, falls commonly predict hospitalization, the onset of frailty, and the need for institutional care. Effective fall prevention strategies are available. On the basis of retrospective data, it was hypothesized that the fall rates of older (> or =65 yr) chronic outpatient hemodialysis (HD) patients would be higher than published rates for community-dwelling seniors (0.6 to 0.8 falls/patient-year). It also was hypothesized that risk factors for falls in dialysis outpatients would include polypharmacy, dialysis-related hypotension, cognitive impairment, and decreased functional status. Using a prospective cohort study design, HD patients who were > or =65 yr of age at a large academic dialysis unit were recruited. All study participants underwent baseline screening for fall risk factors. Patients were followed prospectively for a minimum of 1 yr. Falls were identified through biweekly patient interviews in the HD unit. A total of 162 patients (mean age 74.7 yr) were recruited; 57% were male. A total of 305 falls occurred in 76 (47%) patients over 190.5 person-years of follow-up (fall-incidence 1.60 falls/person-year). Injuries occurred in 19% of falls; 41 patients had multiple falls. Associated risk factors included age, comorbidity, mean predialysis systolic BP, and a history of falls. In the HD population, the fall risk is higher than in the general community, and fall-related morbidity is high. Better identification of HD patients who are at risk for falls and targeted fall intervention strategies are required.

System-Level Barriers and Facilitators for Foregoing or Withdrawing Dialysis: A Qualitative Study of Nephrologists in the United States and England.

PubMed

Grubbs, Vanessa; Tuot, Delphine S; Powe, Neil R; O'Donoghue, Donal; Chesla, Catherine A

2017-11-01

Despite a growing body of literature suggesting that dialysis does not confer morbidity or mortality benefits for all patients with chronic kidney failure, the initiation and continuation of dialysis therapy in patients with poor prognosis is commonplace. Our goal was to elicit nephrologists' perspectives on factors that affect decision making regarding end-stage renal disease. Semistructured, individual, qualitative interviews. Participants were purposively sampled based on age, race, sex, geographic location, and practice type. Each was asked about his or her perspectives and experiences related to foregoing and withdrawing dialysis therapy. Interviews were audiotaped, transcribed, and analyzed using narrative and thematic analysis. We conducted 59 semistructured interviews with nephrologists from the United States (n=41) and England (n=18). Most participants were 45 years or younger, men, and white. Average time since completing nephrology training was 14.2±11.6 (SD) years. Identified system-level facilitators and barriers for foregoing and withdrawing dialysis therapy stemmed from national and institutional policies and structural factors, how providers practice medicine (the culture of medicine), and beliefs and behaviors of the public (societal culture). In both countries, the predominant barriers described included lack of training in end-of-life conversations and expectations for aggressive care among non-nephrologists and the general public. Primary differences included financial incentives to dialyze in the United States and widespread outpatient conservative management programs in England. Participants' views may not fully capture those of all American or English nephrologists. Nephrologists in the United States and England identified several system-level factors that both facilitated and interfered with decision making around foregoing and withdrawing dialysis therapy. Efforts to expand facilitators while reducing barriers could lead to care practices

Sex differences in acute kidney injury requiring dialysis.

PubMed

Neugarten, Joel; Golestaneh, Ladan; Kolhe, Nitin V

2018-06-08

Female sex has been included as a risk factor in models developed to predict the risk of acute kidney injury (AKI) associated with cardiac surgery, aminoglycoside nephrotoxicity and contrast-induced nephropathy. The commentary acompanying the Kidney Disease Improving Global Outcomes Clinical Practice Guideline for Acute Kidney Injury concludes that female sex is a shared susceptibility factor for acute kidney injury based on observations that female sex is associated with the development of hospital-acquired acute kidney injury. In contrast, female sex is reno-protective in animal models. In this context, we sought to examine the role of sex in hospital-associated acute kidney injury in greater detail. We utilized the Hospital Episode Statistics database to calculate the sex-stratified incidence of AKI requiring renal replacement therapy (AKI-D) among 194,157,726 hospital discharges reported for the years 1998-2013. In addition, we conducted a systematic review of the English literature to evaluate dialysis practices among men versus women with AKI. Hospitalized men were more likely to develop AKI-D than hospitalized women (OR 2.19 (2.15, 2.22) p < 0.0001). We found no evidence in the published literature that dialysis practices differ between men and women with AKI. Based on a population of hospitalized patients which is more than 3 times larger than all previously published cohorts reporting sex-stratified AKI data combined, we conclude that male sex is associated with an increased incidence of hospital-associated AKI-D. Our study is among the first reports to highlight the protective role of female gender in AKI.

[Report on chronic dialysis in France in 2016].

PubMed

Société Francophone de Néphrologie Dialyse Et Transplantation

2017-04-01

The report on dialysis in France in 2016 from the French Speaking Society of Nephrology Dialysis and Transplantation (SFNDT) provides an exhaustive and documented inventory on dialysis in France. It underlines the organizations that are important in 2016 to maintain a high quality dialysis. Several measures are proposed to maintain and improve the care of dialysis in France: (1) The regulation of dialysis treatment in France must be maintained; (2) a burden of care indicator is proposed to ensure that patients requiring the most care are treated in the centers. Proposals are also made to stimulate peritoneal dialysis offers, (3) to improve the calculation of the cost of dialysis and warn against lower reimbursement rates of dialysis, (4) to reduce transport costs by minimizing transport by ambulance (5). The SFNDT recalls recent recommendations concerning access to the renal transplant waiting list, are recalled; (6) as well as recommendations that require waiting until clinical signs are present to start dialysis (7). The SFNDT makes the proposal to set up advanced renal failure units. These units are expected to develop care that is not supported today: consultation with a nurse, a dietician, a social worker or psychologist, palliative care, and coordination (8). Finally, the financial and human resources for pediatric dialysis should be maintained. Copyright © 2017. Published by Elsevier Masson SAS.

Renal Dialysis and its Financing.

PubMed

Borelli, Marisa; Paul, David P; Skiba, Michaeline

2016-01-01

The incidence of end-stage renal disease (ESRD) and its associated comorbidities such as diabetes and hypertension continue to increase as the population ages. As most ESRD patients qualify for Medicare coverage, the U.S. government initiated reforms of the payment system for dialysis facilities in an effort to decrease expenditures associated with ESRD reimbursement. The effects of reduced reimbursement rates, bundled payment options, and quality incentives on the current dialysis system, including kidney dialysis units, physicians, and patients, are examined.

Nutritional Competence and Resilience among Hemodialysis Patients in the Setting of Dialysis Initiation and Hospitalization

PubMed Central

Wong, Michelle M.Y.; Usvyat, Len A.; Xiao, Qingqing; Kotanko, Peter; Maddux, Franklin W.

2015-01-01

Background and objectives Dialysis patients have a high risk for inadequate nutrition. Their nutritional status is particularly susceptible to deterioration when faced with intercurrent events such as hospitalization. This study was conducted to improve the understanding of the temporal evolution of nutritional parameters as a foundation for rational and proactive nutritional intervention. Design, setting, participants, & measurements A retrospective cohort study was performed to investigate the temporal evolution of nutritional parameters (serum albumin, serum phosphate, serum creatinine, equilibrated normalized protein catabolic rate, and interdialytic weight gain) and a composite nutritional score derived from these parameters, in two populations: (1) incident hemodialysis (HD) patients who started HD between January 2006 and December 2011 and were followed for up to 54 months (median 16.3), and (2) prevalent patients with HD vintage ≥2.5 years who were hospitalized between January 2006 and December 2011 and followed from 6 months before to 6 months after hospitalization. Results In incident patients (n=126,964), each of the nutritional parameters improved after HD initiation, with a mean composite nutritional score at the 24th percentile at the start of HD and reaching a plateau at the 57th percentile toward the end of the second year on dialysis. Nutritional parameters increased more rapidly and reached higher values among patients who survived longer. In hospitalized patients (n=14,193), the nutritional parameters and the composite score began to decline 1–2 months before hospitalization, reached their lowest level in the month after hospitalization, and then partially recovered in the subsequent 5 months. The degree of recovery of the nutritional score was inversely related to the number of rehospitalizations. Conclusions This study increases the understanding of nutritional resilience and its determinants in HD patients. Application of the nutritional

Systematic barriers to the effective delivery of home dialysis in the United States: a report from the Public Policy/Advocacy Committee of the North American Chapter of the International Society for Peritoneal Dialysis.

PubMed

Golper, Thomas A; Saxena, Anjali B; Piraino, Beth; Teitelbaum, Isaac; Burkart, John; Finkelstein, Fredric O; Abu-Alfa, Ali

2011-12-01

Home dialysis, currently underused in the United States compared with other industrialized countries, likely will benefit from the newly implemented US prospective payment system. Not only is home dialysis less expensive from the standpoint of pure dialysis costs, but overall health system costs may be decreased by more subtle benefits, such as reduced transportation. However, many systematic barriers exist to the successful delivery of home dialysis. We organized these barriers into the categories of educational barriers (patient and providers), governmental/regulatory barriers (state and federal), and barriers specifically related to the philosophies and business practices of dialysis providers (eg, staffing, pharmacies, supplies, space, continuous quality improvement practices, and independence). All stakeholders share the goal of delivering home dialysis therapies in the most cost- and clinically effective and least problematic manner. Identification and recognition of such barriers is the first step. In addition, we have suggested action plans to stimulate the kidney community to find even better solutions so that collectively we may overcome these barriers. Copyright © 2011 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Nutrient intake during peritoneal dialysis at the Prince of Wales Hospital in Hong Kong.

PubMed

Wang, Angela Yee-Moon; Sea, Mandy Man-Mei; Ng, Kenway; Kwan, Mandy; Lui, Siu-Fai; Woo, Jean

2007-05-01

Individuals undergoing peritoneal dialysis are at increased risk of developing cardiac disease and malnutrition. A cross-sectional survey. 249 Chinese continuous ambulatory peritoneal dialysis (CAPD) patients were recruited from the Prince of Wales Hospital in Hong Kong. Another 249 age- and sex-matched controls were recruited from an archive of 1,010 individuals with known food frequency questionnaire (FFQ) data. To compare the dietary intake pattern of CAPD patients with controls and evaluate its association with background cardiac disease. Intake of different nutrients was estimated by using a 7-day FFQ. Intake of all nutrients was lower in CAPD patients than controls, with resulting lower overall energy intake. Nutrient intake was decreased further in CAPD patients with background cardiac disease, which corresponded to worse nutritional status. Controlling for age, male sex, body weight, diabetes mellitus, dialysis therapy duration, residual renal function, peritoneal dialysis urea clearance, and Charlson Comorbidity Index score, background cardiac disease was associated independently with less intake of energy and most macronutrients and micronutrients. However, the association between background cardiac disease and energy and most nutrient intake was decreased or even lost when additional adjustment was made for C-reactive protein and serum albumin levels. An FFQ is limited in that nutrient quantitation is not exact and may be underestimated as a result of underreporting by patients. CAPD patients were compared with a control group without cardiovascular disease ascertainment that did not include subjects with diabetes. Chinese CAPD patients had significantly lower nutrient intake than age- and sex-matched controls. The association between cardiac disease and lower dietary macronutrient and micronutrient intake in CAPD patients was mediated in part through systemic inflammation, which also was associated with more malnutrition. More attention should be

Case mix, outcome and activity for patients admitted to intensive care units requiring chronic renal dialysis: a secondary analysis of the ICNARC Case Mix Programme Database

PubMed Central

Hutchison, Colin A; Crowe, Alex V; Stevens, Paul E; Harrison, David A; Lipkin, Graham W

2007-01-01

Introduction This report describes the case mix, outcome and activity for admissions to intensive care units (ICUs) of patients who require prior chronic renal dialysis for end-stage renal failure (ESRF), and investigates the effect of case mix factors on outcome. Methods This was a secondary analysis of a high-quality clinical database, namely the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database, which includes 276,731 admissions to 170 adult ICUs across England, Wales and Northern Ireland from 1995 to 2004. Results During the eight year study period, 1.3% (n = 3,420) of all patients admitted to ICU were receiving chronic renal dialysis before ICU admission. This represents an estimated ICU utilization of six admissions (32 bed-days) per 100 dialysis patient-years. The ESRF group was younger (mean age 57.3 years versus 59.5 years) and more likely to be male (60.2% versus 57.9%) than those without ESRF. Acute Physiology and Chronic Health Evaluation II score and Acute Physiology Score revealed greater severity of illness on admission in patients with ESRF (mean 24.7 versus 16.6 and 17.2 versus 12.6, respectively). Length of stay in ICU was comparable between groups (median 1.9 days versus 1.8 days) and ICU mortality was only slightly elevated in the ESRF group (26.3% versus 20.8%). However, the ESRF group had protracted overall hospital stay (median 25 days versus 17 days), and increased hospital mortality (45.3% versus 31.2%) and ICU readmission (9.0% vs. 4.7%). Multiple logistic regression analysis adjusted for case mix identified the increased hospital mortality to be associated with increasing age, emergency surgery and nonsurgical cases, cardiopulmonary resuscitation before ICU admission and extremes of physiological norms. The adjusted odds ratio for ultimate hospital mortality associated with chronic renal dialysis was 1.24 (95% confidence interval 1.13 to 1.37). Conclusion Patients with ESRF admitted to UK ICUs are more

Estimating increases in outpatient dialysis costs resulting from scientific and technological advancement.

PubMed

Ozminkowski, R J; Hassol, A; Firkusny, I; Noether, M; Miles, M A; Newmann, J; Sharda, C; Guterman, S; Schmitz, R

1995-04-01

The Medicare program's base payment rate for outpatient dialysis services has never been adjusted for the effects of inflation, productivity changes, or scientific and technological advancement on the costs of treating patients with end-stage renal disease. In recognition of this, Congress asked the Prospective Payment Assessment Commission to annually recommend an adjustment to Medicare's base payment rate to dialysis facilities. One component of this adjustment addresses the cost-increasing effects of technological change--the scientific and technological advances (S&TA) component. The S&TA component is intended to encourage dialysis facilities to adopt technologies that, when applied appropriately, enhance the quality of patient care, even though they may also increase costs. We found the appropriate increase to the composite payment rate for Medicare outpatient dialysis services in fiscal year 1995 to vary from 0.18% to 2.18%. These estimates depend on whether one accounts for the lack of previous adjustments to the composite rate. Mathematically, the S&TA adjustment also depends on whether one considers the likelihood of missing some dialysis sessions because of illness or hospitalization. The S&TA estimates also allow for differences in the incremental costs of technological change that are based on the varying advice of experts in the dialysis industry. The major contributors to the cost of technological change in dialysis services are the use of twin-bag disconnect peritoneal dialysis systems, automated peritoneal dialysis cyclers, and the new generation of hemodialysis machines currently on the market. Factors beyond the control of dialysis facility personnel that influence the cost of patient care should be considered when payment rates are set, and those rates should be updated as market conditions change. The S&TA adjustment is one example of how the composite rate payment system for outpatient dialysis services can be modified to provide appropriate

Addressing the burden of dialysis around the world: A summary of the roundtable discussion on dialysis economics at the First International Congress of Chinese Nephrologists 2015.

PubMed

Li, Philip Kam-Tao; Lui, Sing Leung; Ng, Jack Kit-Chung; Cai, Guan Yan; Chan, Christopher T; Chen, Hung Chun; Cheung, Alfred K; Choi, Koon Shing; Choong, Hui Lin; Fan, Stanley L; Ong, Loke Meng; Yu, Linda Wai Ling; Yu, Xue Qing

2017-12-01

To address the issue of heavy dialysis burden due to the rising prevalence of end-stage renal disease around the world, a roundtable discussion on the sustainability of managing dialysis burden around the world was held in Hong Kong during the First International Congress of Chinese Nephrologists in December 2015. The roundtable discussion was attended by experts from Hong Kong, China, Canada, England, Malaysia, Singapore, Taiwan and United States. Potential solutions to cope with the heavy burden on dialysis include the prevention and retardation of the progression of CKD; wider use of home-based dialysis therapy, particularly PD; promotion of kidney transplantation; and the use of renal palliative care service. © 2017 Asian Pacific Society of Nephrology.

The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS): Unifying Efforts to Inform Practice and Improve Global Outcomes in Peritoneal Dialysis.

PubMed

Perl, Jeffrey; Davies, Simon J; Lambie, Mark; Pisoni, Ronald L; McCullough, Keith; Johnson, David W; Sloand, James A; Prichard, Sarah; Kawanishi, Hideki; Tentori, Francesca; Robinson, Bruce M

2016-01-01

♦ Extending technique survival on peritoneal dialysis (PD) remains a major challenge in optimizing outcomes for PD patients while increasing PD utilization. The primary objective of the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) is to identify modifiable practices associated with improvements in PD technique and patient survival. In collaboration with the International Society for Peritoneal Dialysis (ISPD), PDOPPS seeks to standardize PD-related data definitions and provide a forum for effective international collaborative clinical research in PD. ♦ The PDOPPS is an international prospective cohort study in Australia, Canada, Japan, the United Kingdom (UK), and the United States (US). Each country is enrolling a random sample of incident and prevalent patients from national samples of 20 to 80 sites with at least 20 patients on PD. Enrolled patients will be followed over an initial 3-year study period. Demographic, comorbidity, and treatment-related variables, and patient-reported data, will be collected over the study course. The primary outcome will be all-cause PD technique failure or death; other outcomes will include cause-specific technique failure, hospitalizations, and patient-reported outcomes. ♦ A high proportion of the targeted number of study sites has been recruited to date in each country. Several ancillary studies have been funded with high momentum toward expansion to new countries and additional participation. ♦ The PDOPPS is the first large, international study to follow PD patients longitudinally to capture clinical practice. With data collected, the study will serve as an invaluable resource and research platform for the international PD community, and provide a means to understand variation in PD practices and outcomes, to identify optimal practices, and to ultimately improve outcomes for PD patients. Copyright © 2016 International Society for Peritoneal Dialysis.

The Green Dialysis Survey: Establishing a Baseline for Environmental Sustainability across Dialysis Facilities in Victoria, Australia.

PubMed

Barraclough, Katherine A; Gleeson, Alice; Holt, Stephen G; Agar, John Wm

2017-11-02

The Green Dialysis Survey aimed to 1) establish a baseline for environmental sustainability (ES) across Victorian dialysis facilities, and 2) guide future initiatives to reduce the environmental impact of dialysis delivery. Nurse unit managers of all Victorian public dialysis facilities received an online link to the survey, which asked 107 questions relevant to the ES of dialysis services. Responses were received from 71/83 dialysis facilities in Victoria (86%), representing 628/660 dialysis chairs (95%). Low energy lighting was present in 13 facilities (18%), 18 (25%) recycled reverse osmosis water and 7 (10%) reported use of renewable energy. Fifty-six facilities (79%) performed comingled recycling but only 27 (38%) recycled polyvinyl chloride plastic. A minority educated staff in appropriate waste management (n=30;42%) or formally audited waste generation and segregation (n=19;27%). Forty-four (62%) provided secure bicycle parking but only 33 (46%) provided shower and changing facilities. There was limited use of tele- or video-conferencing to replace staff meetings (n=19;27%) or patient clinic visits (n=13;18%). A minority considered ES in procurement decisions (n=28;39%) and there was minimal preparedness to cope with climate change. Only 39 services (49%) confirmed an ES policy and few had ever formed a green group (n=14; 20%) or were currently undertaking a green project (n=8;11%). Only 15 facilities (21%) made formal efforts to raise awareness of ES. This survey provides a baseline for practices that potentially impact the environmental sustainability of dialysis units in Victoria, Australia. It also identifies achievable targets for attention. This article is protected by copyright. All rights reserved.

[Assisted peritoneal dialysis: home-based renal replacement therapy for the elderly patient].

PubMed

Wiesholzer, Martin

2013-06-01

The number of elderly patients with end stage renal disease is constantly increasing. Conventional hämodiaylsis as the mainstay of renal replacement therapy is often poorly tolerated by frail eldery patients with multiple comorbidities. Although many of these patients would prefer a home based dialysis treatment, the number of elderly patients using peritoneal dialysis (PD) is still low. Impaired physical and cognitive function often generates insurmountable barriers for self care peritoneal dialysis. Assisted peritoneal dialysis can overcome many of these barriers and give elderly patients the ability of a renal replacement therapy in their own homes respecting their needs.

Tailoring dialysis and resuming low-protein diets may favor chronic dialysis discontinuation: report on three cases.

PubMed

Piccoli, Giorgina Barbara; Guzzo, Gabriella; Vigotti, Federica Neve; Capizzi, Irene; Clari, Roberta; Scognamiglio, Stefania; Consiglio, Valentina; Aroasio, Emiliano; Gonella, Silvana; Veltri, Andrea; Avagnina, Paolo

2014-07-01

Renal function recovery (RFR), defined as the discontinuation of dialysis after 3 months of replacement therapy, is reported in about 1% of chronic dialysis patients. The role of personalized, intensive dialysis schedules and of resuming low-protein diets has not been studied to date. This report describes three patients with RFR who were recently treated at a new dialysis unit set up to offer intensive hemodialysis. All three patients were females, aged 73, 75, and 78 years. Kidney disease included vascular-cholesterol emboli, diabetic nephropathy and vascular and dysmetabolic disease. At time of RFR, the patients had been dialysis-dependent from 3 months to 1 year. Dialysis was started with different schedules and was progressively discontinued with a "decremental" policy, progressively decreasing number and duration of the sessions. A moderately restricted low-protein diet (proteins 0.6 g/kg/day) was started immediately after dialysis discontinuation. The most recent update showed that two patients are well off dialysis for 5 and 6 months; the diabetic patient died (sudden death) 3 months after dialysis discontinuation. Within the limits of small numbers, our case series may suggest a role for personalized dialysis treatments and for including low-protein diets in the therapy, in enhancing long-term RFR in elderly dialysis patients. © 2014 International Society for Hemodialysis.

[Census of the renal and dialysis units by Italian Society of Nephrology: structure and organization for renal patient assistance in Italy (2014-2015)].

PubMed

Quintaliani, Giuseppe; Di Luca, Marina; Di Napoli, Anteo; Viglino, Giusto; Postorino, Maurizio; Amore, Alessandro; Andrulli, Simeone; Bellasi, Antonio; Brunori, Giuliano; Buongiorno, Erasmo; Castellino, Santina; D'Amelio, Alessandro; De Nicola, Luca; Gesualdo, Loreto; Di Landro, Domenico; Feriozzi, Sandro; Strippoli, Giovanni; Teatini, Ugo; Santoro, Antonio

2016-01-01

Given the public health challenge and burden of chronic kidney disease, the Italian Society of Nephrology (SIN) promoted a census of the renal and dialysis units to analyse structural and human resources, organizational aspects, activities and workload referring to the year 2014. An online questionnaire, including 64 items exploring structural and human resources, organization aspects, activities and epidemiological data referred to 2014, was sent to chiefs of any renal or dialysis unit. 615 renal units were identified. From these 615 units, 332 were public renal centres (of which 318 centres answered to the census) and 283 were private dialysis centres (of which 113 centres answered to the census). The results show 6 public renal units pmp. Renal biopsies were 4624 (81 pmp). The nephrology beds are about 41 pmp. There are 7.304 nurses working in HD wards, 1.692 in the nephrology wards and only 613 for outpatients clinics. The benchmark data derived from this census show interesting comparisons between centres, regions and groups of regions. These data realised the clinical management of renal disease in Italy.

A Comparison of SF-36 and SF-12 Composite Scores and Subsequent Hospitalization and Mortality Risks in Long-Term Dialysis Patients

PubMed Central

Xu, Jianglin; Lin, Shu-Fang; Dean, Sandie Guerra; Lazarus, J. Michael; Hakim, Raymond M.

2010-01-01

Background and objectives: The Short Form 12 (SF-12) has not been validated for long-term dialysis patients. The study compared physical and mental component summary (PCS/MCS) scores from the SF-36 with those from the embedded SF-12 in a national cohort of dialysis patients. Design, setting, participants, & measurements: All 44,395 patients who had scorable SF-36 and SF-12 from January 1, 2006, to December 31, 2006, and were treated at Fresenius Medical Care, North America facilities were included. Death and first hospitalization were followed for up to 1 year from the date of survey. Correlation and agreement were obtained between PCS-36 and PCS-12 and MCS-36 and MCS-12; then Cox models were constructed to compare associated hazard ratios (HRs) between them. Results: Physical and mental dimensions both exhibited excellent intraclass correlation coefficients of 0.94. Each incremental point for both PCS-12 and PCS-36 was associated with a 2.4% lower adjusted HR of death and 0.4% decline in HR for first hospitalization (both P < 0.0001). Corresponding improvement in HR of death for each MCS point was 1.2% for MCS-12 and 1.3% for MCS-36, whereas both had similar 0.6% lower HR for hospitalization per point (all P < 0.0001). Conclusions: The use of the SF-12 alone or as part of a larger survey is valid in dialysis patients. Composite scores from the SF-12 and SF-36 have similar prognostic association with death and hospitalization risk. Prospective longitudinal studies of SF-12 surveys that consider responsiveness to specific clinical, situational, and interventional changes are needed in this population. PMID:20019120

[Adequacy of dialysis at the Department of Nephrology and Dialysis of the Sveti Duh General Hospital in Zagreb and the Dialysis Outcomes Quality Initiative (DOQI) guidelines--comparison of the years 1998 and 2002].

PubMed

Janković, Nikola; Orsanić-Brcić, Dubravka; Pavlović, Drasko; Varlaj-Knobloch, Vesna; Altabas, Karmela

2003-01-01

Every year ever more and more patients in our country receive some form of dialysis, which provides life-saving renal replacement therapy for end-stage renal disease. In an effort to improve the quality and outcomes of dialysis care, the National Kidney Foundation--Dialysis Outcomes Quality Initiative (NKF-DOQI) have developed clinical practice guidelines for care of dialysis patients regarding hemodialysis adequacy, peritoneal dialysis adequacy, treatment of anemia, and vascular access. The morbidity and mortality of patients is strongly connected with dialysis adequacy and degree of anemia. We compared 180 patients on hemodialysis (HD) in 1998 and 177 patients in 2002, who are regularly treated in our Center with the use of DOQI guidelines. Dialysis adequacy was assessed by use of urea reduction ratio URR = 1-(post. urea/pre. urea), and overall wellbeing according to the degree of anemia, number of blood transfusions, presence of elevated blood pressure, and number of antihypertensives in therapy. In year 2002, 50% of the patients had adequate dialysis compared with 30% in 1998. The average duration on dialysis and the age of patients did not change. We recorded a rise in hemoglobin from 80 g/L to 92 g/L, and in the use of EPO (from 18% to 30%). No case of hypoalbuminemia was observed. The aim of dialysis is to improve the overall wellbeing of uremic patients. Comparing our results with DOQI-guidelines, we demonstrated that dialysis therapy could be improved to prevent complications and early mortality in dialysis patients.

Palliative peritoneal dialysis: Implementation of a home care programme for terminal patients treated with peritoneal dialysis (PD).

PubMed

Gorrin, Maite Rivera; Teruel-Briones, José Luis; Vion, Victor Burguera; Rexach, Lourdes; Quereda, Carlos

2015-01-01

Terminal-stage patients on peritoneal dialysis (PD) are often transferred to haemodialysis as they are unable to perform the dialysis technique themselves since their functional capacities are reduced. We present our experience with five patients on PD with a shortterm life-threatening condition, whose treatment was shared by primary care units and who were treated with a PD modality adapted to their circumstances, which we call Palliative Peritoneal Dialysis. Copyright © 2015. Published by Elsevier España, S.L.U.

Impact of Hemodialysis Catheter Dysfunction on Dialysis and Other Medical Services: An Observational Cohort Study

PubMed Central

Griffiths, Robert I.; Newsome, Britt B.; Leung, Grace; Block, Geoffrey A.; Herbert, Robert J.; Danese, Mark D.

2012-01-01

Practice guidelines define hemodialysis catheter dysfunction as blood flow rate (BFR) <300 mL/min. We conducted a study using data from DaVita and the United States Renal Data System to evaluate the impact of catheter dysfunction on dialysis and other medical services. Patients were included if they had ≥8 consecutive weeks of catheter dialysis between 8/2004 and 12/2006. Actual BFR <300 mL/min despite planned BFR ≥300 mL/min was used to define catheter dysfunction during each dialysis session. Among 9,707 patients, the average age was 62,53% were female, and 40% were black. The median duration of catheter dialysis was 190 days, and the cohort accounted for 1,075,701 catheter dialysis sessions. There were 70,361 sessions with catheter dysfunction, and 6,33 1 (65.2%) patients had at least one session with catheter dysfunction. In multivariate repeated measures analysis, catheter dysfunction was associated with increased odds of missing a dialysis session due to access problems (Odds ratio [OR] 2.50; P < 0.001), having an access-related procedure (OR 2.10; P < 0.001), and being hospitalized (OR 1.10; P = 0.001). Catheter dysfunction defined according to NKF vascular access guidelines results in disruptions of dialysis treatment and increased use of other medical services. PMID:22518313

Evaluating the benefits of home-based peritoneal dialysis

PubMed Central

François, Karlien; Bargman, Joanne M

2014-01-01

Peritoneal dialysis (PD) is an effective renal replacement strategy for patients suffering from end-stage renal disease. PD offers patient survival comparable to or better than in-center hemodialysis while preserving residual kidney function, empowering patient autonomy, and reducing financial burden to payors. The majority of patients suffering from kidney failure are eligible for PD. In patients with cardiorenal syndrome and uncontrolled fluid status, PD is of particular benefit, decreasing hospitalization rates and duration. This review discusses the benefits of chronic PD, performed by the patient or a caregiver at home. Recognition of the benefits of PD is a cornerstone in stimulating the use of this treatment strategy. PMID:25506238

Variation in Dialysis Exposure Prior to Nonpreemptive Living Donor Kidney Transplantation in the United States and Its Association With Allograft Outcomes.

PubMed

Gill, John S; Rose, Caren; Joffres, Yayuk; Landsberg, David; Gill, Jagbir

2018-05-01

The impact of dialysis exposure before nonpreemptive living donor kidney transplantation on allograft outcomes is uncertain. Retrospective cohort study. Adult first-time recipients of kidney-only living donor transplants in the United States who were recorded within the Scientific Registry of Transplant Recipients for 2000 to 2016. Duration of pretransplantation dialysis exposure. Kidney transplant failure from any cause including death, death-censored transplant failure, and death with allograft function. Among the 77,607 living donor transplant recipients studied, longer pretransplantation dialysis exposure was independently associated with progressively higher risk for transplant failure from any cause, including death beginning 6 months after transplantation. Compared with patients with 0.1 to 3.0 months of dialysis exposure, the HR for transplant failure from any cause including death increased from 1.16 (95% CI, 1.07-1.31) among patients with 6.1 to 9.0 months of dialysis exposure to 1.60 (95% CI, 1.43-1.79) among patients with more than 60.0 months of dialysis exposure. Pretransplantation dialysis exposure varied markedly among centers; median exposures were 11.0 and 18.9 months for centers in the 10th and 90th percentiles of dialysis exposure, respectively. Centers with the highest proportions of living donor transplantations had the shortest pretransplantation dialysis exposures. In multivariable analysis, patients of black race, with low income, with nonprivate insurance, with less than high school education, and not working for income had longer pretransplantation dialysis exposures. Dialysis exposure in patients with these characteristics also varied 2-fold between transplantation centers. Why longer dialysis exposure is associated with transplant failure could not be determined. Longer pretransplantation dialysis exposure in nonpreemptive living donor kidney transplantation is associated with increased risk for allograft failure. Pretransplantation

Application of the Activity-Based Costing Method for Unit-Cost Calculation in a Hospital

PubMed Central

Javid, Mahdi; Hadian, Mohammad; Ghaderi, Hossein; Ghaffari, Shahram; Salehi, Masoud

2016-01-01

Background: Choosing an appropriate accounting system for hospital has always been a challenge for hospital managers. Traditional cost system (TCS) causes cost distortions in hospital. Activity-based costing (ABC) method is a new and more effective cost system. Objective: This study aimed to compare ABC with TCS method in calculating the unit cost of medical services and to assess its applicability in Kashani Hospital, Shahrekord City, Iran. Methods: This cross-sectional study was performed on accounting data of Kashani Hospital in 2013. Data on accounting reports of 2012 and other relevant sources at the end of 2012 were included. To apply ABC method, the hospital was divided into several cost centers and five cost categories were defined: wage, equipment, space, material, and overhead costs. Then activity centers were defined. ABC method was performed into two phases. First, the total costs of cost centers were assigned to activities by using related cost factors. Then the costs of activities were divided to cost objects by using cost drivers. After determining the cost of objects, the cost price of medical services was calculated and compared with those obtained from TCS. Results: The Kashani Hospital had 81 physicians, 306 nurses, and 328 beds with the mean occupancy rate of 67.4% during 2012. Unit cost of medical services, cost price of occupancy bed per day, and cost per outpatient service were calculated. The total unit costs by ABC and TCS were respectively 187.95 and 137.70 USD, showing 50.34 USD more unit cost by ABC method. ABC method represented more accurate information on the major cost components. Conclusion: By utilizing ABC, hospital managers have a valuable accounting system that provides a true insight into the organizational costs of their department. PMID:26234974

Application of the Activity-Based Costing Method for Unit-Cost Calculation in a Hospital.

PubMed

Javid, Mahdi; Hadian, Mohammad; Ghaderi, Hossein; Ghaffari, Shahram; Salehi, Masoud

2015-05-17

Choosing an appropriate accounting system for hospital has always been a challenge for hospital managers. Traditional cost system (TCS) causes cost distortions in hospital. Activity-based costing (ABC) method is a new and more effective cost system. This study aimed to compare ABC with TCS method in calculating the unit cost of medical services and to assess its applicability in Kashani Hospital, Shahrekord City, Iran.‎ This cross-sectional study was performed on accounting data of Kashani Hospital in 2013. Data on accounting reports of 2012 and other relevant sources at the end of 2012 were included. To apply ABC method, the hospital was divided into several cost centers and five cost categories were defined: wage, equipment, space, material, and overhead costs. Then activity centers were defined. ABC method was performed into two phases. First, the total costs of cost centers were assigned to activities by using related cost factors. Then the costs of activities were divided to cost objects by using cost drivers. After determining the cost of objects, the cost price of medical services was calculated and compared with those obtained from TCS.‎ The Kashani Hospital had 81 physicians, 306 nurses, and 328 beds with the mean occupancy rate of 67.4% during 2012. Unit cost of medical services, cost price of occupancy bed per day, and cost per outpatient service were calculated. The total unit costs by ABC and TCS were respectively 187.95 and 137.70 USD, showing 50.34 USD more unit cost by ABC method. ABC method represented more accurate information on the major cost components. By utilizing ABC, hospital managers have a valuable accounting system that provides a true insight into the organizational costs of their department.

Outcomes of Transcatheter and Surgical Aortic Valve Replacement in Patients on Maintenance Dialysis.

PubMed

Alqahtani, Fahad; Aljohani, Sami; Boobes, Khaled; Maor, Elad; Sherieh, Assem; Rihal, Charanjit S; Holmes, David R; Alkhouli, Mohamad

2017-12-01

The introduction of transcatheter aortic valve replacement (TAVR) expanded definitive therapy of aortic stenosis to many high-risk patients, but it has not been fully evaluated in the dialysis population. We aimed to evaluate the current trend and in-hospital outcome of surgical aortic valve replacement (SAVR) and TAVR in the dialysis population. Severe aortic stenosis patients on maintenance dialysis who underwent SAVR or TAVR in the Nationwide Inpatient Sample database from January 1, 2005, through December 31, 2014, were included in our comparative analysis. The trends of SAVR and TAVR were assessed. In-hospital mortality, rates of major adverse events, hospital length of stay, cost of care, and intermediate care facility utilization were compared between the 2 groups using both unadjusted and propensity-matched data. Utilization of aortic valve replacement in dialysis patients increased 3-fold; a total of 2531 dialysis patients who underwent either SAVR (n = 2264) or TAVR (n = 267) between 2005 and 2014 were identified. Propensity score matching yielded 197 matched pairs. After matching, a 2-fold increase in in-hospital mortality was found with SAVR compared with TAVR (13.7% vs 6.1%, P = .021). Patients who underwent TAVR had more permanent pacemaker implantation (13.2% vs 5.6%, P = .012) but less blood transfusion (43.7% vs 56.8%, P = .02). Rates of other key morbidities were similar. Hospital length of stay (19 ± 16 vs 11 ± 11 days, P <.001) and non-home discharges (44.7% vs 31.5%, P = .002) were significantly higher with SAVR. Cost of hospitalization was 25% less with TAVR. In patients on maintenance dialysis, TAVR is associated with lower hospital mortality, resource utilization, and cost in comparison with SAVR. Copyright © 2017 Elsevier Inc. All rights reserved.

Home Dialysis in the Prospective Payment System Era.

PubMed

Lin, Eugene; Cheng, Xingxing S; Chin, Kuo-Kai; Zubair, Talhah; Chertow, Glenn M; Bendavid, Eran; Bhattacharya, Jayanta

2017-10-01

The ESRD Prospective Payment System introduced two incentives to increase home dialysis use: bundling injectable medications into a single payment for treatment and paying for home dialysis training. We evaluated the effects of the ESRD Prospective Payment System on home dialysis use by patients starting dialysis in the United States from January 1, 2006 to August 31, 2013. We analyzed data on dialysis modality, insurance type, and comorbidities from the United States Renal Data System. We estimated the effect of the policy on home dialysis use with multivariable logistic regression and compared the effect on Medicare Parts A/B beneficiaries with the effect on patients with other types of insurance. The ESRD Prospective Payment System associated with a 5.0% (95% confidence interval [95% CI], 4.0% to 6.0%) increase in home dialysis use by the end of the study period. Home dialysis use increased by 5.8% (95% CI, 4.3% to 6.9%) among Medicare beneficiaries and 4.1% (95% CI, 2.3% to 5.4%) among patients covered by other forms of health insurance. The difference between these groups was not statistically significant (1.8%; 95% CI, -0.2% to 3.8%). Conversely, in both populations, the training add-on did not associate with increases in home dialysis use beyond the effect of the policy. The ESRD Prospective Payment System bundling, but not the training add-on, associated with substantial increases in home dialysis, which were identical for both Medicare and non-Medicare patients. These spill-over effects suggest that major payment changes in Medicare can affect all patients with ESRD. Copyright © 2017 by the American Society of Nephrology.

Evaluation of non-adherence in patients undergoing dialysis and kidney transplantation: United States transplantation practice patterns survey.

PubMed

Brar, A; Babakhani, A; Salifu, M O; Jindal, R M

2014-06-01

We performed a survey of United States transplantation centers to evaluate practice patterns in the assessment of nonadherence before and after kidney transplantation. An electronically administered, anonymous survey was sent to 181 United Network for Organ Sharing (UNOS) approved transplantation centers in 2012. Seventy-nine centers completed our survey. Of them, 51.3% had a protocol to evaluate medication/dialysis adherence before the listing; most common (36.4%) was the Simplified Medication Adherence Questionnaire. As an alternative to a questionnaire, the most common measure of nonadherence was the number of missed hemodialysis sessions (77.0%). The most common reason for poor adherence to dialysis regimens was difficulty with transportation (81.3%). Also, 94.4% noted the lack of a questionnaire to evaluate adherence to medications but relied on drug levels (73.4%) and self report. Only 12.9% used a questionnaire for the measurement of quality of life (Karnofsky performance scale). Of the participating centers, 27.1% used a formal cognitive testing for potential living donors. A social worker was used by most centers for nonadherent patients. Respondents indicated that patients (in the pretransplantation state) were more compliant with dialysis than with medication regimens. Finally, 37.7% of respondents noted graft failure due to medication nonadherence in 15% to 29% of their patients. There was a significant variability in the methods of screening for nonadherence while the patient was on dialysis, during pretransplantation work up, and during post-transplantation follow-up examinations. We recommend that there should be a standardized technique to evaluate nonadherence to facilitate focused clinical trials to improve adherence. Copyright © 2014 Elsevier Inc. All rights reserved.

Functional linear models for zero-inflated count data with application to modeling hospitalizations in patients on dialysis.

PubMed

Sentürk, Damla; Dalrymple, Lorien S; Nguyen, Danh V

2014-11-30

We propose functional linear models for zero-inflated count data with a focus on the functional hurdle and functional zero-inflated Poisson (ZIP) models. Although the hurdle model assumes the counts come from a mixture of a degenerate distribution at zero and a zero-truncated Poisson distribution, the ZIP model considers a mixture of a degenerate distribution at zero and a standard Poisson distribution. We extend the generalized functional linear model framework with a functional predictor and multiple cross-sectional predictors to model counts generated by a mixture distribution. We propose an estimation procedure for functional hurdle and ZIP models, called penalized reconstruction, geared towards error-prone and sparsely observed longitudinal functional predictors. The approach relies on dimension reduction and pooling of information across subjects involving basis expansions and penalized maximum likelihood techniques. The developed functional hurdle model is applied to modeling hospitalizations within the first 2 years from initiation of dialysis, with a high percentage of zeros, in the Comprehensive Dialysis Study participants. Hospitalization counts are modeled as a function of sparse longitudinal measurements of serum albumin concentrations, patient demographics, and comorbidities. Simulation studies are used to study finite sample properties of the proposed method and include comparisons with an adaptation of standard principal components regression. Copyright © 2014 John Wiley & Sons, Ltd.

Rates of Intentional and Unintentional Nonadherence to Peritoneal Dialysis Regimes and Associated Factors.

PubMed

Yu, Zhen Li; Lee, Vanessa Yin Woan; Kang, Augustine Wee Cheng; Chan, Sally; Foo, Marjorie; Chan, Choong Meng; Griva, Konstadina

2016-01-01

With increasing emphasis on expanding home-based dialysis, there is a need to understand adherence outcomes. This study set out to examine the prevalence and predictors of nonadherence among patients undergoing peritoneal dialysis. A cross sectional sample of 201 peritoneal dialysis patients recruited between 2010-2011 from Singapore General Hospital completed measures of quality of life, medication beliefs, self-efficacy and emotional distress. Nonadherence rates were high; 18% for dialysis, 46% for medication and 78% for diet. Intentional nonadherence was more common for dialysis (p = .03), whereas unintentional nonadherence was more common for medication (p = .002). Multivariate models indicated significant associations for higher education (intermediate vs low OR = 3.18, high vs low OR = 4.70), lower environment quality of life (OR = 0.79), dialysis self-efficacy (OR = 0.80) with dialysis nonadherence; higher education (OR = 2.22), self-care peritoneal dialysis (OR = 3.10), perceived necessity vs concerns over medication (OR = 0.90), self-efficacy (OR = 0.76) with nonadherence to medication. The odds for nonadherence to diet were higher among patients who were younger (OR = 0.96), of Chinese ethnicity (OR = 2.99) and those reporting better physical health (OR = 1.30) and lower self-efficacy (OR = 0.49). Nonadherence is common in peritoneal dialysis. Self-efficacy and beliefs about medication are promising targets for interventions designed to improve adherence.

Blood leakage detection during dialysis therapy based on fog computing with array photocell sensors and heteroassociative memory model.

PubMed

Wu, Jian-Xing; Huang, Ping-Tzan; Lin, Chia-Hung; Li, Chien-Ming

2018-02-01

Blood leakage and blood loss are serious life-threatening complications occurring during dialysis therapy. These events have been of concerns to both healthcare givers and patients. More than 40% of adult blood volume can be lost in just a few minutes, resulting in morbidities and mortality. The authors intend to propose the design of a warning tool for the detection of blood leakage/blood loss during dialysis therapy based on fog computing with an array of photocell sensors and heteroassociative memory (HAM) model. Photocell sensors are arranged in an array on a flexible substrate to detect blood leakage via the resistance changes with illumination in the visible spectrum of 500-700 nm. The HAM model is implemented to design a virtual alarm unit using electricity changes in an embedded system. The proposed warning tool can indicate the risk level in both end-sensing units and remote monitor devices via a wireless network and fog/cloud computing. The animal experimental results (pig blood) will demonstrate the feasibility.

Dialysis modality preference of patients with CKD and family caregivers: a discrete-choice study.

PubMed

Morton, Rachael L; Snelling, Paul; Webster, Angela C; Rose, John; Masterson, Rosemary; Johnson, David W; Howard, Kirsten

2012-07-01

Dialysis modality preferences of patients with chronic kidney disease (CKD) and family caregivers are important, yet rarely quantified. Prospective, unlabeled, discrete-choice experiment with random-parameter logit analysis. Adults with stages 3-5 CKD and caregivers educated about dialysis treatment options from 8 Australian renal clinics. Preferences for and trade-offs between the dialysis treatment attributes of life expectancy, number of hospital visits per week, ability to travel, hours per treatment, treatment time of day, subsidized transport service, and flexibility of treatment schedule. Results presented as ORs for preferring home-based or in-center dialysis to conservative care. 105 predialysis patients and 73 family caregivers completed the study. Median patient age was 63 years, and mean estimated glomerular filtration rate was 18.1 (range, 6-34) mL/min/1.73 m(2). Median caregiver age was 61 years. Home-based dialysis (either peritoneal or home hemodialysis) was chosen by patients in 65% of choice sets; in-center dialysis, in 35%; and conservative care, in 10%. For caregivers, this was 72%, 25%, and 3%, respectively. Both patients and caregivers preferred longer rather than shorter hours of dialysis (ORs of 2.02 [95% CI, 1.51-2.70] and 2.67 [95% CI, 1.85-3.85] for patients and caregivers, respectively), but were less likely to choose nocturnal than daytime dialysis (ORs of 0.07 [95% CI, 0.01-0.75] and 0.03 [95% CI, 0.01-0.20]). Patients were willing to forgo 23 (95% CI, 19-27) months of life expectancy with home-based dialysis to decrease their travel restrictions. For caregivers, this was 17 (95% CI, 16-18) patient-months. Data were limited to stated preferences rather than actual choice of dialysis modality. Our study suggests that it is rare for caregivers to prefer conservative nondialytic care for family members with CKD. Home-based dialysis modalities that enable patients and their family members to travel with minimal restriction would be

Screening for anxiety and depression in dialysis patients: comparison of the Hospital Anxiety and Depression Scale and the Beck Depression Inventory.

PubMed

Preljevic, Valjbona T; Østhus, Tone Brit Hortemo; Sandvik, Leiv; Opjordsmoen, Stein; Nordhus, Inger Hilde; Os, Ingrid; Dammen, Toril

2012-08-01

Although anxiety and depression are frequent comorbid disorders in dialysis patients, they remain underrecognized and often untreated. The aim of the study was to evaluate the Hospital Anxiety and Depression Scale (HADS), the Beck Depression Inventory (BDI) and a truncated version of the BDI, the Cognitive Depression Index (CDI), as screening tools for anxiety and depression in dialysis patients. A total of 109 participants (69.7% males), from four dialysis centers, completed the self-report symptom scales HADS and BDI. Depression and anxiety disorders were diagnosed with the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I). The sensitivity, specificity, positive and negative predictive value, overall agreement, kappa and receiver operating characteristic (ROC) curves were assessed. Depressive disorders were found in 22% of the patients based on the SCID-I, while anxiety disorders occurred in 17%. The optimal screening cut-off score for depression was ≥ 7 for the HADS depression subscale (HADS-D), ≥ 14 for the HADS-total, ≥ 11 for the CDI and ≥ 17 for the BDI. The optimal screening cut-off for anxiety was ≥ 6 for the HADS anxiety subscale (HADS-A) and ≥ 14 for the HADS-total. At cut-offs commonly used in clinical practice for depression screening (HADS-D: 8; BDI: 16), the BDI performed slightly better than HADS-D. The BDI, CDI and HADS demonstrated acceptable performance as screening tools for depression, as did the HADS-A for anxiety, in our sample of dialysis patients. The recommended cut-off scores for each instrument were: ≥ 17 for BDI, ≥ 11 for CDI, ≥ 7 for HADS depression subscale, ≥ 6 for HADS anxiety subscale and ≥ 14 for HADS total. The CDI did not perform better than the BDI in our study. Lower cut-off for the HADS-A than recommended in medically ill patients may be considered when screening for anxiety in dialysis patients. Copyright © 2012 Elsevier Inc. All rights reserved.

Late renal transplant failure: an adverse prognostic factor at initiation of peritoneal dialysis.

PubMed

Sasal, J; Naimark, D; Klassen, J; Shea, J; Bargman, J M

2001-01-01

Early renal transplant failure necessitating a return to dialysis has been shown to be a poor prognostic factor for survival. Little is known about the outcome of patients with late transplant failure returning to dialysis. It was our clinical impression that late transplant failure (>2 months) carries an increased morbidity and mortality risk in patients returning to dialysis. To determine whether patients with a failed renal transplant have an outcome different to those on dialysis who have never received a kidney transplant. Peritoneal dialysis (PD) unit in a teaching hospital. All failed renal transplant patients (fTx) in the Toronto Hospital Peritoneal Dialysis program between 1989 and 1996 were identified. This cohort of 42 fTx patients was compared with a cohort of randomly selected never-transplanted PD patients (non-Tx). The PD program was selected because of the availability of well-documented patient archival material. The non-Tx group was matched for age and presence of diabetes. Data were collected until retransplantation, change of dialysis modality or center, death, or until June 1998. There was no difference at initiation of PD between groups in serum albumin, residual renal function, or mean serum parathyroid hormone level. The mean low-density lipoprotein level was significantly higher in the fTx cohort. The duration of dialysis before Tx in fTx patients accounted for the increased total length of dialysis in fTx (mean 15 months). However, post-Tx the duration of PD was similar for both groups (30.7 months for fTx vs 31.6 months for non-Tx). The fTx group had a considerably worse outcome than the non-Tx group. The time to first peritonitis, subsequent episodes of peritonitis, catheter change, or transfer to hemodialysis occurred at a much faster rate in fTx patients. The most dramatic difference was in survival. There were 3 deaths in the non-Tx group and 12 in the fTx group (p < 0.01). The mean age at time of death in the fTx group was 47.5 years

Advance Directives and End-of-Life Care among Nursing Home Residents Receiving Maintenance Dialysis

PubMed Central

Montez-Rath, Maria E.; Hall, Yoshio N.; Katz, Ronit; O’Hare, Ann M.

2017-01-01

Background and objectives Little is known about the relation between the content of advance directives and downstream treatment decisions among patients receiving maintenance dialysis. In this study, we determined the prevalence of advance directives specifying treatment limitations and/or surrogate decision-makers in the last year of life and their association with end-of-life care among nursing home residents. Design, setting, participants, & measurements Using national data from 2006 to 2007, we compared the content of advance directives among 30,716 nursing home residents receiving dialysis to 30,825 nursing home residents with other serious illnesses during the year before death. Among patients receiving dialysis, we linked the content of advance directives to Medicare claims to ascertain site of death and treatment intensity in the last month of life. Results In the last year of life, 36% of nursing home residents receiving dialysis had a treatment-limiting directive, 22% had a surrogate decision-maker, and 13% had both in adjusted analyses. These estimates were 13%–27%, 5%–11%, and 6%–13% lower, respectively, than for decedents with other serious illnesses. For patients receiving dialysis who had both a treatment-limiting directive and surrogate decision-maker, the adjusted frequency of hospitalization, intensive care unit admission, intensive procedures, and inpatient death were lower by 13%, 17%, 13%, and 14%, respectively, and hospice use and dialysis discontinuation were 5% and 7% higher compared with patients receiving dialysis lacking both components. Conclusions Among nursing home residents receiving dialysis, treatment-limiting directives and surrogates were associated with fewer intensive interventions and inpatient deaths, but were in place much less often than for nursing home residents with other serious illnesses. PMID:28057703

Association of dialysate bicarbonate concentration with mortality in the Dialysis Outcomes and Practice Patterns Study (DOPPS).

PubMed

Tentori, Francesca; Karaboyas, Angelo; Robinson, Bruce M; Morgenstern, Hal; Zhang, Jinyao; Sen, Ananda; Ikizler, T Alp; Rayner, Hugh; Fissell, Rachel B; Vanholder, Raymond; Tomo, Tadashi; Port, Friedrich K

2013-10-01

Most hemodialysis patients worldwide are treated with bicarbonate dialysis using sodium bicarbonate as the base. Few studies have assessed outcomes of patients treated with different dialysate bicarbonate levels, and the optimal concentration remains uncertain. The Dialysis Outcomes and Practice Patterns Study (DOPPS) is an international prospective cohort study. This study included 17,031 patients receiving thrice-weekly in-center hemodialysis from 11 DOPPS countries (2002-2011). Dialysate bicarbonate concentration. All-cause and cause-specific mortality and first hospitalization, using Cox regression to estimate the effects of dialysate bicarbonate concentration, adjusting for potential confounders. Demographics, comorbid conditions, laboratory values, and prescriptions were abstracted from medical records. Mean dialysate bicarbonate concentration was 35.5 ± 2.7 (SD) mEq/L, ranging from 32.2 ± 2.3 mEq/L in Germany to 37.0 ± 2.6 mEq/L in the United States. Prescription of high dialysate bicarbonate concentration (≥38 mEq/L) was most common in the United States (45% of patients). Approximately 50% of DOPPS facilities used a single dialysate bicarbonate concentration. 3,913 patients (23%) died during follow-up. Dialysate bicarbonate concentration was associated positively with mortality (adjusted HR, 1.08 per 4 mEq/L higher [95% CI, 1.01-1.15]; HR for dialysate bicarbonate ≥38 vs 33-37 mEq/L, 1.07 [95% CI, 0.97-1.19]). Results were consistent across levels of pre-dialysis session serum bicarbonate and between facilities that used a single dialysate bicarbonate concentration and those that prescribed different concentrations to individual patients. The association of dialysis bicarbonate concentration with mortality was stronger in patients with longer dialysis vintage. Due to the observational nature of the present study, we cannot rule out that the reported associations may be biased by unmeasured confounders. High dialysate bicarbonate concentrations

Association between the Availability of Hospital-Based Palliative Care and Treatment Intensity for Critically Ill Patients.

PubMed

Hua, May; Ma, Xiaoyue; Morrison, R Sean; Li, Guohua; Wunsch, Hannah

2018-05-29

In the intensive care unit (ICU), studies involving specialized palliative care services have shown decreases in the use of non-beneficial life-sustaining therapies and ICU length of stay for patients. However, whether widespread availability of hospital-based palliative care is associated with less frequent use of high intensity care is unknown. To determine whether availability of hospital-based palliative care is associated with decreased markers of treatment intensity for ICU patients. Retrospective cohort study of adult ICU patients in New York State hospitals, 2008-2014. Multilevel regression was used to assess the relationship between availability of hospital-based palliative care during the year of admission and hospital length of stay, use of mechanical ventilation, dialysis and artificial nutrition, placement of a tracheostomy or gastrostomy tube, days in ICU and discharge to hospice. Of 1,025,503 ICU patients in 151 hospitals, 814,794 (79.5%) received care in a hospital with a palliative care program. Hospital length of stay was similar for patients in hospitals with and without palliative care programs (6 days, interquartile range (IQR) 3-12 vs. 6 days, IQR 3-11, adjusted rate ratio 1.04 [1.03 to 1.05], p < 0.001), as were other healthcare utilization outcomes. However, patients in hospitals with palliative care programs were 46% more likely to be discharged to hospice than those in hospitals without palliative care programs (1.7% vs. 1.4%, adjusted odds ratio 1.46 [1.30 to 1.64], p<0.001). Availability of hospital-based palliative care was not associated with differences in in-hospital treatment intensity but was associated with significantly increased hospice utilization for ICU patients. At this time, the measurable benefit of palliative care programs for critically ill patients may be the increased use of hospice facilities, as opposed to decreased healthcare utilization during an ICU-associated hospitalization.

Peritoneal dialysis is appropriate for elderly patients.

PubMed

Teitelbaum, Isaac

2006-01-01

The utilization of peritoneal dialysis decreases with age. A number of concerns have been raised regarding the suitability of peritoneal dialysis for elderly patients. The purpose of this review is to determine whether these concerns are medically valid. Literature review and synthesis. Most elderly patients possess the manual and cognitive skills necessary to perform peritoneal dialysis. Elderly patients on peritoneal dialysis exhibit excellent compliance with their treatment regimen and display no increase in the rate of infectious complications though they may have a slight increase in hospital days. They easily achieve adequacy targets, experience good technique survival and their nutritional status is at least as good as that of their hemodialysis counterparts. Patient survival varies around the world but is overall comparable to that of age-matched patients on hemodialysis. Quality of life may be somewhat superior to that of older hemodialysis patients. Elderly patients with end-stage renal disease are appropriate candidates for peritoneal dialysis. It is not medically justifiable to exclude them from consideration for this therapeutic modality.

Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States.

PubMed

Kozhimannil, Katy B; Hung, Peiyin; Henning-Smith, Carrie; Casey, Michelle M; Prasad, Shailendra

2018-03-27

Hospital-based obstetric services have decreased in rural US counties, but whether this has been associated with changes in birth location and outcomes is unknown. To examine the relationship between loss of hospital-based obstetric services and location of childbirth and birth outcomes in rural counties. A retrospective cohort study, using county-level regression models in an annual interrupted time series approach. Births occurring from 2004 to 2014 in rural US counties were identified using birth certificates linked to American Hospital Association Annual Surveys. Participants included 4 941 387 births in all 1086 rural counties with hospital-based obstetric services in 2004. Loss of hospital-based obstetric services in the county of maternal residence, stratified by adjacency to urban areas. Primary outcomes were county rates of (1) out-of-hospital births; (2) births in hospitals without obstetric units; and (3) preterm births (<37 weeks' gestation). Between 2004 and 2014, 179 rural counties lost hospital-based obstetric services. Of the 4 941 387 births studied, the mean (SD) maternal age was 26.2 (5.8) years. A mean (SD) of 75.9% (23.2%) of women who gave birth were non-Hispanic white, and 49.7% (15.6%) were college graduates. Rural counties not adjacent to urban areas that lost hospital-based obstetric services had significant increases in out-of-hospital births (0.70 percentage points [95% CI, 0.30 to 1.10]); births in a hospital without an obstetric unit (3.06 percentage points [95% CI, 2.66 to 3.46]); and preterm births (0.67 percentage points [95% CI, 0.02 to 1.33]), in the year after loss of services, compared with those with continual obstetric services. Rural counties adjacent to urban areas that lost hospital-based obstetric services also had significant increases in births in a hospital without obstetric services (1.80 percentage points [95% CI, 1.55 to 2.05]) in the year after loss of services, compared with those with continual obstetric

Dialysis: Choice of dialysis--what to do with economic incentives.

PubMed

Chow, Kai Ming; Li, Philip Kam-Tao

2012-09-01

A survey of seven countries has found a striking difference in dialysis reimbursement policies, even when data were adjusted for gross domestic product per capita. Although increased reimbursement is perceived to be a valuable incentive for certain treatments, this perception is not supported by current data and alternative strategies to promote home-based dialysis should be pursued.

Historical Study (1986-2014): Improvements in Nutritional Status of Dialysis Patients.

PubMed

Koefoed, Mette; Kromann, Charles Boy; Hvidtfeldt, Danni; Juliussen, Sophie Ryberg; Andersen, Jens Rikardt; Marckmann, Peter

2016-09-01

Malnutrition is common in dialysis patients and is associated with adverse clinical outcomes. Despite an increased focus on improved nutrition in dialysis patients, it is claimed that the prevalence of malnutrition in this group of patients has not changed during the last decades. Direct historical comparisons of the nutritional status of dialysis patients have never been published. To directly compare the nutritional status of past and current dialysis patients, we implemented the methodology of a study from 1986 on a population of dialysis patients in 2014. Historical study comparing results of two cross-sectional studies performed in 1986 and 2014. We compared the nutritional status of hemodialysis (HD) and peritoneal dialysis (PD) patients attending the dialysis center at Roskilde Hospital, Denmark, in February to June 2014, with that of HD and PD patients treated at the dialysis center at Fredericia Hospital, Denmark, in April 1986. Maintenance PD and HD patients (n = 64 in 2014 and n = 48 in 1986). We performed anthropometry (body weight, triceps skinfold, and midarm muscle circumferences [MAMCs]) and determined plasma transferrin. Relative body weight, triceps skinfold, MAMC, body mass index, and prevalence of protein-caloric malnutrition as defined in the original study from 1986. Average relative body weight, triceps skinfold, MAMC, and body mass index were significantly higher in 2014 compared with 1986. The prevalence of protein-caloric malnutrition was significantly lower in 2014 (18%) compared with 1986 (52%). The nutritional status of maintenance dialysis patients has improved during the last 3 decades. The reason for this improvement could not be identified in the present study, but the most likely contributors are the higher prevalence of obesity in the general population, less predialytic malnutrition, and an improved focus on nutrition in maintenance dialysis patients. Copyright © 2016 National Kidney Foundation, Inc. Published by

HLA molecules and nasal carriage of Staphylococcus aureus isolated from dialysis and kidney transplant patients at a hospital in Southern Brazil

PubMed Central

2012-01-01

Background Healthy individuals can host Staphylococcus aureus in the nasopharynx, body surface and vagina. Most invasive infections by this bacterium are endogenous, caused by strains spread from the nasopharynx of carriers. S. aureus is a pathogen involved in the etiology of hospital- and community-acquired infections. Transplant and dialysis patients are at risk of colonization or infection by multi-resistant S. aureus. Infection is directly linked to individual immunity, and the major histocompatibility complex (MHC) plays a crucial role in determining susceptibility to diseases. Different MHC specificities have been shown to be more frequent in individuals suffering from certain diseases. This study aimed to investigate the association between HLA class I (HLA-A and -B) and class II (HLA-DRB1) molecules and nasal carriage of S. aureus in dialysis and kidney transplant patients at a hospital in Southern Brazil. Results The sample consisted of 70 dialysis and 46 kidney transplant patients, totaling 116 patients. All subjects were typed for HLA molecules using LABType® SSO (One Lambda). Nasal swab samples of S. aureus were isolated from the nasal cavity (both nostrils) of patients undergoing dialysis or kidney transplantation. In renal dialysis patients, HLA-A*02 was the most frequent allele in both carriers (25.5%) and non-carriers (21.2%) of S. aureus. Allele A*68 was not observed in the carrier group, but the allele was observed six times in the non-carrier group (p = 0.0097). Regarding HLA-B and HLA-DRB1, no allele was shown to be involved in protection against or susceptibility to carriage of S. aureus. In kidney transplant patients, allele A*03 was more frequent in the non-carrier (20.83%) than in the carrier (5.88%) group (p = 0.0486). HLA-B*15 was present in carriers (5.88%) and non-carriers (25%) (p = 0.0179). Regarding class II alleles, DRB1*03 appeared to be related to susceptibility to carriage of S. aureus (p = 0.0319). Conclusions Our findings

The financial impact of increasing home-based high dose haemodialysis and peritoneal dialysis.

PubMed

Liu, Frank Xiaoqing; Treharne, Catrin; Culleton, Bruce; Crowe, Lydia; Arici, Murat

2014-10-02

Evidence suggests that high dose haemodialysis (HD) may be associated with better health outcomes and even cost savings (if conducted at home) versus conventional in-centre HD (ICHD). Home-based regimens such as peritoneal dialysis (PD) are also associated with significant cost reductions and are more convenient for patients. However, the financial impact of increasing the use of high dose HD at home with an increased tariff is uncertain. A budget impact analysis was performed to investigate the financial impact of increasing the proportion of patients receiving home-based dialysis modalities from the perspective of the England National Health Service (NHS) payer. A Markov model was constructed to investigate the 5 year budget impact of increasing the proportion of dialysis patients receiving home-based dialysis, including both high dose HD at home and PD, under the current reimbursement tariff and a hypothetically increased tariff for home HD (£575/week). Five scenarios were compared with the current England dialysis modality distribution (prevalent patients, 14.1% PD, 82.0% ICHD, 3.9% conventional home HD; incident patients, 22.9% PD, 77.1% ICHD) with all increases coming from the ICHD population. Under the current tariff of £456/week, increasing the proportion of dialysis patients receiving high dose HD at home resulted in a saving of £19.6 million. Conducting high dose HD at home under a hypothetical tariff of £575/week was associated with a budget increase (£19.9 million). The costs of high dose HD at home were totally offset by increasing the usage of PD to 20-25%, generating savings of £40.0 million - £94.5 million over 5 years under the increased tariff. Conversely, having all patients treated in-centre resulted in a £172.6 million increase in dialysis costs over 5 years. This analysis shows that performing high dose HD at home could allow the UK healthcare system to capture the clinical and humanistic benefits associated with this therapy while

Financial implications to Medicare from changing the dialysis modality mix under the bundled prospective payment system.

PubMed

Liu, Frank X; Walton, Surrey M; Leipold, Robert; Isbell, Deborah; Golper, Thomas A

2014-01-01

The economic burden of treating end-stage renal disease (ESRD) continues to grow. As one response, effective January 1, 2011, Medicare implemented a bundled prospective payment system (PPS, including injectable drugs) for dialysis patients. This study investigated the 5-year budget impact on Medicare under the new PPS of changes in the distribution of patients undergoing peritoneal dialysis (PD), in-center hemodialysis (ICHD), and home hemodialysis (HHD). An Excel-based budget impact model was created to assess dialysis-associated Medicare costs. The model accounted for dialysis access establishment, the current monthly capitation physician payment for ESRD, Medicare dialysis payments (including start-up costs), training, oral drug costs, and the costs and probabilities of adverse events including access failure, hospitalization for access infection, pneumonia, septicemia, and cardiovascular events. United States Renal Data System (USRDS) data were used to project the US Medicare dialysis patient population across time. The baseline scenario assumed a stable distribution of PD (7.7%), HHD (1.3%) and ICHD (91.0%) over 5 years. Three comparison scenarios raised the proportions of PD and HHD by (1) 1% and 0.5%, (2) 2% and 0.75%, and (3) 3% and 1% each year; a fourth scenario held HHD constant and lowered PD by 1% per year. Under the bundled PPS, scenarios that increased PD and HHD from 7.7% and 1.3% over 5 years resulted in cumulative savings to Medicare of $114.8M (Scenario 1, 11.7% PD and 3.3% HHD at year 5), $232.9M (Scenario 2, 15.7% PD and 4.3% HHD at year 5), and $350.9M (Scenario 3, 19.7% PD and 5.3% HHD at year 5). When the PD population was decreased from 7.7% in 2013 to 3.7% by 2017 with a constant HHD population, the total Medicare payment for dialysis patients increased by over $121.2M. Under Medicare bundled PPS, increasing the proportion of patients on PD and HHD vs ICHD could generate substantial savings in dialysis-associated costs to Medicare

A study on the information-motivation-behavioural skills model among Chinese adults with peritoneal dialysis.

PubMed

Chang, Tian-Ying; Zhang, Yi-Lin; Shan, Yan; Liu, Sai-Sai; Song, Xiao-Yue; Li, Zheng-Yan; Du, Li-Ping; Li, Yan-Yan; Gao, Douqing

2018-05-01

To examine whether the information-motivation-behavioural skills model could predict self-care behaviour among Chinese peritoneal dialysis patients. Peritoneal dialysis is a treatment performed by patients or their caregivers in their own home. It is important to implement theory-based projects to increase the self-care of patients with peritoneal dialysis. The information-motivation-behavioural model has been verified in diverse populations as a comprehensive, effective model to guide the design, implementation and evaluation of self-care programmes. A cross-sectional, observational study. A total of 201 adults with peritoneal dialysis were recruited at a 3A grade hospital in China. Participant data were collected on demographics, self-care information (knowledge), social support (social motivation), self-care attitude (personal motivation), self-efficacy (behaviour skills) and self-care behaviour. We also collected data on whether the recruited patients had peritoneal dialysis-associated peritonitis from electronic medical records. Measured variable path analysis was performed using mplus 7.4 to identify the information-motivation-behavioural model. Self-efficacy, information and social motivation predict peritoneal dialysis self-care behaviour directly. Information and personal support affect self-care behaviour through self-efficacy, whereas peritoneal dialysis self-care behaviour has a direct effect on the prevention of peritoneal dialysis-associated peritonitis. The information-motivation-behavioural model is an appropriate and applicable model to explain and predict the self-care behaviour of Chinese peritoneal dialysis patients. Poor self-care behaviour among peritoneal dialysis patients results in peritoneal dialysis-associated peritonitis. The findings suggest that self-care education programmes for peritoneal dialysis patients should include strategies based on the information-motivation-behavioural model to enhance knowledge, motivation and behaviour

Broadening Options for Long-term Dialysis in the Elderly (BOLDE): differences in quality of life on peritoneal dialysis compared to haemodialysis for older patients.

PubMed

Brown, Edwina A; Johansson, Lina; Farrington, Ken; Gallagher, Hugh; Sensky, Tom; Gordon, Fabiana; Da Silva-Gane, Maria; Beckett, Nigel; Hickson, Mary

2010-11-01

Health-related quality of life (QOL) is an important outcome for older people who are often on dialysis for life. Little is, however, known about differences in QOL on haemodialysis (HD) and peritoneal dialysis (PD) in older age groups. Randomising patients to either modality to assess outcomes is not feasible. In this cross-sectional, multi-centred study we conducted QOL assessments (Short Form-12 Mental and Physical Component Summary scales, Hospital Anxiety and Depression Scale and Illness Intrusiveness Ratings Scale) in 140 people (aged 65 years or older) on PD and HD. The groups were similar in age, gender, time on dialysis, ethnicity, Index of Deprivation (based on postcode), dialysis adequacy, cognitive function (Mini-Mental State Exam and Trail-Making Test B), nutritional status (Subjective Global Assessment) and social networks. There was a higher comorbidity score in the HD group. Regression analyses were undertaken to ascertain which variables significantly influence each QOL assessment. All were influenced by symptom count highlighting that the patient's perception of their symptoms is a critical determinant of their mental and physical well being. Modality was found to be an independent predictor of illness intrusion with greater intrusion felt in those on HD. Overall, in two closely matched demographic groups of older dialysis patients, QOL was similar, if not better, in those on PD. This study strongly supports offering PD to all suitable older people.

Update on dialysis economics in the UK.

PubMed

Sharif, Adnan; Baboolal, Keshwar

2011-03-01

The burgeoning population of patients requiring renal replacement therapy contributes a disproportionate strain on National Health Service resources. Although renal transplantation is the preferred treatment modality for patients with established renal failure, achieving both clinical and financial advantages, limitations to organ donation and clinical comorbidities will leave a significant proportion of patients with established renal failure requiring expensive dialysis therapy in the form of either hemodialysis or peritoneal dialysis. An understanding of dialysis economics is essential for both healthcare providers and clinical leaders to establish clinically efficient and cost-effective treatment modalities that maximize service provision. In light of changes to the provision of healthcare funds in the form of "Payment by Results," it is imperative for UK renal units to adopt clinically effective and financially accountable dialysis programs. This article explores the role of dialysis economics and implications for UK renal replacement therapy programs.

The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS): Unifying Efforts to Inform Practice and Improve Global Outcomes in Peritoneal Dialysis

PubMed Central

Perl, Jeffrey; Davies, Simon J.; Lambie, Mark; Pisoni, Ronald L.; McCullough, Keith; Johnson, David W.; Sloand, James A.; Prichard, Sarah; Kawanishi, Hideki; Tentori, Francesca; Robinson, Bruce M.

2016-01-01

♦ Background: Extending technique survival on peritoneal dialysis (PD) remains a major challenge in optimizing outcomes for PD patients while increasing PD utilization. The primary objective of the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) is to identify modifiable practices associated with improvements in PD technique and patient survival. In collaboration with the International Society for Peritoneal Dialysis (ISPD), PDOPPS seeks to standardize PD-related data definitions and provide a forum for effective international collaborative clinical research in PD. ♦ Methods: The PDOPPS is an international prospective cohort study in Australia, Canada, Japan, the United Kingdom (UK), and the United States (US). Each country is enrolling a random sample of incident and prevalent patients from national samples of 20 to 80 sites with at least 20 patients on PD. Enrolled patients will be followed over an initial 3-year study period. Demographic, comorbidity, and treatment-related variables, and patient-reported data, will be collected over the study course. The primary outcome will be all-cause PD technique failure or death; other outcomes will include cause-specific technique failure, hospitalizations, and patient-reported outcomes. ♦ Results: A high proportion of the targeted number of study sites has been recruited to date in each country. Several ancillary studies have been funded with high momentum toward expansion to new countries and additional participation. ♦ Conclusion: The PDOPPS is the first large, international study to follow PD patients longitudinally to capture clinical practice. With data collected, the study will serve as an invaluable resource and research platform for the international PD community, and provide a means to understand variation in PD practices and outcomes, to identify optimal practices, and to ultimately improve outcomes for PD patients. PMID:26526049

Peritoneal dialysis--experiences.

PubMed

Mirković, Tatjana Durdević

2010-01-01

Peritoneal dialysis is the method of treatment of terminal-stage chronic kidney failure. Nowadays, this method is complementary to haemodialysis. It is based on the principles of the diffusion of solutes and ultrafiltration of fluids across the peritoneal membrane, which acts as a filter. The dialysate is introduced into the peritoneum via the previously positioned peritoneal catheter. The peritoneal dialysis is carried out on daily basis, at home by the patient, and the "exchange" is repeated 4-5 times during the 24 hours. The first steps in peritoneal dialysis at the Department for Haemodialysis of the Clinical Centre of Vojvodina date back to 1973. Until 1992, the patients were subjected to this program only sporadically. Since 1998 the peritoneal dialysis method has been performed at the Clinic for Nephrology and Clinical Immunology. In the period 1998-2008 ninety nine peritoneal catheters were placed. Chronic glomerulonephritis, nephroangiosclerosis and diabetes were identified as the most common causes of chronic renal failure. Two methods of catheter placement were applied: the standard open surgery method (majority of patients) and laparoscopy. Most of the patients were subjected to continuous ambulatory peritoneal dialysis, whereas four patients received automatic dialysis. Transplantation was performed in 10 patients, i.e. cadaveric transplantation and living-related donor transplantation, each in 5 patients. Peritoneal dialysis was available as a service outside our institution as well. A ten-year experience in peritoneal dialysis gained at our Centre has proved the advantages and qualities of this method, strongly supporting its wider application in the treatment of terminal-stage chronic kidney failure.

Dialysis in the Elderly and Impact of Institutionalization in the United States Renal Data System.

PubMed

Brar, Amarpali; Mallappallil, Mary; Stefanov, Dimitre G; Kau, David; Salifu, Moro O

2017-01-01

We hypothesized that in the very elderly dialysis patients in the United States, institutionalization in nursing homes would increase mortality in addition to age alone. Incident dialysis patients from 2001 to 2008 above the age of 70 were included. Patients above 70 were categorized into 4 groups according to age as 70-75, 76-80, 81-85, and >85 years and further divided into institutionalized and noninstitutionalized. Kaplan-Meier survival curves were plotted to assess patient survival. A total of 349,440 patients were identified above the age of 70 at the time of initiation of dialysis. For institutionalized patients, the mean survival was significantly lower, 1.71 ± 0.03 years for those in the age range 70-75, 1.44 ± 0.02 years for those in the age range 76-80, 1.25 ± 0.02 years for those in the age range 81-85, and 1.04 ± 0.02 for those in the >85 years age group (p = 0.0001). The hazard ratio for mortality in institutionalized elderly patients on dialysis was 1.80 ([95% CI 1.77-1.83]; p = 0.0001). After adjustment for other variables (multivariate Cox regression), to be institutionalized was still an independent risk factor for mortality (adjusted hazard ratio = 1.57 [95% CI 1.54-1.60]; p = 0.0001). There was increased mortality in institutionalized elderly patients as compared to noninstutionalized elderly patients in the same age group. In accordance with the increased frailty and decreased benefits of therapies in the very elderly, especially in those with additional co-morbidities besides age, palliative and end-of-life care should be considered. © 2017 S. Karger AG, Basel.

[Customization of hemodialysis therapy: dialysis is not a washing machine].

PubMed

Santoro, Antonio

2018-02-01

In recent years, the population of chronic dialysis has grown in number but also in age and frequency of co-morbidies such as cardiac diseases, vascular pathologies, diabetes, etc. The majority of patients on chronic hemodialysis are over 70 years and, given the high number of comorbidities, they often exhibit poor tolerance to dialysis treatments. A non-tolerated dialytic treatment can have side-effects that would require an intensification of the dialysis sessions and many hospitalizations. Consequently, the problematic dialysis treatments, as well as harmful for the patient, become economically more detrimental than other treatments apparently more expensive but more tolerated ones In the current days we have, thanks to the huge developments in dialysis technology, powerful weapons to ensure effective and scarcely symptomatic dialysis treatments to the majority of the HD patients. New, highly biocompatible membranes with defined and modular cut-off and / or absorption capacity may allow us to provide adequate purification. Moreover the monitoring and biofeedback systems such as blood volume tracking, body temperature monitoring (BTM) and blood pressure (BPM) can be very useful in reducing the risk of intra-dialytic hypotension and symptoms. Therefore, the dialytic therapy, as well as all the pharmacological therapies for the chronic patient, must consider the specificity of the patient, basing on his metabolic problems, cardiovascular tolerance, residual renal function and on his dietary and general compliance. The central aim of the nephrologist is to formulate the better prescription for the individual patient, considering the dialysis modalities, the membrane type, the dry weight (ideal post-dialysis body weight), the frequency and the duration of the weekly sessions and the technological tools that can optimize the treatment. Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.

Blood leakage detection during dialysis therapy based on fog computing with array photocell sensors and heteroassociative memory model

PubMed Central

Wu, Jian-Xing; Huang, Ping-Tzan; Li, Chien-Ming

2018-01-01

Blood leakage and blood loss are serious life-threatening complications occurring during dialysis therapy. These events have been of concerns to both healthcare givers and patients. More than 40% of adult blood volume can be lost in just a few minutes, resulting in morbidities and mortality. The authors intend to propose the design of a warning tool for the detection of blood leakage/blood loss during dialysis therapy based on fog computing with an array of photocell sensors and heteroassociative memory (HAM) model. Photocell sensors are arranged in an array on a flexible substrate to detect blood leakage via the resistance changes with illumination in the visible spectrum of 500–700 nm. The HAM model is implemented to design a virtual alarm unit using electricity changes in an embedded system. The proposed warning tool can indicate the risk level in both end-sensing units and remote monitor devices via a wireless network and fog/cloud computing. The animal experimental results (pig blood) will demonstrate the feasibility. PMID:29515815

Effect of dialysis modality on frailty phenotype, disability, and health-related quality of life in maintenance dialysis patients.

PubMed

Kang, Seok Hui; Do, Jun Young; Lee, So-Young; Kim, Jun Chul

2017-01-01

Health-related quality of life (HRQoL) surveys are needed to evaluate regional and ethnic specificies. The aim of the present study was to evaluate the differences in HRQoL, frailty, and disability according to dialysis modality in the Korean population. We enrolled relatively stable maintenance dialysis patients. A total of 1,616 patients were recruited into our study. The demographic and laboratory data collected at enrollment included age, sex, comorbidities, frailty, disability, and HRQoL scales. A total of 1,250 and 366 participants underwent hemodialysis (HD) and peritoneal dialysis (PD), respectively. The numbers of participants with pre-frailty and frailty were 578 (46.2%) and 422 (33.8%) in HD patients, and 165 (45.1%) and 137 (37.4%) in PD patients, respectively (P = 0.349). Participants with a disability included 195 (15.6%) HD patients and 109 (29.8%) PD patients (P < 0.001). On multivariate analysis, the mean physical component scale (PCS) and mental component scale (MCS), symptom/problems, and sleep scores were higher in HD patients than in PD patients. Cox regression analyses showed that an increased PCS in both HD and PD patients was positively associated with patient survival and first hospitalization-free survival. An increased MCS in both HD and PD patients was positively associated with first hospitalization-free survival only. There was no significant difference in frailty between patients treated with the two dialysis modalities; however, disability was more common in PD patients than in HD patients. The MCS and PCS were more favorable in HD patients than in PD patients. Symptom/problems, sleep, quality of social interaction, and social support were more favorable in HD patients than in PD patients; however, patient satisfaction and dialysis staff encouragement were more favorable in PD patients than in HD patients.

Understanding by Older Patients of Dialysis and Conservative Management for Chronic Kidney Failure

PubMed Central

Tonkin-Crine, Sarah; Okamoto, Ikumi; Leydon, Geraldine M.; Murtagh, Fliss E.M.; Farrington, Ken; Caskey, Fergus; Rayner, Hugh; Roderick, Paul

2015-01-01

Background Older adults with chronic kidney disease stage 5 may be offered a choice between dialysis and conservative management. Few studies have explored patients’ reasons for choosing conservative management and none have compared the views of those who have chosen different treatments across renal units. Study Design Qualitative study with semistructured interviews. Settings & Participants Patients 75 years or older recruited from 9 renal units. Units were chosen to reflect variation in the scale of delivery of conservative management. Methodology Semistructured interviews audiorecorded and transcribed verbatim. Analytical Approach Data were analyzed using thematic analysis. Results 42 interviews were completed, 4 to 6 per renal unit. Patients were sampled from those receiving dialysis, those preparing for dialysis, and those choosing conservative management. 14 patients in each group were interviewed. Patients who had chosen different treatments held varying beliefs about what dialysis could offer. The information that patients reported receiving from clinical staff differed between units. Patients from units with a more established conservative management pathway were more aware of conservative management, less often believed that dialysis would guarantee longevity, and more often had discussed the future with staff. Some patients receiving conservative management reported that they would have dialysis if they became unwell in the future, indicating the conditional nature of their decision. Limitations Recruitment of older adults with frailty and comorbid conditions was difficult and therefore transferability of findings to this population is limited. Conclusions Older adults with chronic kidney disease stage 5 who have chosen different treatment options have contrasting beliefs about the likely outcomes of dialysis for those who are influenced by information provided by renal units. Supporting renal staff in discussing conservative management as a valid

Dialysis outcomes and analysis of practice patterns suggests the dialysis schedule affects day-of-week mortality

PubMed Central

Zhang, Hui; Schaubel, Douglas E; Kalbfleisch, John D; Bragg-Gresham, Jennifer L; Robinson, Bruce M; Pisoni, Ronald L; Canaud, Bernard; Jadoul, Michel; Akiba, Takashi; Saito, Akira; Port, Friedrich K; Saran, Rajiv

2012-01-01

The risk of death for hemodialysis patients is thought to be highest on the days following the longest interval without dialysis (usually Mondays and Tuesdays); however, existing results are inconclusive. To clarify this we analyzed Dialysis Outcomes and Practice Patterns Study (DOPPS) data of 22,163 hemodialysis patients from the United States, Europe and Japan. Our study focused on the association between dialysis schedule and day-of-week of all-cause, cardiovascular and non-cardiovascular mortality with day-of-week coding as a time-dependent covariate. The models were adjusted for dialysis schedule, age, country, DOPPS Phase I or II, and other demographic and clinical covariates comparing mortality on each day to the 7-day average. Patients on a Monday-Wednesday-Friday (MFW) schedule had elevated all-cause mortality on Monday, and those on a Tuesday-Thursday-Saturday (TTS) schedule increased risk of mortality on Tuesday in all 3 regions. The association between day-of-week mortality and schedule was generally stronger for cardiovascular than non-cardiovascular mortality, and most pronounced in the United States. Unexpectedly, Japanese patients on a MWF schedule had a higher risk of non-cardiovascular mortality on Fridays, and European patients on a TTS schedule experienced an elevated cardiovascular mortality on Saturdays. Thus, future studies are needed to evaluate the influence of practice patterns on schedule-specific mortality and factors that could modulate this effect. PMID:22297673

Types of vicarious learning experienced by pre-dialysis patients.

PubMed

McCarthy, Kate; Sturt, Jackie; Adams, Ann

2015-01-01

Haemodialysis and peritoneal dialysis renal replacement treatment options are in clinical equipoise, although the cost of haemodialysis to the National Health Service is £16,411/patient/year greater than peritoneal dialysis. Treatment decision-making takes place during the pre-dialysis year when estimated glomerular filtration rate drops to between 15 and 30 mL/min/1.73 m(2). Renal disease can be familial, and the majority of patients have considerable health service experience when they approach these treatment decisions. Factors affecting patient treatment decisions are currently unknown. The objective of this article is to explore data from a wider study in specific relation to the types of vicarious learning experiences reported by pre-dialysis patients. A qualitative study utilised unstructured interviews and grounded theory analysis during the participant's pre-dialysis year. The interview cohort comprised 20 pre-dialysis participants between 24 and 80 years of age. Grounded theory design entailed thematic sampling and analysis, scrutinised by secondary coding and checked with participants. Participants were recruited from routine renal clinics at two local hospitals when their estimated glomerular filtration rate was between 15 and 30 mL/min/1.73 m(2). Vicarious learning that contributed to treatment decision-making fell into three main categories: planned vicarious leaning, unplanned vicarious learning and historical vicarious experiences. Exploration and acknowledgement of service users' prior vicarious learning, by healthcare professionals, is important in understanding its potential influences on individuals' treatment decision-making. This will enable healthcare professionals to challenge heuristic decisions based on limited information and to encourage analytic thought processes.

Impact of Pre-Dialysis Care on Clinical Outcomes in Peritoneal Dialysis Patients.

PubMed

Spigolon, Dandara N; de Moraes, Thyago P; Figueiredo, Ana E; Modesto, Ana Paula; Barretti, Pasqual; Bastos, Marcus Gomes; Barreto, Daniela V; Pecoits-Filho, Roberto

2016-01-01

Structured pre-dialysis care is associated with an increase in peritoneal dialysis (PD) utilization, but not with peritonitis risk, technical and patient survival. This study aimed at analyzing the impact of pre-dialysis care on these outcomes. All incident patients starting PD between 2004 and 2011 in a Brazilian prospective cohort were included in this analysis. Patients were divided into 2 groups: early pre-dialysis care (90 days of follow-up by a nephrology team); and late pre-dialysis care (absent or less than 90 days follow-up). The socio-demographic, clinical and biochemical characteristics between the 2 groups were compared. Risk factors for the time to the first peritonitis episode, technique failure and mortality based on Cox proportional hazards models. Four thousand one hundred seven patients were included. Patients with early pre-dialysis care presented differences in gender (female - 47.0 vs. 51.1%, p = 0.01); race (white - 63.8 vs. 71.7%, p < 0.01); education (<4 years - 61.9 vs. 71.0%, p < 0.01), respectively, compared to late care. Patients with early pre-dialysis care presented a higher prevalence of comorbidities, lower levels of creatinine, phosphorus, and glucose with a significantly better control of hemoglobin and potassium serum levels. There was no impact of pre-dialysis care on peritonitis rates (hazard ratio (HR) 0.88; 95% CI 0.77-1.01) and technique survival (HR 1.12; 95% CI 0.92-1.36). Patient survival (HR 1.20; 95% CI 1.03-1.41) was better in the early pre-dialysis care group. Earlier pre-dialysis care was associated with improved patient survival, but did not influence time to the first peritonitis nor technique survival in this national PD cohort. © 2016 S. Karger AG, Basel.

Measures of blood pressure and cognition in dialysis patients

USDA-ARS?s Scientific Manuscript database

There are few reports on the relationship of blood pressure with cognitive function in maintenance dialysis patients. The Cognition and Dialysis Study is an ongoing investigation of cognitive function and its risk factors in six Boston area hemodialysis units. In this analysis, we evaluated the rela...

Trends in Hospitalizations for Acute Kidney Injury - United States, 2000-2014.

PubMed

Pavkov, Meda E; Harding, Jessica L; Burrows, Nilka R

2018-03-16

Acute kidney injury is a sudden decrease in kidney function with or without kidney damage, occurring over a few hours or days. Diabetes, hypertension, and advanced age are primary risk factors for acute kidney injury. It is increasingly recognized as an in-hospital complication of sepsis, heart conditions, and surgery (1,2). Its most severe stage requires treatment with dialysis. Acute kidney injury is also associated with higher likelihood of long-term care, incidence of chronic kidney disease and hospital mortality, and health care costs (1,2). Although a number of U.S. studies have indicated an increasing incidence of dialysis-treated acute kidney injury since the late 1990s (3), no data are available on national trends in diabetes-related acute kidney injury. To estimate diabetes- and nondiabetes-related acute kidney injury trends, CDC analyzed 2000-2014 data from the National Inpatient Sample (NIS) (4) and the National Health Interview Survey (NHIS) (5). Age-standardized rates of acute kidney injury hospitalizations increased by 139% (from 23.1 to 55.3 per 1,000 persons) among adults with diagnosed diabetes, and by 230% (from 3.5 to 11.7 per 1,000 persons) among those without diabetes. Improving both patient and provider awareness that diabetes, hypertension, and advancing age are frequently associated with acute kidney injury might reduce its occurrence and improve management of the underlying diseases in an aging population.

The Effect of BCAA and ISO-WHEY Oral Nutritional Supplements on Dialysis Adequacy.

PubMed

Afaghi, Effat; Tayebi, Ali; Ebadi, Abbas; Sobhani, Vahid; Einollahi, Behzad; Tayebi, Mehdi

2016-11-01

Protein-energy malnutrition is a common problem in hemodialysis patients and has different outcomes such as reduced quality of life, longer hospitalization time, lower dialysis adequacy, and higher mortality rate. Investigation of dialysis adequacy is an important method for assessing hemodialysis patients, and improving the dialysis adequacy is an important healthcare team goal. The present study aims to investigate and compare the effects of BCAA and ISO-WHEY oral nutritional supplements on dialysis adequacy. In a clinical trial study, 66 hemodialysis patients were randomly divided into three groups: Group A (n = 22), Group B (n = 22), and Group C or the control group (n = 22). In Groups A and B, as prescribed and controlled by nutritionists and nephrologists, respectively, ISO-WHEY and BCAA protein powder were used for 2 months on a daily basis. For all groups, before intervention and 1 and 2 months after intervention, the dialysis adequacy was measured using URR and Kt/V. Finally, the data were analyzed using IBM SPSS Statistics Base 21.0 software. Out of 66 patients, 61 (19 in Group A, 20 in Group B, and 22 in Group C) completed the study period, and before intervention, all groups were equal in terms of quality and quantity variables (P > 0.05). After intervention, there was a significant difference between the three groups with regard to the variables of dialysis adequacy based on Kt/V and URR to independent-t test and repeated measures ANOVA (P < 0.05). Results show that the intake of oral nutritional supplements leads to an improvement in the dialysis adequacy of hemodialysis patients. Therefore, the use of nutritional supplements along with patients' training and regular consultation will be helpful in improving the nutritional status, dialysis adequacy, and eventually the quality of life.

Body-image disturbance in adult dialysis patients.

PubMed

Partridge, Kate Alexandra; Robertson, Noelle

2011-01-01

An increasing number of individuals in the UK develop end-stage renal failure and receive dialysis to prolong their lives. Dialysis-users report elevated levels of psychological morbidity which are associated with poorer quality of life, adjustment to illness and increased mortality. Circumscribed evidence has also identified body-image (BI) changes occurring in dialysis-users which are already known to be associated with psychological morbidity in other chronically ill populations. This study aimed to identify the prevalence of body-image disturbance (BID) in a dialysis population, correlation with psychological distress, and to identify any variables associated with increased BID and psychological morbidity. Particular attention was given to cognitive models of emotion which postulate a key role for self-consciousness and appearance-related beliefs. Between May and August 2007, 97 adult haemodialysis and peritoneal dialysis patients from a UK regional specialist centre responded to a questionnaire survey. Outcome measures comprised the Body Image Disturbance Questionnaire, Hospital Anxiety and Depression Scale, Self-consciousness Scale and the Appearance Schemas Inventory-Revised. Prevalence of anxiety and depression was 24.7% and 18.6%, respectively, with levels of BID significantly above community norms for both male and female respondents. Significant associations were found between psychological morbidity and BID and with specific aspects of appearance-schematisation and self-focus. Patients should be educated regarding the likely physical consequences of dialysis-types to aid decision-making and prepare them for impacts once dialysis is commenced. Clinicians may wish to monitor dialysis-users for distress and BI difficulties at follow-up appointments. Interventions that target appearance-related beliefs and BID may be of benefit to this population.

Determinants of Regret in Elderly Dialysis Patients.

PubMed

Tan, Edlyn Gui Fang; Teo, Irene; Finkelstein, Eric A; Chan, Choong Meng

2018-05-07

In Singapore, most elderly end stage renal disease (ESRD) patients choose dialysis over palliative management. However, dialysis may not be the optimal treatment option given only moderate survival benefits and high costs and treatment burden compared to non-dialysis management. Elderly patients may therefore come to regret this decision. This study investigated (1) extent of patients' decision regret after starting dialysis, and (2) potentially modifiable predictors of regret: satisfaction with chronic kidney disease education, decisional conflict, and decision-making involvement. Cross-sectional study of 103 dialysis patients above 70 years old surveyed at Singapore General Hospital's renal medicine clinics between March and June 2017. Participants reported their levels of decision regret on the Decision Regret Scale (DRS), retrospective decisional conflict on the Decisional Conflict Scale, information satisfaction, and decision-making involvement. 81% of participants reported no decision regret (DRS score <50), 11% ambivalence (DRS =50), and 8% regret (DRS >50). In individual DRS items, 19% felt dialysis had done them harm and 16% would not make the same decision again. In multivariable analyses, lower information satisfaction [b = -0.07 (95% CI: -0.13, -0.01)] and decisional conflict [b = 0.004 (95% CI: 0.002, 0.006)] were significantly associated with decision regret. Although majority of elderly dialysis patients were comfortable with their decision to start dialysis, a proportion was ambivalent or regretted this choice. Regret was more likely among those who experienced decisional conflict and/or expressed poorer information satisfaction. Healthcare professionals should recognize these risk factors and take steps to minimize chances of regret among this population subset. This article is protected by copyright. All rights reserved.

Broadening Options for Long-term Dialysis in the Elderly (BOLDE): differences in quality of life on peritoneal dialysis compared to haemodialysis for older patients

PubMed Central

Brown, Edwina A.; Johansson, Lina; Farrington, Ken; Gallagher, Hugh; Sensky, Tom; Gordon, Fabiana; Da Silva-Gane, Maria; Beckett, Nigel; Hickson, Mary

2010-01-01

Background. Health-related quality of life (QOL) is an important outcome for older people who are often on dialysis for life. Little is, however, known about differences in QOL on haemodialysis (HD) and peritoneal dialysis (PD) in older age groups. Randomising patients to either modality to assess outcomes is not feasible. Methods. In this cross-sectional, multi-centred study we conducted QOL assessments (Short Form-12 Mental and Physical Component Summary scales, Hospital Anxiety and Depression Scale and Illness Intrusiveness Ratings Scale) in 140 people (aged 65 years or older) on PD and HD. Results. The groups were similar in age, gender, time on dialysis, ethnicity, Index of Deprivation (based on postcode), dialysis adequacy, cognitive function (Mini-Mental State Exam and Trail-Making Test B), nutritional status (Subjective Global Assessment) and social networks. There was a higher comorbidity score in the HD group. Regression analyses were undertaken to ascertain which variables significantly influence each QOL assessment. All were influenced by symptom count highlighting that the patient’s perception of their symptoms is a critical determinant of their mental and physical well being. Modality was found to be an independent predictor of illness intrusion with greater intrusion felt in those on HD. Conclusions. Overall, in two closely matched demographic groups of older dialysis patients, QOL was similar, if not better, in those on PD. This study strongly supports offering PD to all suitable older people. PMID:20400451

Quality of Life and Physical Function in Older Patients on Dialysis: A Comparison of Assisted Peritoneal Dialysis with Hemodialysis

PubMed Central

Iyasere, Osasuyi U.; Johansson, Lina; Huson, Les; Smee, Joanna; Maxwell, Alexander P.; Farrington, Ken; Davenport, Andrew

2016-01-01

Background and objectives In-center hemodialysis (HD) is often the default dialysis modality for older patients. Few centers use assisted peritoneal dialysis (PD), which enables treatment at home. This observational study compared quality of life (QoL) and physical function between older patients on assisted PD and HD. Design, setting, participants, & measurements Patients on assisted PD who were >60 years old and on dialysis for >3 months were recruited and matched to patients on HD (needing hospital transport) by age, sex, diabetes, dialysis vintage, ethnicity, and index of deprivation. Frailty was assessed using the Clinical Frailty Scale. QoL assessments included Hospital Anxiety and Depression Scale (HADS), Short Form-12, Palliative Outcomes Symptom Scale (renal), Illness Intrusiveness Rating Scale, and Renal Treatment Satisfaction Questionnaire (RTSQ). Physical function was evaluated by Barthel Score and timed up and go test. Results In total, 251 patients (129 PD and 122 HD) were recruited. In unadjusted analysis, patients on assisted PD had a higher prevalence of possible depression (HADS>8; PD=38.8%; HD=23.8%; P=0.05) and higher HADS depression score (median: PD=6; HD=5; P=0.05) but higher RTSQ scores (median: PD=55; HD=51; P<0.01). In a generalized linear regression model adjusting for age, sex, comorbidity, dialysis vintage, and frailty, assisted PD continued to be associated with higher RTSQ scores (P=0.04) but not with other QoL measures. Conclusions There are no differences in measures of QoL and physical function between older patients on assisted PD and comparable patients on HD, except for treatment satisfaction, which is higher in patients on PD. Assisted PD should be considered as an alternative to HD for older patients, allowing them to make their preferred choices. PMID:26712808

From portable dialysis to a bioengineered kidney.

PubMed

van Gelder, Maaike K; Mihaila, Silvia M; Jansen, Jitske; Wester, Maarten; Verhaar, Marianne C; Joles, Jaap A; Stamatialis, Dimitrios; Masereeuw, Roos; Gerritsen, Karin G F

2018-05-01

Since the advent of peritoneal dialysis (PD) in the 1970s, the principles of dialysis have changed little. In the coming decades, several major breakthroughs are expected. Areas covered: Novel wearable and portable dialysis devices for both hemodialysis (HD) and PD are expected first. The HD devices could facilitate more frequent and longer dialysis outside of the hospital, while improving patient's mobility and autonomy. The PD devices could enhance blood purification and increase technique survival of PD. Further away from clinical application is the bioartificial kidney, containing renal cells. Initially, the bioartificial kidney could be applied for extracorporeal treatment, to partly replace renal tubular endocrine, metabolic, immunoregulatory and secretory functions. Subsequently, intracorporeal treatment may become possible. Expert commentary: Key factors for successful implementation of miniature dialysis devices are patient attitudes and cost-effectiveness. A well-functioning and safe extracorporeal blood circuit is required for HD. For PD, a double lumen PD catheter would optimize performance. Future research should focus on further miniaturization of the urea removal strategy. For the bio-artificial kidney (BAK), cost effectiveness should be determined and a general set of functional requirements should be defined for future studies. For intracorporeal application, water reabsorption will become a major challenge.

Hospital Magnet Status, Unit Work Environment, and Pressure Ulcers.

PubMed

Ma, Chenjuan; Park, Shin Hye

2015-11-01

To identify how organizational nursing factors at different structural levels (i.e., unit-level work environment and hospital Magnet status) are associated with hospital-acquired pressure ulcers (HAPUs) in U.S. acute care hospitals. A cross-sectional observational study used data from the National Database of Nursing Quality Indicators®. Responses from 33,845 registered nurses (RNs) were used to measure unit work environments. The unit of analysis was the nursing unit, and there were 1,381 units in 373 hospitals in the United States. Unit work environment was measured by the Practice Environment Scale of Nurse Working Index (PES-NWI). Multilevel logistic regressions were used to estimate the effects of unit work environment and hospital Magnet status on HAPUs. All models were controlled for hospital and unit characteristics when considering clustering of units within hospitals. Magnet hospital units had 21% lower odds of having an HAPU than non-Magnet hospital units (95% confidence interval [CI], 0.64-0.98). With one unit increase of the PES-NWI score, units had 29% lower odds of having an HAPU (95% CI, 0.55-0.91). When including both hospital Magnet status and unit work environment in the model, hospital Magnet status no longer had a significant effect on HAPUs (odds ratio [OR] = 0.82; 95% CI, 0.66-1.02), whereas the significant effect of unit work environment persisted (OR = 0.73; 95% CI, 0.56-0.93). Both hospital and unit environments were significantly associated with HAPUs, and the unit-level work environment can be more influential in reducing HAPUs. Investment in the nurse work environments at both the hospital level and unit level has the potential to reduce HAPUs; and additional to hospital-level initiatives (e.g., Magnet recognition program), efforts targeting on-unit work environments deserve more attention. © 2015 Sigma Theta Tau International.

Ensemble-based methods for forecasting census in hospital units.

PubMed

Koestler, Devin C; Ombao, Hernando; Bender, Jesse

2013-05-30

The ability to accurately forecast census counts in hospital departments has considerable implications for hospital resource allocation. In recent years several different methods have been proposed forecasting census counts, however many of these approaches do not use available patient-specific information. In this paper we present an ensemble-based methodology for forecasting the census under a framework that simultaneously incorporates both (i) arrival trends over time and (ii) patient-specific baseline and time-varying information. The proposed model for predicting census has three components, namely: current census count, number of daily arrivals and number of daily departures. To model the number of daily arrivals, we use a seasonality adjusted Poisson Autoregressive (PAR) model where the parameter estimates are obtained via conditional maximum likelihood. The number of daily departures is predicted by modeling the probability of departure from the census using logistic regression models that are adjusted for the amount of time spent in the census and incorporate both patient-specific baseline and time varying patient-specific covariate information. We illustrate our approach using neonatal intensive care unit (NICU) data collected at Women & Infants Hospital, Providence RI, which consists of 1001 consecutive NICU admissions between April 1st 2008 and March 31st 2009. Our results demonstrate statistically significant improved prediction accuracy for 3, 5, and 7 day census forecasts and increased precision of our forecasting model compared to a forecasting approach that ignores patient-specific information. Forecasting models that utilize patient-specific baseline and time-varying information make the most of data typically available and have the capacity to substantially improve census forecasts.

Configurations of leadership practices in hospital units.

PubMed

Meier, Ninna

2015-01-01

The purpose of this paper is to explore how leadership is practiced across four different hospital units. The study is a comparative case study of four hospital units, based on detailed observations of the everyday work practices, interactions and interviews with ten interdisciplinary clinical managers. Comparing leadership as configurations of practices across four different clinical settings, the author shows how flexible and often shared leadership practices were embedded in and central to the core clinical work in all units studied here, especially in more unpredictable work settings. Practices of symbolic work and emotional support to staff were particularly important when patients were severely ill. Based on a study conducted with qualitative methods, these results cannot be expected to apply in all clinical settings. Future research is invited to extend the findings presented here by exploring leadership practices from a micro-level perspective in additional health care contexts: particularly the embedded and emergent nature of such practices. This paper shows leadership practices to be primarily embedded in the clinical work and often shared across organizational or professional boundaries. This paper demonstrated how leadership practices are embedded in the everyday work in hospital units. Moreover, the analysis shows how configurations of leadership practices varied in four different clinical settings, thus contributing with contextual accounts of leadership as practice, and suggested "configurations of practice" as a way to carve out similarities and differences in leadership practices across settings.

Oral health status of dialysis patients based on their renal dialysis history in Kerman, Iran.

PubMed

Chamani, Goli; Zarei, Mohammad Reza; Radvar, Mehrdad; Rashidfarrokhi, Farin; Razazpour, Fateme

2009-01-01

Maintaining a high level of periodontal and oral health in patients undergoing renal dialysis is of paramount importance because of the inherent compromised host defence mechanisms. The aim of the present study was to determine the periodontal status and the level of dental caries in renal dialysis patients in Kerman, Iran. A cross-sectional study was conducted on two groups of patients: one including 68 renal dialysis patients (test) and the other including 30 healthy subjects (control). Half-mouth measurements of Gingival Index (GI), Plaque Index (PI), probing pocket depth (PPD), gingival recession (GR), clinical attachment level (CAL) and bleeding on probing (BOP) as well as decayed, missing or filled teeth (DMFT) index were recorded. The GI, BOP, PPD, CAL and GR were significantly greater among the test group as compared with the control group; however, the DMFT did not differ significantly among the groups. There was no relationship between the duration of the dialysis and the periodontal indices. It seems that patients with chronic renal failure have less favourable periodontal health than normal patients. The present study showed that oral home care practices were inadequate. Thus, preventive programmes to promote the oral health status of haemodialysis patients are needed.

Additional funding mechanisms for Public Hospitals in Greece: the case of Chania Mental Health Hospital

PubMed Central

2010-01-01

Objectives To investigate whether the long term lease of public hospital owned land could be an additional financing mechanism for Greek public (mental) health hospitals. Methods We performed a financial analysis of the official 2008 data of a case - study hospital (Mental Health Hospital of Chania). We used a capital budgeting approach to investigate whether value is created for the public hospital by engaging its assets in a project for the development of a private renal dialysis Unit. Results The development of the private unit in hospital owned land is a good investment decision, as it generates high project Net Present Value and Internal Rate of Return. When the project commences generating operating cash flows, nearly €400.000 will be paid annually to the Mental Health Hospital of Chania as rent, thereby gradually decreasing the annual deficit of the hospital. Conclusions Revenue generated from the long term lease of public hospital land is crucial to gradually eliminate hospital deficit. The Ministry of Health should encourage similar forms of Public Private Partnerships in order to ensure the sustainability of public (mental) hospitals. PMID:21067580

[Optimal use of peritoneal dialysis with multi-disciplinary management].

PubMed

Elios Russo, Gaspare; Martinez, A; Mazzaferro, S; Nunzi, A; Testorio, M; Rocca, A R; Lai, S; Morgia, A; Borzacca, B; Gnerre Musto, T

2013-01-01

Considering the increasing incidence of chronic kidney disease and the increased use of peritoneal dialysis, we wanted to assess whether the multidisciplinary management of patients in peritoneal dialysis might produce improvement in the quality of patients' lives when compared to management by a routine team of operators. Our study observed 40 patients on peritoneal dialysis in our Department between 2010 and 2012. They were randomly assigned to either group A, the routine team which consisted of a nephrologist and a nurse, or group B, a multidisciplinary team comprising several medical specialists, a nurse, a psychologist and a social worker. Two tests, KDQOL-SF and MMPI-2, were administered to both groups. In group B, the number of days of hospitalization and day hospital were more than 88% lower when compared to group A. The multidisciplinary team achieved better results with the KDQOL-SF test with regards to both emotional and objective dimensions. The Pearson coefficient between the results of the two questionnaires shows how multidisciplinary management can positively influence the perceived well-being of the patient and his or her adherence to treatment. In a multidisciplinary team, each operator, in addition to his or her specific role, also contributes to the achievement of the overall objective, namely of ensuring an optimal quality of life to the patient on peritoneal dialysis thereby allowing these patients to continue their professional and social lives.

Dialysis Dependence Predicts Complications, Intensive Care Unit Care, Length of Stay, and Skilled Nursing Needs in Elective Primary Total Knee and Hip Arthroplasty.

PubMed

Patterson, Joseph T; Tillinghast, Kyle; Ward, Derek

2018-07-01

Limited data describe risks and perioperative resource needs of total joint arthroplasty (TJA) in dialysis-dependent patients. Retrospective multiple cohort analysis of dialysis-dependent American College of Surgeons National Surgical Quality Improvement Program patients undergoing primary elective total hip and knee arthroplasty compared to non-dialysis-dependent controls from 2005 to 2015. Relative risks (RRs) of 30-day adverse events were determined by multivariate regression adjusting for baseline differences. Six hundred forty-five (0.2%) dialysis-dependent patients of 342,730 TJA patients were dialysis-dependent and more likely to be dependent, under weight, anemic, hypoalbuminemic, and have cardiopulmonary disease. In total hip arthroplasty patients, dialysis was associated with greater risk of any adverse event (RR = 1.1, P < .001), mortality (RR = 2.8, P = .012), intensive care unit (ICU) care (RR = 9.8, P < .001), discharge to facility (RR = 1.3, P < .001), and longer admission (1.5×, P < .001). In total knee arthroplasty patients, dialysis conferred greater risk of any adverse event (RR = 1.1, P < .001), ICU care (RR = 6.0, P < .001), stroke (RR = 7.6, P < .001), cardiac arrest (RR = 4.8, P = .014), discharge to facility (RR = 1.5, P < .001), readmission (RR = 1.8, P = .002), and longer admission (1.3×, P < .001). Dialysis-dependence is an independent risk factor for 30-day adverse events, ICU care, longer admission, and rehabilitation needs in TJA patients. Thirty days is not sufficient to detect infectious complications among these patients. These findings inform shared decision-making, perioperative resource planning, and risk adjustment under alternative reimbursement models. Copyright © 2018 Elsevier Inc. All rights reserved.

Hospital librarianship in the United States: at the crossroads

PubMed Central

Wolf, Diane G.; Chastain-Warheit, Christine C.; Easterby-Gannett, Sharon; Chayes, Marion C.; Long, Bradley A.

2002-01-01

This paper examines recent developments in hospital librarianship in the United States, including the current status of hospital-based clinical library services. Several examples of hospital library services are presented that demonstrate some characteristics of struggling and thriving services. The implications of the informationist concept are considered. The continuation of the hospital librarian's primary role in support of patient care is explored, as core competencies are reexamined for relevancy in the new millennium. PMID:11838458

Hospital librarianship in the United States: at the crossroads.

PubMed

Wolf, Diane G; Chastain-Warheit, Christine C; Easterby-Gannett, Sharon; Chayes, Marion C; Long, Bradley A

2002-01-01

This paper examines recent developments in hospital librarianship in the United States, including the current status of hospital-based clinical library services. Several examples of hospital library services are presented that demonstrate some characteristics of struggling and thriving services. The implications of the informationist concept are considered. The continuation of the hospital librarian's primary role in support of patient care is explored, as core competencies are reexamined for relevancy in the new millennium.

Pre-hospital care after a seizure: Evidence base and United Kingdom management guidelines.

PubMed

Osborne, Andrew; Taylor, Louise; Reuber, Markus; Grünewald, Richard A; Parkinson, Martin; Dickson, Jon M

2015-01-01

Seizures are a common presentation to pre-hospital emergency services and they generate significant healthcare costs. This article summarises the United Kingdom (UK) Ambulance Service guidelines for the management of seizures and explores the extent to which these guidelines are evidence-based. Summary of the Clinical Practice Guidelines of the UK Joint Royal Colleges Ambulance Liaison Committee relating to the management of seizures. Review of the literature relating to pre-hospital management of seizure emergencies. Much standard practice relating to the emergency out of hospital management of patients with seizures is drawn from generic Advanced Life Support (ALS) guidelines although many patients do not need ALS during or after a seizure and the benefit of many ALS interventions in seizure patients remains to be established. The majority of studies identified pertain to medical treatment of status epilepticus. These papers show that benzodiazepines are safe and effective but it is not possible to draw definitive conclusions about the best medication or the optimal route of administration. The evidence base for current pre-hospital guidelines for seizure emergencies is incomplete. A large proportion of patients are transported to hospital after a seizure but many of these may be suitable for home management. However, there is very little research into alternative care pathways or criteria that could be used to help paramedics avoid transport to hospital. More research is needed to improve care for people after a seizure and to improve the cost-effectiveness of the healthcare systems within which they are treated. Copyright © 2014 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

Changing Landscape for Peritoneal Dialysis: Optimizing Utilization.

PubMed

Schreiber, Martin J

2017-03-01

The future growth of peritoneal dialysis (PD) will be directly linked to the shift in US healthcare to a value-based payment model due to PD's lower yearly cost, early survival advantage over in-center hemodialysis, and improved quality of life for patients treating their kidney disease in the home. Under this model, nephrology practices will need an increased focus on managing the transition from chronic kidney disease to end-stage renal disease (ESRD), providing patient education with the aim of accomplishing modality selection and access placement ahead of dialysis initiation. Physicians must expand their knowledge base in home therapies and work toward increased technique survival through implementation of specific practice initiatives that highlight PD catheter placement success, preservation of residual renal function, consideration of incremental PD, and competence in urgent start PD. Avoidance of both early and late PD technique failures is also critical to PD program growth. Large dialysis organizations must continue to measure and improve quality metrics for PD, expand their focus beyond the sole provision of PD to holistic patient care, and initiate programs to reduce PD hospitalization rates and encourage physicians to consider the benefits of PD as an initial modality for appropriate patients. New and innovative strategies are needed to address the main reasons for PD technique failure, improve the connectivity of the patient in the home, leverage home biometric data to improve overall outcomes, and develop PD cycler devices that lower patient treatment burden and reduce both treatment fatigue and treatment-dependent complications. © 2017 Wiley Periodicals, Inc.

[Malnutrition screening in hospitalized children: influence of the hospital unit on its management].

PubMed

Marteletti, O; Caldari, D; Guimber, D; Mention, K; Michaud, L; Gottrand, F

2005-08-01

The aims of this study were to assess the prevalence of malnutrition in a pediatric population hospitalized in a French regional hospital and to evaluate the influence of type of hospital unit (pediatric or not) in the screening and the management of malnutrition. This one-day cross-sectional survey was performed in three different seasons during 2003. Every child aged 2 months to 16 years old, hospitalized for more than 48 hours was included. Weight for height, Z-score and Body Mass Index Z-score were used for nutritional assessment. Type of hospitalisation unit, date of admission, associated diagnosis, screening and treatment of malnutrition were also taken into account. Two hundred and eighty hospitalized children were undernourished (11%) and thirty-one children were obese (11%) with no difference in prevalence of malnutrition between pediatric and non-pediatric units. At the time of the study, malnutrition was recognized in one third of the children, at a similar rate whatever the type of hospitalized unit. The children hospitalized in pediatrics wards benefited more frequently from nutritional intervention, i.e. dietician care (43 vs. 16% P < 0.01). Prevalence of malnutrition in hospitalized children is low and the same in pediatric or non-pediatric units. Screening of malnutrition remains unsatisfactory in hospital. However, malnutrition is more frequently treated in pediatric unit compared with non-pediatric unit.

Ensemble-based methods for forecasting census in hospital units

PubMed Central

2013-01-01

Background The ability to accurately forecast census counts in hospital departments has considerable implications for hospital resource allocation. In recent years several different methods have been proposed forecasting census counts, however many of these approaches do not use available patient-specific information. Methods In this paper we present an ensemble-based methodology for forecasting the census under a framework that simultaneously incorporates both (i) arrival trends over time and (ii) patient-specific baseline and time-varying information. The proposed model for predicting census has three components, namely: current census count, number of daily arrivals and number of daily departures. To model the number of daily arrivals, we use a seasonality adjusted Poisson Autoregressive (PAR) model where the parameter estimates are obtained via conditional maximum likelihood. The number of daily departures is predicted by modeling the probability of departure from the census using logistic regression models that are adjusted for the amount of time spent in the census and incorporate both patient-specific baseline and time varying patient-specific covariate information. We illustrate our approach using neonatal intensive care unit (NICU) data collected at Women & Infants Hospital, Providence RI, which consists of 1001 consecutive NICU admissions between April 1st 2008 and March 31st 2009. Results Our results demonstrate statistically significant improved prediction accuracy for 3, 5, and 7 day census forecasts and increased precision of our forecasting model compared to a forecasting approach that ignores patient-specific information. Conclusions Forecasting models that utilize patient-specific baseline and time-varying information make the most of data typically available and have the capacity to substantially improve census forecasts. PMID:23721123

Serum Alkaline Phosphatase Levels Predict Infection-Related Mortality and Hospitalization in Peritoneal Dialysis Patients.

PubMed

Hwang, Seun Deuk; Kim, Su-Hyun; Kim, Young Ok; Jin, Dong Chan; Song, Ho Chul; Choi, Euy Jin; Kim, Yong-Lim; Kim, Yon-Su; Kang, Shin-Wook; Kim, Nam-Ho; Yang, Chul Woo; Kim, Yong Kyun

2016-01-01

Serum alkaline phosphatase (ALP) levels have been reported to be associated with all-cause and cardiovascular mortality in peritoneal dialysis (PD) patients. However, it is unclear whether serum ALP levels predict infection-related clinical outcomes in PD patients. The aim of this study was to determine the relationships between serum ALP levels, infection-related mortality and hospitalization in PD patients. PD patients from the Clinical Research Center registry for end-stage renal disease, a multicenter prospective observational cohort study in Korea, were included in the present study. Patients were categorized into three groups by serum ALP tertiles as follows: Tertile 1, ALP <78 U/L; Tertile 2, ALP = 78-155 U/L; Tertile 3, ALP >155 U/L. Tertile 1 was used as the reference category. The primary outcomes were infection-related mortality and hospitalization. A total of 1,455 PD patients were included. The median follow-up period was 32 months. The most common cause of infection-related mortality and hospitalization was PD-related peritonitis. Multivariate Cox regression analyses showed that patients in the highest tertiles of serum ALP levels were at higher risk of infection-related mortality (HR 2.29, 95% CI, 1.42-5.21, P = 0.008) after adjustment for clinical variables. Higher tertiles of serum ALP levels were associated with higher risk of infection-related hospitalization (Tertile 2: HR 1.56, 95% CI, 1.18-2.19, P = 0.009, tertile 3: HR 1.34, 95% CI, 1.03-2.62, P = 0.031). Our data showed that elevated serum ALP levels were independently associated with a higher risk of infection-related mortality and hospitalization in PD patients.

Factors influencing patient choice of dialysis versus conservative care to treat end-stage kidney disease

PubMed Central

Morton, Rachael L.; Snelling, Paul; Webster, Angela C.; Rose, John; Masterson, Rosemary; Johnson, David W.; Howard, Kirsten

2012-01-01

Background: For every patient with chronic kidney disease who undergoes renal-replacement therapy, there is one patient who undergoes conservative management of their disease. We aimed to determine the most important characteristics of dialysis and the trade-offs patients were willing to make in choosing dialysis instead of conservative care. Methods: We conducted a discrete choice experiment involving adults with stage 3–5 chronic kidney disease from eight renal clinics in Australia. We assessed the influence of treatment characteristics (life expectancy, number of visits to the hospital per week, ability to travel, time spent undergoing dialysis [i.e., time spent attached to a dialysis machine per treatment, measured in hours], time of day at which treatment occurred, availability of subsidized transport and flexibility of the treatment schedule) on patients’ preferences for dialysis versus conservative care. Results: Of 151 patients invited to participate, 105 completed our survey. Patients were more likely to choose dialysis than conservative care if dialysis involved an increased average life expectancy (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.57–2.15), if they were able to dialyse during the day or evening rather than during the day only (OR 8.95, 95% CI 4.46–17.97), and if subsidized transport was available (OR 1.55, 95% CI 1.24–1.95). Patients were less likely to choose dialysis over conservative care if an increase in the number of visits to hospital was required (OR 0.70, 95% CI 0.56–0.88) and if there were more restrictions on their ability to travel (OR = 0.47, 95%CI 0.36–0.61). Patients were willing to forgo 7 months of life expectancy to reduce the number of required visits to hospital and 15 months of life expectancy to increase their ability to travel. Interpretation: Patients approaching end-stage kidney disease are willing to trade considerable life expectancy to reduce the burden and restrictions imposed by dialysis

Patient-Staff Interactions and Mental Health in Chronic Dialysis Patients

ERIC Educational Resources Information Center

Swartz, Richard D.; Perry, Erica; Brown, Stephanie; Swartz, June; Vinokur, Amiram

2008-01-01

Chronic dialysis imposes ongoing stress on patients and staff and engenders recurring contact and long-term relationships. Thus, chronic dialysis units are opportune settings in which to investigate the impact of patients' relationships with staff on patient well-being. The authors designed the present study to examine the degree to which…

A comparative study of the effect of icodextrin based peritoneal dialysis and hemodialysis on lipid metabolism.

PubMed

Kadiroğlu, A K; Ustündag, S; Kayabaşi, H; Yilmaz, Z; Yildirım, Y; Sen, S; Yilmaz, M E

2013-09-01

Dyslipidemia is frequent in patients with end stage renal disease. Excessive peritoneal glucose absorption from high glucose-containing peritoneal dialysis solutions may enhance disturbances on the lipid metabolism of patients on peritoneal dialysis. We compared the effect of icodextrin-based peritoneal dialysis therapy with hemodialysis (HD) therapy on lipid metabolism. A total of 157 non-diabetic patients on dialysis at least for 3 months; 78 patients on Icodextrin-based continuous ambulatory peritoneal dialysis (CAPD) (44 M, 34 F) and 79 patients in HD group (47M, 32F) were included into the study. After 12 h of fasting and before the dialysis session, serum urea, creatinin, glucose, Sodium, potasium, and albumin, total cholesterol (TC), triglycerides (TG), very low density lipoprotein (VLDL), low density lipoprotein (LDL)-C, high-density lipoprotein (HDL)-C, apolipoprotein A (Apo A), apolipoprotein B, and lipoprotein a were measured. TG (P = 0018) and VLDL (P = 0.022) were lower in CAPD group than HD group, HDL-C (P < 0.001) and Apo A (P = 0.001) were higher in CAPD group than in HD group. A total of 24.4% in CAPD group and 11.4% in HD group (P < 0.034) had normal serum levels of TG, LDL-C, and HDL-C. More patients in CAPD group (47.4%) had high serum Apo A levels than in HD group (21.5%) (P = 0.001). We suggest that patients receiving icodextrin-based CAPD may have better TG, HDL-C, and Apo A levels than patients on HD.

Psychosocial predictors of nonadherence to medical management among patients on maintenance dialysis.

PubMed

Alosaimi, Fahad Dakheel; Asiri, Mohammed; Alsuwayt, Saleh; Alotaibi, Tariq; Bin Mugren, Mohammed; Almufarrih, Abdulmalik; Almodameg, Saad

2016-01-01

A number of reports suggest a link between depression and nonadherence to recommended management for end-stage renal disease (ESRD) patients on maintenance dialysis. However, the relationship between nonadherence and other psychosocial factors have been inadequately examined. To examine the prevalence of psychosocial factors including depression, anxiety, insecure attachment style, as well as cognitive impairment and their associations with adherence to recommended management of ESRD. A cross-sectional observational study was carried out from 2014 to 2015. Chronic dialysis patients were recruited conveniently from four major dialysis units in Riyadh, Saudi Arabia. Nonadherence was defined as decreased attendance in dialysis sessions, failure to take prescribed medications, and/or follow food/fluid restrictions and exercise recommendations. A total of 234 patients (147 males and 87 females) were included in this analysis, with 45 patients (19.2%) considered as nonadherent (visual analog scale < 8). Approximately 17.9% of the patients had depression (Patient Health Questionnaire score ≥10), 13.2% had anxiety (Hospital Anxiety and Depression scale-anxiety >7), while 77.4% had cognitive impairment (Montreal Cognitive Assessment score <26). Nonadherence was significantly associated with depression and anxiety ( p <0.001 for both) but not cognitive impairment ( p =0.266). The Experiences in Close Relationships - Modified 16 (ECR-M16) scale score was 27.99±10.87 for insecure anxiety and 21.71±9.06 for insecure avoidance relationship, with nonadherence significantly associated with anxiety ( p =0.001) but not avoidance ( p =0.400). Nonadherence to different aspects of ESRD continues to be a serious problem among dialysis patients, and it is closely linked to depression and anxiety. The findings from this study reemphasize the importance of early detection and management of psychosocial ailments in these patients.

[An assessment approach to the adequacy of peritoneal dialysis based on modified MART2 network].

PubMed

Zhang, Mei; Zhao, Jing; Hu, Yueming

2009-06-01

Against the large number of assessment indices to the adequacy peritoneal dialysis and incompatibility of some indices, an intelligent assessment approach to the peritoneal dialysis adequacy based on MART2 (modified from ART2) network is proposed. After non-dimension and weighting preconditioning, the assessment indices were put to MART2 and sorted into many clusters. The center-of-gravity of each cluster was identified as adequacy or inadequacy according to the assessment criteria of dialysis adequacy, and the adequacy of each cluster could be determined by the adequacy of corresponding center-of-gravity when the network threshold was high. Finally, the peritoneal dialysis adequacy of each patient could be judged according to the adequacy of cluster to which the patients' indices belong. Experimental results demounstrate its effectiveness.

Views of Japanese patients on the advantages and disadvantages of hemodialysis and peritoneal dialysis.

PubMed

Nakamura-Taira, Nanako; Muranaka, Yoshimi; Miwa, Masako; Kin, Seikon; Hirai, Kei

2013-08-01

The preference for dialysis modalities is not well understood in Japan. This study explored the subjective views of Japanese patients undergoing dialysis regarding their treatments. The participants were receiving in-center hemodialysis (CHD) or continuous ambulatory peritoneal dialysis (CAPD). In Study 1, 34 participants (17 CHD and 17 CAPD) were interviewed about the advantages and disadvantages of dialysis modalities. In Study 2, 454 dialysis patients (437 CHD and 17 CAPD) rated the advantages and disadvantages of CHD and CAPD in a cross-sectional survey. Interviews showed that professional care and dialysis-free days were considered as advantages of CHD, while independence, less hospital visits, and flexibility were considered as advantages of CAPD. Disadvantages of CHD included restriction of food and fluids and unpleasant symptoms after each dialysis session. Catheter care was an additional disadvantage of CAPD. Survey showed that the highly ranked advantages were professional care in CHD and less frequent hospital visits in CAPD, while the highly ranked disadvantages were concerns about emergency and time restrictions in CHD, and catheter care and difficulty in soaking in a bath in CAPD. The total scores of advantages and disadvantages showed that CHD patients subjectively rated their own modality better CHD over CAPD, while CAPD patients had the opposite opinion. The results of this study indicate that the factors affecting the decision-making process of Japanese patients are unique to Japanese culture, namely considering the trouble caused to the people around patients (e.g., families, spouses, and/or caregivers).

Pilot non dialysis chronic renal insufficiency study (P-ND-CRIS): a pilot study of an open prospective hospital-based French cohort.

PubMed

Massol, Jacques; Janin, Gérard; Bachot, Camille; Gousset, Christophe; Deville, Geoffroy Sainte-Claire; Chalopin, Jean-Marc

2017-02-01

Before establishing a prospective cohort, an initial pilot study is recommended. However, there are no precise guidelines on this subject. This paper reports the findings of a French regional pilot study carried out in three nephrology departments, before realizing a major prospective Non Dialysis Chronic Renal Insufficiency study (ND-CRIS). We carried out an internal pilot study. The objectives of this pilot study were to validate the feasibility (regulatory approval, providing patients with information, availability of variables, refusal rate of eligible patients) and quality criteria (missing data, rate of patients lost to follow-up, characteristics of the patients included and non-included eligible patients, quality control of the data gathered) and estimate the human resources necessary (number of clinical research associates required). The authorizations obtained (CCTIRS - CNIL) and the contracts signed with hospitals have fulfilled the regulatory requirements. After validating the information on the study provided to patients, 1849 of them were included in three centres (university hospital, intercommunal hospital, town hospital) between April 2012 and September 2015. The low refusal rate (51 patients) and the characteristics of non-included patients have confirmed the benefit for patients of participating in the study and provide evidence of the feasibility and representativeness of the population studied. The lack of missing data on the variables studied, the quality of the data analyzed and the low number of patients lost to follow-up are evidence of the quality of the study. By taking into account the time spent by CRAs to enter data and to travel, as well as the annual patient numbers in each hospital, we estimate that five CRAs will be required in total. With no specific guidelines on how to realize a pilot study before implementing a major prospective cohort, we considered it pertinent to report our experience of P-ND-CRIS. This experience confirms

Choosing to live with home dialysis-patients' experiences and potential for telemedicine support: a qualitative study

PubMed Central

2012-01-01

Background This study examines the patients' need for information and guidance in the selection of dialysis modality, and in establishing and practicing home dialysis. The study focuses on patients' experiences living with home dialysis, how they master the treatment, and their views on how to optimize communication with health services and the potential of telemedicine. Methods We used an inductive research strategy and conducted semi-structured interviews with eleven patients established in home dialysis. Our focus was the patients' experiences with home dialysis, and our theoretical reference was patients' empowerment through telemedicine solutions. Three informants had home haemodialysis (HHD); eight had peritoneal dialysis (PD), of which three had automated peritoneal dialysis (APD); and five had continuous ambulatory peritoneal dialysis (CAPD). The material comprises all PD-patients in the catchment area capable of being interviewed, and all known HHD-users in Norway at that time. Results All of the interviewees were satisfied with their choice of home dialysis, and many experienced a normalization of daily life, less dominated by disease. They exhibited considerable self-management skills and did not perceive themselves as ill, but still required very close contact with the hospital staff for communication and follow-up. When choosing a dialysis modality, other patients' experiences were often more influential than advice from specialists. Information concerning the possibility of having HHD, including knowledge of how to access it, was not easily available. Especially those with dialysis machines, both APD and HHD, saw a potential for telemedicine solutions. Conclusions As home dialysis may contribute to a normalization of life less dominated by disease, the treatment should be organized so that the potential for home dialysis can be fully exploited. Pre-dialysis information should be unbiased and include access to other patients' experiences. Telemedicine

Mechanical complications of continuous ambulatory peritoneal dialysis: Experience at the Ibn Sina University Hospital.

PubMed

Flayou, Kaoutar; Ouzeddoun, Naima; Bayahia, Rabia; Rhou, Hakima; Benamar, Loubna

2016-01-01

Peritoneal dialysis is a new renal replacement therapy recently introduced in Morocco since 2006. Continuous ambulatory peritoneal dialysis has proven to be as effective as hemodialysis. However, it is associated with several complications. The aim of this study was to evaluate the outcome of complications in patients treated with peritoneal dialysis at our center. The nature of non-infectious complications was noted during follow-up in these patients. Fiftyseven complications were noted among 34 patients between June 2006 and June 2014. Catheter migration was the most common complication (36.8%), followed by obstruction (14%), dialysate leaks (14%), hemorrhagic complications (10.5%) and, finally, hernia (12.2%), catheter perforation (5.2%) and externalization (3.5%).

A simulation model to estimate the cost and effectiveness of alternative dialysis initiation strategies.

PubMed

Lee, Chris P; Chertow, Glenn M; Zenios, Stefanos A

2006-01-01

Patients with end-stage renal disease (ESRD) require dialysis to maintain survival. The optimal timing of dialysis initiation in terms of cost-effectiveness has not been established. We developed a simulation model of individuals progressing towards ESRD and requiring dialysis. It can be used to analyze dialysis strategies and scenarios. It was embedded in an optimization frame worked to derive improved strategies. Actual (historical) and simulated survival curves and hospitalization rates were virtually indistinguishable. The model overestimated transplantation costs (10%) but it was related to confounding by Medicare coverage. To assess the model's robustness, we examined several dialysis strategies while input parameters were perturbed. Under all 38 scenarios, relative rankings remained unchanged. An improved policy for a hypothetical patient was derived using an optimization algorithm. The model produces reliable results and is robust. It enables the cost-effectiveness analysis of dialysis strategies.

“Is There Life on Dialysis?”: Time and Aging in a Clinically Sustained Existence

PubMed Central

Russ, Ann J.; Shim, Janet K.; Kaufman, Sharon R.

2008-01-01

Increasingly, in the United States, lives are being extended at ever-older ages through the implementation of routine medical procedures such as renal dialysis. This paper discusses the lives and experiences of a number of individuals 70 years of age and older at two dialysis units in California. It considers what kind of life it is that is being sustained and prolonged in these units, the meanings of the time gained through (and lost to) dialysis for older people, and the relationship of “normal” life outside the units to an exceptional state on the inside that some patients see as not-quite-life. Highlighting the unique dimensions of gerontological time on chronic life support, the article PMID:16249136

Exploring the opinion of hemodialysis patients about their dialysis unit.

PubMed

Donia, Ahmed Farouk; Elhadedy, Mohamed Ahmed; El-Maghrabi, Hanzada Mohamed; Abbas, Mohamed Hamed; Foda, Mohamed Ashraf

2015-01-01

Hemodialysis (HD) patients are subjected to a number of physical and mental stresses. Physicians might be unaware of some of these problems. We assessed our patients' opinion about the service provided at the dialysis unit. Our unit has 89 patients on HD. A questionnaire exploring our patients' opinion relative to the service provided was prepared. The patients were asked to fill-in the questionnaire in a confidential manner. Questionnaires were then collected and examined while unaware of patient identities. Sixty-nine patients (77.5%) responded to the questionnaire. Eight patients (11.6%) revealed their names on the questionnaire. According to the questionnaire, the patients were asked to assess the service of each service by choosing one of the following grades: "excellent," "mediocre" or "bad." For the whole group of contributing patients, there were 563 "excellent," 85 "mediocre" and five "bad" choices in addition to 37 blank "no comment" choices. Food service had the least percentage (68%) of evaluation as "excellent," while doctor' performance got the highest excellent evaluation (85.5%). Thirty-five patients (50.7%) added further comment(s). An audit meeting was conducted to discuss these results. Exploring the opinion of patients on HD might uncover some areas of dissatisfaction and help in improving the provided service. We recommend widespread usage of questionnaires to assess patient satisfaction as well as to assess other health-care aspects.

Effect of the timing of dialysis initiation on left ventricular hypertrophy and ınflammation in pediatric patients.

PubMed

Bakkaloğlu, Sevcan A; Kandur, Yaşar; Serdaroğlu, Erkin; Noyan, Aytül; Bayazıt, Aysun Karabay; Sever, Lale; Özlü, Sare Gülfem; Özçelik, Gül; Dursun, İsmail; Alparslan, Caner

2017-09-01

The optimal time for dialysis initiation in adults and children with chronic kidney disease remains unclear. The aim of this study was to evaluate the impact of dialysis timing on different outcome parameters, in particular left ventricular (LV) morphology and inflammation, in pediatric patients receiving peritoneal dialysis and hemodialysis. The medical records of pediatric dialysis patients who were followed-up in nine pediatric nephrology centers in Turkey between 2008 and 2013 were retrospectively reviewed. In addition to demographic data, we retrieved anthropometric measurements, data on dialysis treatment modalities, routine biochemical parameters, complete blood count, serum ferritin, parathormone, C-reactive protein (CRP), and albumin levels, as well as echocardiographic data and hospitalization records. The patients were divided into two groups based on their estimated glomerular filtration rate (eGFR) levels at dialysis initiation, namely, an early-start group, characterized by an eGFR of >10 ml/min/1.73 m 2 , and a late-start group, with an eGFR of < 7 ml/min/1.73 m 2 . The collected data were compared between these groups. A total of 245 pediatric dialysis patients (mean age ± standard deviation 12.3 ± 5.1 years, range 0.5-21 years) were enrolled in this study. Echocardiographic data were available for 137 patients, and the mean LV mass index (LVMI) was 58 ± 31 (range 21-215) g/m 2.7 . The LVMI was 75 ± 30 g/m 2.7 (n = 81) and 34 ± 6 g/m 2.7 (n = 56) in patients with or without LV hypertrophy (LVH) (p < 0.001). Early-start (eGFR >10 ml/min/1.73 m 2 ) versus late-start dialysis (eGFR < 7 ml/min/1.73 m 2 ) groups did not significantly differ in LVMI and LVH status (p > 0.05) nor in number of hospitalizations. Serum albumin levels were significantly higher in the early-dialysis group compared with the late-dialysis group (3.3 ± 0.7 vs. 3.1 ± 0.7 g/dl, respectively; p < 0.05). The early-start group had relatively

Myths in peritoneal dialysis.

PubMed

Lee, Martin B; Bargman, Joanne M

2016-11-01

To clarify misconceptions about the feasibility and risks of peritoneal dialysis that unnecessarily limit peritoneal dialysis uptake or continuation in patients for whom peritoneal dialysis is the preferred dialysis modality. The inappropriate choice of haemodialysis as a result of these misconceptions contributes to low peritoneal dialysis penetrance, increases transfer from peritoneal dialysis to haemodialysis, increases expenditure on haemodialysis and compromises quality of life for these patients. Peritoneal dialysis is an excellent renal replacement modality that is simple, cost-effective and provides comparable clinical outcomes to conventional in-centre haemodialysis. Unfortunately, many patients are deemed unsuitable to start or continue peritoneal dialysis because of false or inaccurate beliefs about peritoneal dialysis. Here, we examine some of these 'myths' and critically review the evidence for and against each of them. We review the feasibility and risk of peritoneal dialysis in patients with prior surgery, ostomies, obesity and mesh hernia repairs. We examine the fear of mediastinitis with peritoneal dialysis after coronary artery bypass graft surgery and the belief that the use of hypertonic glucose dialysate causes peritoneal membrane failure. By clarifying common myths about peritoneal dialysis, we hope to reduce overly cautious practices surrounding this therapy.

Mortality after Renal Allograft Failure and Return to Dialysis.

PubMed

Brar, Amarpali; Markell, Mariana; Stefanov, Dimitre G; Timpo, Edem; Jindal, Rahul M; Nee, Robert; Sumrani, Nabil; John, Devon; Tedla, Fasika; Salifu, Moro O

2017-01-01

The outcomes of patients who fail their kidney transplant and return to dialysis (RTD) has not been investigated in a nationally representative sample. We hypothesized that variations in management of transplant chronic kidney disease stage 5 leading to kidney allograft failure (KAF) and RTD, such as access, nutrition, timing of dialysis, and anemia management predict long-term survival. We used an incident cohort of patients from the United States Renal Data System who initiated hemodialysis between January 1, 2003 and December 31, 2008, after KAF. We used Cox regression analysis for statistical associations, with mortality as the primary outcome. We identified 5,077 RTD patients and followed them for a mean of 30.9 ± 22.6 months. Adjusting for all possible confounders at the time of RTD, the adjusted hazards ratio (AHR) for death was increased with lack of arteriovenous fistula at initiation of dialysis (AHR 1.22, 95% CI 1.02-1.46, p = 0.03), albumin <3.5 g/dL (AHR 1.33, 95% CI 1.18-1.49, p = 0.0001), and being underweight (AHR 1.30, 95% CI 1.07-1.58, p = 0.006). Hemoglobin <10 g/dL (AHR 0.96, 95% CI 0.86-1.06, p = 0.46), type of insurance, and zip code-based median household income were not associated with higher mortality. Glomerular filtration rate <10 mL/min/1.73 m2 at time of dialysis initiation (AHR 0.83, 95% CI 0.75-0.93, p = 0.001) was associated with reduction in mortality. Excess mortality risk observed in patients starting dialysis after KAF is multifactorial, including nutritional issues and vascular access. Adequate preparation of patients with failing kidney transplants prior to resuming dialysis may improve outcomes. © 2017 S. Karger AG, Basel.

Taking hospital treatments home: a mixed methods case study looking at the barriers and success factors for home dialysis treatment and the influence of a target on uptake rates.

PubMed

Combes, Gill; Allen, Kerry; Sein, Kim; Girling, Alan; Lilford, Richard

2015-10-27

Despite healthcare policies and evidence which promote home dialysis, uptake rates have been falling for over 10 years in England. A target introduced by commissioners in the West Midlands provided a unique opportunity to study how hospitals can increase home-based treatment for a group of patients with complex life-threatening conditions. Quantitative changes in home treatment uptake rates in seven hospitals in the West Midlands were compared with the rest of England for 3 years pre and post the introduction of the target in 2010, using a logistic regression model. Qualitative interviews in four hospitals with 96 clinical and managerial staff and 93 dialysis patients explored the barriers and facilitators to increasing the uptake of home treatment and the impact of the target. Home treatment uptake rates increased significantly in the seven study hospitals compared with the 3 years prior to the introduction of the target and compared with the rest of England where rates remained static. The four main factors facilitating increased uptake were as follows: the commissioner's target, linked to financial penalties; additional funding for specialist staff and equipment; committed, visible clinical champions and good systems for patient training and ongoing healthcare support at home. The three main barriers were as follows: lack of training for non-specialist staff, poorly developed patient education and considerable unrecognised and unmet emotional and psychological patient needs. This study shows the impact of using targets with financial penalties to achieve change and how hospitals can increase significantly the uptake of home-based self-care for a group of patients with complex medical needs. It provides useful pointers to the main barriers and facilitators, which are likely to be relevant to other groups of patients who could be treated at home. It also highlights two neglected areas which need to improve if patients with life-threatening long-term conditions

A call to arms: economic barriers to optimal dialysis care.

PubMed

McFarlane, P A; Mendelssohn, D C

2000-01-01

Epidemic growth rates and the enormous cost of dialysis pressure end-stage renal disease (ESRD) delivery systems around the world. Payers of dialysis services can constrain costs through (1) limiting access to dialysis, (2) reducing the quality of dialysis, and (3) placing constraints on modality distribution. In order to secure the necessary resources for ESRD care, we propose that the nephrology community consider the following suggestions: First, future leaders in dialysis should acquire additional advanced training in innovative pathways such as health care economics, business and health care administration, and health care policy. Second, the international nephrology community must strongly engage in ongoing advocacy for accessible, high quality, cost-effective care.Third, efforts should be made to better define and then implement optimal dialysis modality distributions that maximize patient outcomes but limit unnecessary costs. Fourth, industry should be encouraged to lower the unit cost of dialysis, allowing for improved access to dialysis, especially in developing countries. Fifth, research should be encouraged that seeks to identify measures that will reduce dialysis costs but will not impair quality of care. Finally, early referral of patients with progressive renal disease to nephrology clinics, empowerment of informed patient choice of dialysis modality, and proper and timely access creation should be encouraged and can be expected to help limit overall expenditures. Ongoing efforts in these areas by the nephrology community will be essential if we are to overcome the challenges of ESRD growth in this new decade.

Comparative Effectiveness of Renin-Angiotensin System Antagonists in Maintenance Dialysis Patients

PubMed Central

Shireman, Theresa I.; Mahnken, Jonathan D.; Phadnis, Milind A.; Ellerbeck, Edward F.; Wetmore, James B.

2017-01-01

Background/Aims Whether angiotensin converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) are differentially associated with reductions in cardiovascular events and mortality in patients receiving maintenance dialysis is uncertain. We compared outcomes between ACE and ARB users among hypertensive, maintenance dialysis patients. Methods National retrospective cohort study of hypertensive, Medicare-Medicaid eligible patients initiating chronic dialysis between 1/1/2000 to 12/31/2005. The exposure of interest was new use of either an ACEI or ARB. Outcomes were all-cause mortality (ACM) and combined cardiovascular hospitalization or death (CV-endpoint). Cox proportion hazards models were used to compare the effect of ACEI vs ARB use on ACM and, separately, CV-endpoint. Results ACM models were based on 3,555 ACEI and 1,442 ARB new users, while CV-endpoint models included 3,289 ACEI and 1,346 ARB new users. After statistical adjustments, ACEI users had higher hazard ratios for ACM (AHR = 1.22, 99% CI 1.05–1.42) and CV-endpoint (AHR = 1.12, 99% CI 0.99–1.27). Conclusions Patients initiating maintenance dialysis who received an ACEI faced an increased risk for mortality and a trend towards an increased risk for CV-endpoints when compared to patients who received an ARB. Validation of these results in a rigorous clinical trial is warranted. PMID:27871075

Comparative Effectiveness of Renin-Angiotensin System Antagonists in Maintenance Dialysis Patients.

PubMed

Shireman, Theresa I; Mahnken, Jonathan D; Phadnis, Milind A; Ellerbeck, Edward F; Wetmore, James B

2016-01-01

Whether angiotensin converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) are differentially associated with reductions in cardiovascular events and mortality in patients receiving maintenance dialysis is uncertain. We compared outcomes between ACE and ARB users among hypertensive, maintenance dialysis patients. National retrospective cohort study of hypertensive, Medicare-Medicaid eligible patients initiating chronic dialysis between 1/1/2000 to 12/31/2005. The exposure of interest was new use of either an ACEI or ARB. Outcomes were all-cause mortality (ACM) and combined cardiovascular hospitalization or death (CV-endpoint). Cox proportion hazards models were used to compare the effect of ACEI vs ARB use on ACM and, separately, CV-endpoint. ACM models were based on 3,555 ACEI and 1,442 ARB new users, while CV-endpoint models included 3,289 ACEI and 1,346 ARB new users. After statistical adjustments, ACEI users had higher hazard ratios for ACM (AHR = 1.22, 99% CI 1.05-1.42) and CV-endpoint (AHR = 1.12, 99% CI 0.99-1.27). Patients initiating maintenance dialysis who received an ACEI faced an increased risk for mortality and a trend towards an increased risk for CV-endpoints when compared to patients who received an ARB. Validation of these results in a rigorous clinical trial is warranted. © 2016 The Author(s) Published by S. Karger AG, Basel.

Mobility decline in patients hospitalized in an intensive care unit

PubMed Central

de Jesus, Fábio Santos; Paim, Daniel de Macedo; Brito, Juliana de Oliveira; Barros, Idiel de Araujo; Nogueira, Thiago Barbosa; Martinez, Bruno Prata; Pires, Thiago Queiroz

2016-01-01

Objective To evaluate the variation in mobility during hospitalization in an intensive care unit and its association with hospital mortality. Methods This prospective study was conducted in an intensive care unit. The inclusion criteria included patients admitted with an independence score of ≥ 4 for both bed-chair transfer and locomotion, with the score based on the Functional Independence Measure. Patients with cardiac arrest and/or those who died during hospitalization were excluded. To measure the loss of mobility, the value obtained at discharge was calculated and subtracted from the value obtained on admission, which was then divided by the admission score and recorded as a percentage. Results The comparison of these two variables indicated that the loss of mobility during hospitalization was 14.3% (p < 0.001). Loss of mobility was greater in patients hospitalized for more than 48 hours in the intensive care unit (p < 0.02) and in patients who used vasopressor drugs (p = 0.041). However, the comparison between subjects aged 60 years or older and those younger than 60 years indicated no significant differences in the loss of mobility (p = 0.332), reason for hospitalization (p = 0.265), SAPS 3 score (p = 0.224), use of mechanical ventilation (p = 0.117), or hospital mortality (p = 0.063). Conclusion There was loss of mobility during hospitalization in the intensive care unit. This loss was greater in patients who were hospitalized for more than 48 hours and in those who used vasopressors; however, the causal and prognostic factors associated with this decline need to be elucidated. PMID:27410406

A prospective echocardiographic evaluation of pulmonary hypertension in chronic hemodialysis patients in the United States: prevalence and clinical significance.

PubMed

Ramasubbu, Kumudha; Deswal, Anita; Herdejurgen, Cheryl; Aguilar, David; Frost, Adaani E

2010-10-05

Pulmonary hypertension (PH), a disease which carries substantial morbidity and mortality, has been reported to occur in 25%-45% of dialysis patients. No prospective evaluation of the prevalence or clinical significance of PH in chronic dialysis patients in the United States (US) has been undertaken. Echocardiograms were performed prospectively in chronic hemodialysis patients prior to dialysis at a single dialysis center. PH was defined as a tricuspid regurgitant jet ≥2.5 m/s and "more severe PH" as ≥3.0 m/s. Clinical outcomes recovered were all-cause hospitalizations and death at 12 months. In a cohort of 90 patients, 42 patients (47%) met the definition of PH. Of those, 18 patients (20%) met the definition of more severe PH. At 12 months, mortality was significantly higher in patients with PH (26%) compared with patients without PH (6%). All-cause hospitalizations were similar in patients with PH and without PH. Echocardiographic findings suggesting impaired left ventricular function and elevated pulmonary capillary wedge pressure were significantly associated with PH. This prospective cross-sectional study of a single dialysis unit suggests that PH may be present in nearly half of US dialysis patients and when present is associated with increased mortality. Echocardiographic findings demonstrate an association between elevated filling pressures, elevated pulmonary artery pressures, and higher mortality, suggesting that the PH may be secondary to diastolic dysfunction and compounded by volume overload.

A prospective echocardiographic evaluation of pulmonary hypertension in chronic hemodialysis patients in the United States: prevalence and clinical significance

PubMed Central

Ramasubbu, Kumudha; Deswal, Anita; Herdejurgen, Cheryl; Aguilar, David; Frost, Adaani E

2010-01-01

Background Pulmonary hypertension (PH), a disease which carries substantial morbidity and mortality, has been reported to occur in 25%–45% of dialysis patients. No prospective evaluation of the prevalence or clinical significance of PH in chronic dialysis patients in the United States (US) has been undertaken. Methods Echocardiograms were performed prospectively in chronic hemodialysis patients prior to dialysis at a single dialysis center. PH was defined as a tricuspid regurgitant jet ≥2.5 m/s and “more severe PH” as ≥3.0 m/s. Clinical outcomes recovered were all-cause hospitalizations and death at 12 months. Results In a cohort of 90 patients, 42 patients (47%) met the definition of PH. Of those, 18 patients (20%) met the definition of more severe PH. At 12 months, mortality was significantly higher in patients with PH (26%) compared with patients without PH (6%). All-cause hospitalizations were similar in patients with PH and without PH. Echocardiographic findings suggesting impaired left ventricular function and elevated pulmonary capillary wedge pressure were significantly associated with PH. Conclusion This prospective cross-sectional study of a single dialysis unit suggests that PH may be present in nearly half of US dialysis patients and when present is associated with increased mortality. Echocardiographic findings demonstrate an association between elevated filling pressures, elevated pulmonary artery pressures, and higher mortality, suggesting that the PH may be secondary to diastolic dysfunction and compounded by volume overload. PMID:21042428

Risk factors of workplace violence at hospitals in Japan.

PubMed

Fujita, Shigeru; Ito, Shinya; Seto, Kanako; Kitazawa, Takefumi; Matsumoto, Kunichika; Hasegawa, Tomonori

2012-02-01

Patients and their relatives exposed to mental stress caused by hospitalization or illness might use violence against healthcare staff and interfere with quality healthcare. The aim of this study was to investigate incidences of workplace violence and the attributes of healthcare staff who are at high risk. A questionnaire-based, anonymous, and self-administered cross-sectional survey. Healthcare staff (n = 11,095) of 19 hospitals in Japan. Incidence rates and adjusted odd ratios of workplace violence were calculated to examine the effect of attributes of healthcare staff to workplace violence by using logistic regression analysis. The response rate for survey completion was 79.1% (8711/11,095). Among the respondents, 36.4% experienced workplace violence by patients or their relatives in the past year; 15.9% experienced physical aggression, 29.8% experienced verbal abuse, and 9.9% experienced sexual harassment. Adjusted odds ratios of physical aggression were significantly high in psychiatric wards, critical care centers/intensive care units (ICU)/cardiac care units (CCU), long-term care wards, for nurses, nursing aides/care workers, and for longer working hours. Adjusted odds ratios of verbal abuse were significantly high in psychiatric wards, long-term care wards, outpatient departments, dialysis departments, and for longer years of work experience, and for longer working hours. Adjusted odds ratios of sexual harassment were significantly high in dialysis departments, for nurses, nursing aides/care workers, technicians, therapists and females. The general ward and direct interaction with patients were common risk factors for each type of workplace violence. The mechanisms and the countermeasures for each type of workplace violence at those high-risk areas should be investigated. Copyright © 2011 Society of Hospital Medicine.

The economic considerations of patients and caregivers in choice of dialysis modality

PubMed Central

Howard, Kirsten; Tong, Allison; Palmer, Suetonia C.; Marshall, Mark R.; Morton, Rachael L.

2016-01-01

Abstract Introduction Broader adoption of home dialysis could lead to considerable cost savings for health services. Globally, however, uptake remains low. The aim of this study was to describe patient and caregiver perspectives of the economic considerations that influence dialysis modality choice, and elicit policy‐relevant recommendations. Methods Semistructured interviews with predialysis or dialysis patients and their caregivers, at three hospitals in New Zealand. Interview transcripts were analyzed thematically. Findings 43 patients and 9 caregivers (total n = 52) participated. The three themes related to economic considerations were: (i) productivity losses associated with changes in employment; (ii) the need for personal subsidization of home dialysis expenses; and (iii) the role of socio‐economic disadvantage as a barrier to home dialysis. Patients weighed the flexibility of home dialysis which allowed them to remain employed, against time required for training and out‐of‐pocket costs. Patients saw the lack of reimbursement of home dialysis costs as unjust and suggested that reimbursement would incentivize home dialysis uptake. Social disadvantage was a barrier to home dialysis as patients’ housing was often unsuitable; they could not afford the additional treatment costs. Home hemodialysis was considered to have the highest out‐of‐pocket costs and was sometimes avoided for this reason. Discussion Our data suggests that economic considerations underpin the choices patients make about dialysis treatments, however these are rarely reported. To promote home dialysis, strategies to improve employment retention and housing, and to minimize out‐of‐pocket costs, need to be addressed directly by healthcare providers and payers. PMID:27196634

Associations of employment status and educational levels with mortality and hospitalization in the dialysis outcomes and practice patterns study in Japan.

PubMed

Imanishi, Yasuo; Fukuma, Shingo; Karaboyas, Angelo; Robinson, Bruce M; Pisoni, Ronald L; Nomura, Takanobu; Akiba, Takashi; Akizawa, Tadao; Kurokawa, Kiyoshi; Saito, Akira; Fukuhara, Shunichi; Inaba, Masaaki

2017-01-01

Socioeconomic status (SES) factors such as employment, educational attainment, income, and marital status can affect the health and well-being of the general population and have been associated with the prevalence of chronic kidney disease (CKD). However, no studies to date in Japan have reported on the prognosis of patients with CKD with respect to SES. This study aimed to investigate the influences of employment and education level on mortality and hospitalization among maintenance hemodialysis (HD) patients in Japan. Data on 7974 HD patients enrolled in Dialysis Outcomes and Practice Patterns Study phases 1-4 (1999-2011) in Japan were analysed. Employment status, education level, demographic data, and comorbidities were abstracted at entry into DOPPS from patient records. Mortality and hospitalization events were collected during follow-up. Patients on dialysis < 120 days at study entry were excluded from the analyses. Cox regression modelled the association between employment and both mortality and hospitalization among patients < 60 years old. The association between education and outcomes was also assessed. The association between patient characteristics and employment among patients < 60 years old was assessed using logistic regression. During a median follow-up of 24.9 months (interquartile range, 18.4-32.0), 10% of patients died and 43% of patients had an inpatient hospitalization. Unemployment was associated with mortality (hazard ratio [HR] = 1.57; 95% confidence interval [CI]: 1.05-2.36) and hospitalization (HR = 1.25; 95% CI: 1.08-1.44). Compared to patients who graduated from university, patients with less than a high school (HS) education and patients who graduated HS with some college tended to have elevated mortality (HR = 1.41; 95% CI, 1.04-1.92 and HR = 1.36; 95% CI: 1.02-1.82, respectively) but were not at risk for increased hospitalizations. Factors associated with unemployment included lower level of education, older age, female gender, longer

Comparison of three chronic dialysis models.

PubMed

Peng, W X; Guo, Q Y; Liu, S M; Liu, C Z; Lindholm, B; Wang, T

2000-01-01

The chronic peritoneal dialysis model is important for understanding the pathophysiology of peritoneal transport and for studying biocompatibility of peritoneal dialysis solutions. In this study, we compared three different chronic peritoneal dialysis models. A peritoneal catheter was placed in 23 male Sprague-Dawley rats, 12 of which had an intact omentum (model 1) and 11 of which received an omentectomy (model 2). Seven other rats, without a catheter, received a daily intraperitoneal injection (model 3). Each rat received a daily infusion of 25 mL of 3.86% glucose dialysis solution either through the catheter (models 1 and 2) or through injection (model 3) for 4 weeks. Then, a 4-hour dwell study using 3.86% glucose solution with an intraperitoneal volume marker and frequent dialysate and blood sampling was performed in each rat. The intraperitoneal volume was significantly lower in all the dialysis groups as compared to a control group (n = 6) in which the rats had no chronic dialysate exposure. The peritoneal fluid absorption rate, as well as the direct lymphatic absorption rate, was significantly higher in the three dialysis groups as compared to the control group. In general, no significant differences were seen in any of the parameters among the three dialysis models. Owing to catheter obstruction, three rats in model 1 and four rats in model 2 were lost during dialysis. Histological examination showed no significant differences among the three dialysis groups. Our results suggest that omentectomy may not be necessary in the chronic peritoneal dialysis model when using dialysate infusion and no drainage. Based on the present study, we think that perhaps model 1 may be the method of choice to test new peritoneal dialysis solutions. However, owing to its simplicity, model 3 could also be used if great care is taken to avoid puncturing the intestine or injecting into the abdominal wall.

Psychosocial adjustment and adherence to dialysis treatment regimes.

PubMed

Brownbridge, G; Fielding, D M

1994-12-01

Sixty children and adolescents in end-stage renal failure who were undergoing either haemodialysis or continuous ambulatory peritoneal dialysis at one of five United Kingdom dialysis centres were assessed on psychosocial adjustment and adherence to their fluid intake, diet and medication regimes. Parental adjustment was also measured and data on sociodemographic and treatment history variables collected. A structured family interview and standardised questionnaire measures of anxiety, depression and behavioural disturbance were used. Multiple measures of treatment adherence were obtained, utilising children's and parents' self-reports, weight gain between dialysis, blood pressure, serum potassium level, blood urea level, dietitians' surveys and consultants' ratings. Correlational analyses showed that low treatment adherence was associated with poor adjustment to diagnosis and dialysis by children and parents (P < 0.01), self-ratings of anxiety and depression in children and parents (P < 0.001), age (adolescents tended to show poorer adherence than younger children, P < 0.001), duration of dialysis (P < 0.05), low family socioeconomic status (P < 0.05) and family structure (P < 0.01). These findings demonstrate the importance of psychosocial care in the treatment of this group of children. Future research should develop and evaluate psychosocial interventions aimed at improving treatment adherence.

Effect of costing methods on unit cost of hospital medical services.

PubMed

Riewpaiboon, Arthorn; Malaroje, Saranya; Kongsawatt, Sukalaya

2007-04-01

To explore the variance of unit costs of hospital medical services due to different costing methods employed in the analysis. Retrospective and descriptive study at Kaengkhoi District Hospital, Saraburi Province, Thailand, in the fiscal year 2002. The process started with a calculation of unit costs of medical services as a base case. After that, the unit costs were re-calculated based on various methods. Finally, the variations of the results obtained from various methods and the base case were computed and compared. The total annualized capital cost of buildings and capital items calculated by the accounting-based approach (averaging the capital purchase prices throughout their useful life) was 13.02% lower than that calculated by the economic-based approach (combination of depreciation cost and interest on undepreciated portion over the useful life). A change of discount rate from 3% to 6% results in a 4.76% increase of the hospital's total annualized capital cost. When the useful life of durable goods was changed from 5 to 10 years, the total annualized capital cost of the hospital decreased by 17.28% from that of the base case. Regarding alternative criteria of indirect cost allocation, unit cost of medical services changed by a range of -6.99% to +4.05%. We explored the effect on unit cost of medical services in one department. Various costing methods, including departmental allocation methods, ranged between -85% and +32% against those of the base case. Based on the variation analysis, the economic-based approach was suitable for capital cost calculation. For the useful life of capital items, appropriate duration should be studied and standardized. Regarding allocation criteria, single-output criteria might be more efficient than the combined-output and complicated ones. For the departmental allocation methods, micro-costing method was the most suitable method at the time of study. These different costing methods should be standardized and developed as

Increasing hip fractures in patients receiving hemodialysis and peritoneal dialysis.

PubMed

Mathew, Anna T; Hazzan, Azzour; Jhaveri, Kenar D; Block, Geoffrey A; Chidella, Shailaja; Rosen, Lisa; Wagner, John; Fishbane, Steve

2014-01-01

Dialysis patients are at increased risk for hip fractures. Because changes in treatment of metabolic bone disease in this population may have impacted bone fragility, this study aims to analyze the longitudinal risk for fractures in hemodialysis (HD) and peritoneal dialysis (PD) patients. Using the United States Renal Data System database from 1992 to 2009, the temporal trend in hip fractures requiring hospitalization was analyzed using an overdispersed Poisson regression model. Generalized Estimating Equations were used to assess the adjusted effect of dialysis modality on hip fractures. 842,028 HD and 87,086 PD patients were included. There was a significant temporal increase in hip fractures in both HD and PD with stabilization of rates after 2005. With stratification, the increase in fractures occurred in patients who were white and over 65 years of age. In adjusted analyses, HD patients had 1.6 times greater odds of hip fracture than PD patients (OR 1.60 95% CI 1.52, 1.68, p < 0.001). In contrast to the declining hip fracture rates in the general population, we identified a temporal rise in incidence of hip fractures in HD and PD patients. HD patients were at a higher risk for hip fractures than PD patients after adjustment for recognized bone fragility risk factors. The increase in fracture rate over time was limited to older white patients in both HD and PD, the demographics being consistent with osteoporosis risk. Further research is indicated to better understand the longitudinal trend in hip fractures and the discordance between HD and PD. © 2014 S. Karger AG, Basel.

Cost comparison of peritoneal dialysis versus hemodialysis in end-stage renal disease.

PubMed

Berger, Ariel; Edelsberg, John; Inglese, Gary W; Bhattacharyya, Samir K; Oster, Gerry

2009-08-01

To compare healthcare utilization and costs in patients with end-stage renal disease (ESRD) beginning peritoneal dialysis (PD) or hemodialysis (HD). Retrospective cohort study. Using a US health insurance database, we identified all patients with ESRD who began dialysis between January 1, 2004, and December 31, 2006. Patients were designated as PD patients or as HD patients based on first-noted treatment. Patients with less than 6 months of pretreatment data and those with less than 12 months of data following initiation of dialysis ("pretreatment" and "follow-up," respectively) were dropped from the study sample. The PD patients were matched to HD patients using propensity scoring to control for differences in pretreatment characteristics. Healthcare utilization and costs were then compared over 12 months between propensity-matched PD patients and HD patients using paired t tests and Wilcoxon signed rank tests for continuous variables and using Bowker and McNemar tests for categorical variables, as appropriate. A total of 463 patients met all study entrance criteria; 56 (12%) began treatment with PD, and 407 (88%) began treatment with HD. Fifty PD patients could be propensity matched to an equal number of HD patients. The HD patients were more than twice as likely as matched PD patients to be hospitalized over the subsequent 12 months (hazard ratio, 2.17; 95% confidence interval, 1.34-3.51; P <.01). Their median healthcare costs over the 12-month follow-up period were $43,510 higher ($173,507 vs $129,997 for PD patients, P = .03). Among patients with ESRD, PD patients are less likely than HD patients to be hospitalized in the year following initiation of dialysis. They also have significantly lower total healthcare costs.

Unit cost of healthcare services at 200-bed public hospitals in Myanmar: what plays an important role of hospital budgeting?

PubMed

Than, Thet Mon; Saw, Yu Mon; Khaing, Moe; Win, Ei Mon; Cho, Su Myat; Kariya, Tetsuyoshi; Yamamoto, Eiko; Hamajima, Nobuyuki

2017-09-19

Cost information is important for efficient allocation of healthcare expenditure, estimating future budget allocation, and setting user fees to start new financing systems. Myanmar is in political transition, and trying to achieve universal health coverage by 2030. This study assessed the unit cost of healthcare services at two public hospitals in the country from the provider perspective. The study also analyzed the cost structure of the hospitals to allocate and manage the budgets appropriately. A hospital-based cross-sectional study was conducted at 200-bed Magway Teaching Hospital (MTH) and Pyinmanar General Hospital (PMN GH), in Myanmar, for the financial year 2015-2016. The step-down costing method was applied to calculate unit cost per inpatient day and per outpatient visit. The costs were calculated by using Microsoft Excel 2010. The unit costs per inpatient day varied largely from unit to unit in both hospitals. At PMN GH, unit cost per inpatient day was 28,374 Kyats (27.60 USD) for pediatric unit and 1,961,806 Kyats (1908.37 USD) for ear, nose, and throat unit. At MTH, the unit costs per inpatient day were 19,704 Kyats (19.17 USD) for medicine unit and 168,835 Kyats (164.24 USD) for eye unit. The unit cost of outpatient visit was 14,882 Kyats (14.48 USD) at PMN GH, while 23,059 Kyats (22.43 USD) at MTH. Regarding cost structure, medicines and medical supplies was the largest component at MTH, and the equipment was the largest component at PMN GH. The surgery unit of MTH and the eye unit of PMN GH consumed most of the total cost of the hospitals. The unit costs were influenced by the utilization of hospital services by the patients, the efficiency of available resources, type of medical services provided, and medical practice of the physicians. The cost structures variation was also found between MTH and PMN GH. The findings provided the basic information regarding the healthcare cost of public hospitals which can apply the efficient utilization of the

Paying the Hospital: Foreign Lessons For the United States

PubMed Central

Glaser, William A.

1983-01-01

This special report synthesizes the findings of a Health Care Financing Administration grant which allowed the author to analyze hospital finance in six foreign countries and in the United States. The author identified the principal problems facing hospital owners, carriers, and governments in the United States, and he conducted lengthy field work abroad to learn how each country dealt with the same problems. One set of the author's conclusions makes more clear issues that are debated in the United States, such as the meaning of “cost-based reimbursement” and “prospective reimbursement”. Some of the author's findings show the difficulty of implementing policies often proposed in the United States, such as incentive reimbursement schemes. Other findings of the author show the conditions necessary for cost containment, such as strong representation of consumers and firm political will by government. PMID:10310003

Preparing emergency personnel in dialysis: a just-in-time training program for additional staffing during disasters.

PubMed

Stoler, Genevieve B; Johnston, James R; Stevenson, Judy A; Suyama, Joe

2013-06-01

There are 341 000 patients in the United States who are dependent on routine dialysis for survival. Recent large-scale disasters have emphasized the importance of disaster preparedness, including supporting dialysis units, for people with chronic disease. Contingency plans for staffing are important for providing continuity of care for a technically challenging procedure such as dialysis. PReparing Emergency Personnel in Dialysis (PREP-D) is a just-in-time training program designed to train individuals having minimum familiarity with the basic steps of dialysis to support routine dialysis staff during a disaster. A 5-module educational program was developed through a collaborative, multidisciplinary effort. A pilot study testing the program was performed using 20 nontechnician dialysis facility employees and 20 clinical-year medical students as subjects. When comparing pretest and posttest scores, the entire study population showed a mean improvement of 28.9%, with dialysis facility employees and medical students showing improvements of 21.8% and 36.4%, respectively (P < .05 for all comparisons). PREP-D participants were able to demonstrate improved tests scores when taught in a just-in-time training format. The knowledge gained by using the PREP-D program during a staffing shortage may allow for continuity of care for critical services such as dialysis during a disaster.

The cost of caring for end-stage kidney disease patients: an analysis based on hospital financial transaction records.

PubMed

Bruns, F J; Seddon, P; Saul, M; Zeidel, M L

1998-05-01

The costs of care for end-stage renal disease patients continue to rise because of increased numbers of patients. Efforts to contain these costs have focused on the development of capitated payment schemes, in which all costs for the care of these patients are covered in a single payment. To determine the effect of a capitated reimbursement scheme on care of dialysis patients (both hemodialysis [HD] and peritoneal dialysis [PD]), complete financial records (all reimbursements for inpatient and outpatient care, as well as physician collections) of dialysis patients at a single medical center over 1 year were analyzed. For the period from July 1994 to July 1995, annualized cost per dialysis patient-year averaged $63,340, or 9.8% higher than the corrected estimate from the U.S. Renal Data Service (USRDS; $57,660). The "most expensive" 25% of patients engendered 44 to 48% of the total costs, and inpatient costs accounted for 37 to 40% of total costs. Nearly half of the inpatient costs resulted from only two categories (room charges and inpatient dialysis), whereas other categories each made up a small fraction of the inpatient costs. PD patients were far less expensive to care for than HD patients, due to reduced hospital days and lower cost of outpatient dialysis. Care for a university-based dialysis population was only slightly more expensive than estimates predicted from the USRDS. These results validate the USRDS spending data and suggest that they can be used effectively for setting capitated rates. Efforts to control costs without sacrificing quality of care must center on reducing inpatient costs, particularly room charges and the cost of inpatient dialysis.

Home dialysis in the new USA bundled payment plan: implications and impact.

PubMed

Golper, Thomas A; Guest, Steven; Glickman, Joel D; Turk, Joe; Pulliam, Joseph P

2011-01-01

On 1 January 2011, a new payment system for Medicare patients will be implemented in the United States. This new system bundles services previously charged separately and under a "fee for service" environment. The authors discuss the implications of this approach. Over the next several pages is a response by American physicians and dialysis innovators to a federal initiative to change the way dialysis is paid for in the United States. Peter Blake, the Editor-in-Chief of Peritoneal Dialysis International, invited Thomas Golper to articulate physicians' concerns with this new payment scheme. After the government of the USA closed its comment period over the new payment methodology, called "bundling," Golper sought out colleagues from diverse backgrounds and compiled this collective view of the situation.

Adequacy in dialysis: intermittent versus continuous therapies.

PubMed

Misra, M; Nolph, K D

2000-01-01

A vital conceptual difference between intermittent and continuous dialysis therapies is the difference in the relationship between Kt/V urea and dietary protein intake. For a given level of protein intake the intermittent therapies require a higher Kt/V urea due to the reasons mentioned above. The recently released adequacy guidelines by DOQI for intermittent and continuous therapies are based on these assumptions. The link between adequacy targets and patient survival is well documented for an intermittent therapy like HD. For a continuous therapy like CAPD however, the evidence linking improved peritoneal clearance to better survival is not as direct. However, present consensus allows one to extrapolate results based on HD. The concept of earlier and healthier initiation of dialysis is gaining hold and incremental dialysis forms an integral aspect of the whole concept. Tools like urea kinetic modeling give us valuable insight in making mathematical projections about the timing as well as dosing of dialysis. Daily home hemodialysis is still an underutilized modality despite offering best survival figures. Hopefully, with increasing availability of better and simpler machines its use will increase. Still several questions remain unanswered. Despite availability of data in hemodialysis patients suggesting that an increased dialysis prescription leads to a better survival, optimal dialysis dose is yet to be defined. Concerns regarding methodology of such studies and conclusions thereof has been raised. Other issues relating to design of the studies, variation in dialysis delivery, use of uncontrolled historical standards and lack of patient randomization etc also need to be considered when designing such trials. Hopefully an ongoing prospective randomized trial, namely the HEMO study, looking at two precisely defined and carefully maintained dialysis prescriptions will provide some insight into adequacy of dialysis dose and survival. In diabetic patients, the

High rates of death and hospitalization follow bone fracture among hemodialysis patients

PubMed Central

Tentori, Francesca; McCullough, Keith; Kilpatrick, Ryan D.; Bradbury, Brian D.; Robinson, Bruce M.; Kerr, Peter G.; Pisoni, Ronald L.

2013-01-01

Altered bone structure and function contribute to the high rates of fractures in dialysis patients compared to the general population. Fracture events may increase the risk of subsequent adverse clinical outcomes. Here we assessed incidence of post-fracture morbidity and mortality in an international cohort of 34, 579 in-center hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). We estimated country-specific rates of fractures requiring a hospital admission and associated length of stay in the hospital. Incidence rates of death and of a composite event of death/re-hospitalization were estimated for the 1-year post-fracture. Overall, 3% of participants experienced a fracture. Fracture incidence varied across countries, from 12 events/1000 patient year (p-y) in Japan to 45/1000 p-y in Belgium. In all countries, fracture rates were higher in the hemodialysis group compared to those reported for the general population. Median length of stay ranged from 7 to 37 days in the United States and Japan, respectively. In most countries, post-fracture mortality rates exceeded 500/1000 p-y and death/re-hospitalization rates exceeded 1500/1000 p-y. Fracture patients had higher unadjusted rates of death (3.7- fold) and death/re-hospitalization (4.0-fold) compared to the overall DOPPS population. Mortality and hospitalization rates were highest in the first month after the fracture and declined thereafter. Thus, the high frequency of fractures and increased adverse outcomes following a fracture pose a significant health burden for dialysis patients. Fracture prevention strategies should be identified and applied broadly in nephrology practices. PMID:23903367

Knowledge, understanding and experiences of peritonitis amongst patients, and their families, undertaking peritoneal dialysis: A mixed methods study protocol.

PubMed

Baillie, Jessica; Gill, Paul; Courtenay, Molly

2018-01-01

This article is a report of a study protocol designed to examine patients' and families' knowledge and experiences of peritoneal dialysis-associated peritonitis. Peritonitis is a considerable problem for people using peritoneal dialysis, leading to antibiotics, hospitalization and decreased quality of life. For some patients, peritonitis requires changing renal replacement therapy and can be fatal. Peritonitis is distressing and some patients are unfamiliar with the signs and symptoms. Patients with better knowledge of peritonitis and adherence to peritoneal dialysis procedures have lower rates of peritonitis. Little is known about patients' and families' knowledge and experience of peritoneal dialysis-associated peritonitis in the United Kingdom. Ethical approval was gained in March 2017. To meet the study aim, a two-phase sequential explanatory mixed methods study is proposed. Phase One: An author-developed questionnaire will be sent to patients using peritoneal dialysis at five sites in England and Wales. Patients will be asked to consider inviting a relative to participate. The questionnaire will assess peritonitis knowledge and experience. Data will be analysed statistically. Phase Two: Semi-structured interviews will be conducted with a purposive sample of Phase One participants (n = 30) to explore their experiences of peritonitis in further depth. The data will be analysed thematically using Wolcott's (1994) approach. Data from the two phases will be synthesized to identify patients' and families' peritonitis information needs, to ensure they are appropriately supported to prevent, monitor, identify and report peritonitis. © 2017 John Wiley & Sons Ltd.

Five years of hospital based surveillance of influenza-like illness and influenza in a short-stay geriatric unit

PubMed Central

2014-01-01

Background Data on influenza in the healthcare setting are often based on retrospective investigations of outbreaks and a few studies described influenza during several consecutive seasons. The aim of the present work is to report data on influenza like illness (ILI) and influenza from 5-year prospective surveillance in a short-stay geriatrics unit. Findings A short stay geriatrics unit underwent 5 years of ILI surveillance from November 2004 to March 2009, with the aim of describing ILI in a non-outbreak context. The study was proposed to patients who presented ILI, defined as fever >37.8°C or cough or sore throat. Among 1,353 admitted patients, 115 presented an ILI, and 34 had hospital-acquired ILI (HA-ILI). Influenza was confirmed in 23 patients, 13 of whom had been vaccinated. Overall attack rates were 2.78% and 0.02% for HA-ILI and HA-confirmed influenza respectively, during the 5 seasons. Conclusions This 5-year surveillance study supports the notion that influenza infections are common in hospitals, mostly impacting the elderly hospitalized in short-stay units. It highlights the need for appropriate control measures to prevent HA-ILI in geriatric units and protect elderly patients. PMID:24555834

Factors Associated with the Choice of Peritoneal Dialysis in Patients with End-Stage Renal Disease.

PubMed

Chiang, Pei-Chun; Hou, Jia-Jeng; Jong, Ing-Ching; Hung, Peir-Haur; Hsiao, Chih-Yen; Ma, Tsung-Liang; Hsu, Yueh-Han

2016-01-01

The purpose of this study was to analyze the factors associated with receiving peritoneal dialysis (PD) in patients with incident end-stage renal disease (ESRD) in a hospital in Southern Taiwan. The study included all consecutive patients with incident ESRD who participated in a multidisciplinary predialysis education (MPE) program and started their first dialysis therapy between January 1, 2008, and June 30, 2013, in the study hospital. We provided small group teaching sessions to advanced CKD patients and their family to enhance understanding of various dialysis modalities. Multivariate logistic regression models were used to analyze the association of patient characteristics with the chosen dialysis modality. Of the 656 patients, 524 (80%) chose hemodialysis and 132 chose PD. Our data showed that young age, high education level, and high scores of activities of daily living (ADLs) were positively associated with PD treatment. Patients who received small group teaching sessions had higher percentages of PD treatment (30.5% versus 19.5%; P = 0.108) and preparedness for dialysis (61.1% versus 46.6%; P = 0.090). Young age, high education level, and high ADL score were positively associated with choosing PD. Early creation of vascular access may be a barrier for PD.

Associations of health literacy with dialysis adherence and health resource utilization in patients receiving maintenance hemodialysis.

PubMed

Green, Jamie A; Mor, Maria K; Shields, Anne Marie; Sevick, Mary Ann; Arnold, Robert M; Palevsky, Paul M; Fine, Michael J; Weisbord, Steven D

2013-07-01

Although limited health literacy is common in hemodialysis patients, its effects on clinical outcomes are not well understood. Observational study. 260 maintenance hemodialysis patients enrolled in a randomized clinical trial of symptom management strategies from January 2009 through April 2011. Limited health literacy. Dialysis adherence (missed and abbreviated treatments) and health resource utilization (emergency department visits and end-stage renal disease [ESRD]-related hospitalizations). We assessed health literacy using the Rapid Estimate of Adult Literacy in Medicine (REALM) and used negative binomial regression to analyze the independent associations of limited health literacy with dialysis adherence and health resource utilization over 12-24 months. 41 of 260 (16%) patients showed limited health literacy (REALM score, ≤60). There were 1,152 missed treatments, 5,127 abbreviated treatments, 552 emergency department visits, and 463 ESRD-related hospitalizations. Limited health literacy was associated independently with an increased incidence of missed dialysis treatments (missed, 0.6% vs 0.3%; adjusted incidence rate ratio [IRR], 2.14; 95% CI, 1.10-4.17), emergency department visits (annual visits, 1.7 vs 1.0; adjusted IRR, 1.37; 95% CI, 1.01-1.86), and hospitalizations related to ESRD (annual hospitalizations, 0.9 vs 0.5; adjusted IRR, 1.55; 95% CI, 1.03-2.34). Generalizability and potential for residual confounding. Patients receiving maintenance hemodialysis who have limited health literacy are more likely to miss dialysis treatments, use emergency care, and be hospitalized related to their kidney disease. These findings have important clinical practice and cost implications. Copyright © 2013 National Kidney Foundation, Inc. All rights reserved.

[Crisis unit at the general hospital: Determinants of further hospitalization].

PubMed

Norotte, C; Omnès, C; Crozier, C; Verlyck, C; Romanos, M

2017-10-01

The availability of short-stay beds for brief admission (less than 72hours) of crisis patients presenting to the emergency room is a model that has gained a growing interest because it allows time for developing alternatives to psychiatric hospitalization and favors a maintained functioning in the community. Still, the determinants influencing the disposition decision at discharge after crisis intervention remain largely unexplored. The primary objective of this study was to determine the factors predicting aftercare dispositions at crisis unit discharge: transfer for further hospitalization or return to the community. Secondary objectives included the description of clinical and socio-demographic characteristics of patients admitted to the crisis unit upon presentation to the emergency room. All patients (n=255) admitted to the short-stay unit of the emergency department of Rambouillet General Hospital during a one-year period were included in the study. Patient characteristics were collected in a retrospective manner from medical records: patterns of referral, acute stressors, presenting symptoms, initial patient demand, Diagnostic and Statistical Manual, 5th edition (DSM-5) disorders, psychiatric history, and socio-demographic characteristics were inferred. Logistic regression analysis was used to determine the factors associated with hospitalization decision upon crisis intervention at discharge. Following crisis intervention at the short-stay unit, 100 patients (39.2%) required further hospitalization and were transferred. Statistically significant factors associated with a higher probability of hospitalization (P<0.05) included the patient's initial wish to be hospitalized (OR=4.28), the presence of a comorbid disorder (OR=3.43), a referral by family or friends (OR=2.89), a history of psychiatric hospitalization (OR=2.71) and suicidal ideation on arrival in the emergency room (OR=2.26). Conversely, significant factors associated with a lower probability of

The dynamic process of adherence to a renal therapeutic regimen: perspectives of patients undergoing continuous ambulatory peritoneal dialysis.

PubMed

Lam, Lai Wah; Lee, Diana T F; Shiu, Ann T Y

2014-06-01

The nature of end-stage renal disease and the need for continuous ambulatory peritoneal dialysis require patients to manage various aspects of the disease, its symptoms and treatment. After attending a training programme, patients are expected to adhere to the renal therapeutic regimen and manage their disease with the knowledge and skills learned. While patients are the stakeholders of their health and related behaviour, their perceptions of adherence and how they adhere to their renal therapeutic regimen remains unexplored. To understand adherence from patients' perspectives and to describe changes in adherence to a therapeutic regimen among patients undergoing continuous ambulatory peritoneal dialysis. This study used a mixed methods design with two phases - a survey in phase I and semi-structured interviews in phase II. This paper presents phase II of the study. The study was conducted at a renal unit of an acute hospital in Hong Kong. Based on the phase I survey results, maximum variation sampling was employed to purposively recruit 36 participants of different genders (18 males, 18 females), ages (35-76 years), and lengths of dialysis experience (11-103 months) for the phase II interviews. Data were collected by tape-recorded semi-structured interviews. Content analysis was employed to analyse the transcribed data. Data collection and analysis were conducted simultaneously. Adherence was a dynamic process with three stages. At the stage of initial adherence, participants attempted to follow instructions but found that strict persistent adherence was impossible. After the first 2-6 months of dialysis, participants entered the stage of subsequent adherence, when they adopted selective adherence through experimenting, monitoring and making continuous adjustments. The stage of long-term adherence commenced after 3-5 years of dialysis, when participants were able to assimilate the modified therapeutic regimen into everyday life. The process of adherence was

How hospitals view unit-level nurse turnover data collection: analysis of a hospital survey.

PubMed

Park, Shin Hye; Boyle, Diane K

2015-02-01

The objectives of this study were to examine the quality of unit-level nurse turnover data collection among the National Database of Nursing Quality Indicators hospitals and to identify the burdens of collecting such data. Tracking and managing nurse turnover at the unit level are critical for administrators who determine managerial strategies. Little is known about the quality of and burdens of unit-level turnover data collection. Surveys from 178 hospitals were analyzed descriptively. Most hospitals strongly agreed or agreed with the quality of unit-level turnover data collection. Hospitals identified the burdens of additional time and resources needed for unit-level turnover data collection and the difficulty of obtaining specific reasons for turnover. Collecting unit-level nurse turnover data can be important and useful for administrators to improve nurse retention, workforce stability, and quality of care. We suggest that the advantages of unit-level nurse turnover data and reports can overcome the identified burdens.

Solute clearance measurement in the assessment of dialysis adequacy among African continuous ambulatory peritoneal dialysis patients.

PubMed

Abdu, Aliyu; Naidoo, Sagren; Malgas, Shirin; Naicker, Jocelyn T; Paget, Graham; Naicker, Saraladevi

2015-01-01

Solute clearance measurement is an objective means of quantifying the dose of peritoneal dialysis (PD). Despite continued debate on the interpretation and precise prognostic value of small solute clearance in PD patients, guidelines based on solute clearance values are common in clinical practice. There is limited information on the solute clearance indices and PD adequacy parameters among this predominantly low socioeconomic status PD population. We investigated the solute clearance among continuous ambulatory peritoneal dialysis (CAPD) patients at the Charlotte Maxeke Johannesburg Academic Hospital and its relationship with other parameters of PD adequacy. Seventy patients on CAPD were studied in this cross-sectional study. Solute clearance was assessed using urea clearance (Kt/V). Linear regression analysis was used to determine factors associated with solute clearance, while analysis of variance was used to test the influence of weekly Kt/V on blood pressure (BP), hemoglobin (Hb) and other biochemical parameters. The mean age of the study population was 37.9 ± 12.4 years, 43% were females and 86% were black Africans. The mean duration on CAPD was 19.7 ± 20.8 months. Mean systolic and diastolic BP were 144 ± 28 and 92 ± 17 mm Hg, respectively. The mean Hb was 11.1 ± 2.2 g/dL and the mean weekly Kt/V was 1.7 ± 0.3. Factors like systolic BP, Hb level, serum levels of cholesterol, calcium, phosphate, parathyroid hormone and albumin were not significantly associated with the weekly Kt/V. We conclude that the dose of PD received by the majority of our patients in terms of the weekly Kt/V is within the recommended values and that this finding is significant considering the low socioeconomic background of our patients. There is no significant association between Kt/V and other indices of dialysis adequacy.

The Effect of Dialysis Chains on Mortality among Patients Receiving Hemodialysis

PubMed Central

Zhang, Yi; Cotter, Dennis J; Thamer, Mae

2011-01-01

Objective To examine the association between dialysis facility chain affiliation and patient mortality. Study Setting Medicare dialysis population. Study Design Data from the United States Renal Data System (USRDS) were used to identify 3,601 free-standing dialysis facilities and 34,914 Medicare patients' incidence to end-stage renal disease (ESRD) in 2004. Mixed-effect regression models were used to estimate patient mortality by dialysis facility chain and profit status during the 2-year follow-up. Data Collection USRDS data were matched with facility, cost, and census data. Principle Findings Of the five largest dialysis chains, the lowest mortality risk was observed among patients dialyzed at nonprofit (NP) Chain 5 facilities. Compared with Chain 5, hazard ratios were 19 percent higher (95 percent CI 1.06–1.34) and 24 percent higher (95 percent CI 1.10–1.40) for patients dialyzed at for-profit (FP) Chain 1 and Chain 2 facilities, respectively. In addition, patients at FP facilities had a 13 percent higher risk of mortality than those in NP facilities (95 percent CI 1.06–1.22). Conclusions Large chain affiliation is an independent risk factor for ESRD mortality in the United States. Given the movement toward further consolidation of large FP chains, reasons behind the increase in mortality require scrutiny. PMID:21143480

"Who matters most?": Clinician perspectives of influence and recommendation on home dialysis uptake.

PubMed

Walker, Rachael C; Marshall, Roger; Howard, Kirsten; Morton, Rachael L; Marshall, Mark R

2017-12-01

There is little research exploring the association between clinicians' behaviours and home dialysis uptake. This paper aims to better understand the influence of clinicians on home dialysis modality recommendations and uptake. Online survey of all NZ renal units to determine the influence of individuals within pre-dialysis teams. We used the self-declaration scale of influence to rate the identified member's perceived influence on decision-making. We used this measure of 'decisional power' to compare the perceived influence of pre-dialysis nurses with nephrologists using both parametric and non-parametric methods. We developed a generalized linear model to investigate the relationship between the influence of nephrologists and pre-dialysis nurses with home dialysis uptake by individual centre using additional data from Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). Finally, respondents rated the importance of a list of patient and service-level factors in recommendations for home dialysis. Data suggest the nephrologists are the most influential member of the pre-dialysis team. This contrasts with perceptions of survey respondents who view pre-dialysis nurses as most influential. Nephrologists' recommendations are likely to be a successful way of increasing home dialysis. A single point increase in nephrologist decisional power is associated with a 6.1% increase in the prevalence of home dialysis. The decisional power around home dialysis in NZ sits with nephrologists. It is therefore critical that nephrologists exercise their decisional power in advocating home dialysis and address reasons why they may not recommend home dialysis to well-suited and appropriate patients. © 2016 Asian Pacific Society of Nephrology.

Association of education level with dialysis outcome.

PubMed

Khattak, Muhammad; Sandhu, Gurprataap S; Desilva, Ranil; Goldfarb-Rumyantzev, Alexander S

2012-01-01

The impact of education on health care outcome has been studied in the past, but its role in the dialysis population is unclear. In this report, we evaluated this association. We used the United States Renal Data System data of end-stage renal disease patients aged 18 years. Education level at the time of end-stage renal disease onset was the primary variable of interest. The outcome of the study was patient mortality. We used four categories of education level: 0 = less than 12 years of education; 1 = high school graduate; 2 = some college; 3 = college graduate. Subgroups based on age, race, sex, donor type, and diabetic status were also analyzed. After adjustments for covariates in the Cox model, using individuals with less than 12 years of education as a reference, patients with college education showed decreased mortality with hazard ratio of 0.81 (95% confidence interval 0.69–0.95), P = 0.010. In conclusion, we showed that higher education level is associated with improved survival of patients on dialysis.

Geographic disparities in patient travel for dialysis in the United States.

PubMed

Stephens, J Mark; Brotherton, Samuel; Dunning, Stephan C; Emerson, Larry C; Gilbertson, David T; Harrison, David J; Kochevar, John J; McClellan, Ann C; McClellan, William M; Wan, Shaowei; Gitlin, Matthew

2013-01-01

To estimate travel distance and time for US hemodialysis patients and to compare travel of rural versus urban patients. Dialysis patient residences were estimated from ZIP code-level patient counts as of February 2011 allocated within the ZIP code proportional to census tract-level population, obtained from the 2010 U.S. Census. Dialysis facility addresses were obtained from Medicare public-use files. Patients were assigned to an "original" and "replacement" facility, assuming patients used the facility closest to home and would select the next closest facility as a replacement, if a replacement facility was required. Driving distances and times were calculated between patient residences and facility locations using GIS software. The mean one-way driving distance to the original facility was 7.9 miles; for rural patients average distances were 2.5 times farther than for urban patients (15.9 vs. 6.2 miles). Mean driving distance to a replacement facility was 10.6 miles, with rural patients traveling on average 4 times farther than urban patients to a replacement facility (28.8 vs. 6.8 miles). Rural patients travel much longer distances for dialysis than urban patients. Accessing alternative facilities, if required, would greatly increase rural patient travel, while having little impact on urban patients. Increased travel could have clinical implications as longer travel is associated with increased mortality and decreased quality of life. © 2013 National Rural Health Association.

Peritoneal Dialysis

MedlinePlus

... include: Infections. An infection of the abdominal lining (peritonitis) is a common complication of peritoneal dialysis. An ... day. You might have a lower risk of peritonitis because you connect and disconnect to the dialysis ...

Nephrologists' professional ethics in dialysis practices.

PubMed

Ozar, David T; Kristensen, Cynthia; Fadem, Stephen Z; Blaser, Robert; Singer, Dale; Moss, Alvin H

2013-05-01

Although the number of incidents is unknown, professional quality-oriented renal organizations have become aware of an increased number of complaints regarding nephrologists who approach patients with the purpose of influencing patients to change nephrologists or dialysis facilities (hereinafter referred to as patient solicitation). This development prompted the Forum of ESRD Networks and the Renal Physicians Association to publish a policy statement on professionalism and ethics in medical practice as these concepts relate to patient solicitation. Also common but not new is the practice of nephrologists trying to recruit their own patients to a new dialysis unit in which they have a financial interest. This paper presents two illustrative cases and provides an ethical framework for analyzing patient solicitation and physician conflict of interest. This work concludes that, in the absence of objective data that medical treatment is better elsewhere, nephrologists who attempt to influence patients to change nephrologists or dialysis facilities fall short of accepted ethical standards pertaining to professional conduct, particularly with regard to the physician-patient relationship, informed consent, continuity of care, and conflict of interest.

Secular trends in acute dialysis after elective major surgery — 1995 to 2009

PubMed Central

Siddiqui, Nausheen F.; Coca, Steven G.; Devereaux, Philip J.; Jain, Arsh K.; Li, Lihua; Luo, Jin; Parikh, Chirag R.; Paterson, Michael; Philbrook, Heather Thiessen; Wald, Ron; Walsh, Michael; Whitlock, Richard; Garg, Amit X.

2012-01-01

Background: Acute kidney injury is a serious complication of elective major surgery. Acute dialysis is used to support life in the most severe cases. We examined whether rates and outcomes of acute dialysis after elective major surgery have changed over time. Methods: We used data from Ontario’s universal health care databases to study all consecutive patients who had elective major surgery at 118 hospitals between 1995 and 2009. Our primary outcomes were acute dialysis within 14 days of surgery, death within 90 days of surgery and chronic dialysis for patients who did not recover kidney function. Results: A total of 552 672 patients underwent elective major surgery during the study period, 2231 of whom received acute dialysis. The incidence of acute dialysis increased steadily from 0.2% in 1995 (95% confidence interval [CI] 0.15–0.2) to 0.6% in 2009 (95% CI 0.6–0.7). This increase was primarily in cardiac and vascular surgeries. Among patients who received acute dialysis, 937 died within 90 days of surgery (42.0%, 95% CI 40.0–44.1), with no change in 90-day survival over time. Among the 1294 patients who received acute dialysis and survived beyond 90 days, 352 required chronic dialysis (27.2%, 95% CI 24.8–29.7), with no change over time. Interpretation: The use of acute dialysis after cardiac and vascular surgery has increased substantially since 1995. Studies focusing on interventions to better prevent and treat perioperative acute kidney injury are needed. PMID:22733671

Exercise and limitations in physical activity levels among new dialysis patients in the United States: an epidemiologic study.

PubMed

Stack, Austin G; Murthy, Bhamidipati

2008-12-01

Epidemiologic studies of physical activity among patients with end-stage renal disease (ESRD) are lacking. The aim of this study was to describe the patterns of physical activity among new dialysis patients in the United States. Multivariate logistic regression analyses examined associations of self-reported limitations in physical activity and exercise frequency with sociodemographic and clinical variables in 2,264 patients from Wave 2 of the Dialysis Morbidity and Mortality Study. Overall, 56% of patients exercised less than once a week, 75% reported severe limitations in vigorous activities, whereas 42% had severe limitations in moderate physical activities. Fewer limitations in moderate or vigorous activities correlated positively with male gender (odds-ratio [OR] = 1.61), black race OR =1.49), Hispanic ethnicity (OR = 2.39), serum albumin (OR = 1.69 per 1 g/L higher), positive affect (OR = 2.33), peritoneal dialysis (OR = 1.90), and negatively with age (OR = 0.67), heart failure (OR = 0.75), peripheral vascular disease (OR = 0.69), malnutrition (OR = 0.67), and depression (OR = 0.39). Patients reporting fewer limitations in moderate or vigorous activities (OR = 1.35 and 1.28, respectively), or frequent visits with a dietitian (2 to 3 times per week vs. less) (OR = 1.21) in the pre-ESRD period exercised more frequently. Limitations in physical activity are common among new ESRD patients and these, in part, are related to pre-existing cardiovascular disease, malnutrition, and mental health.

Periodontal treatment reduces chronic systemic inflammation in peritoneal dialysis patients.

PubMed

Siribamrungwong, Monchai; Yothasamutr, Kasemsuk; Puangpanngam, Kutchaporn

2014-06-01

Chronic systemic inflammation, a non traditional risk factor of cardiovascular diseases, is associated with increasing mortality in chronic kidney disease, especially peritoneal dialysis patients. Periodontitis is a potential treatable source of systemic inflammation in peritoneal dialysis patients. Clinical periodontal status was evaluated in 32 stable chronic peritoneal dialysis patients by plaque index and periodontal disease index. Hematologic, blood chemical, nutritional, and dialysis-related data as well as highly sensitive C-reactive protein were analyzed before and after periodontal treatment. At baseline, high sensitive C-reactive protein positively correlated with the clinical periodontal status (plaque index; r = 0.57, P < 0.01, periodontal disease index; r = 0.56, P < 0.01). After completion of periodontal therapy, clinical periodontal indexes were significantly lower and high sensitivity C-reactive protein significantly decreased from 2.93 to 2.21 mg/L. Moreover, blood urea nitrogen increased from 47.33 to 51.8 mg/dL, reflecting nutritional status improvement. Erythropoietin dosage requirement decreased from 8000 to 6000 units/week while hemoglobin level was stable. Periodontitis is an important source of chronic systemic inflammation in peritoneal dialysis patients. Treatment of periodontal diseases can improve systemic inflammation, nutritional status and erythropoietin responsiveness in peritoneal dialysis patients. © 2013 The Authors. Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis.

Hospital-at-home Integrated Care Program for Older Patients With Orthopedic Processes: An Efficient Alternative to Usual Hospital-Based Care.

PubMed

Closa, Conxita; Mas, Miquel À; Santaeugènia, Sebastià J; Inzitari, Marco; Ribera, Aida; Gallofré, Miquel

2017-09-01

To compare outcomes and costs for patients with orthogeriatric conditions in a home-based integrated care program versus conventional hospital-based care. Quasi-experimental longitudinal study. An acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe. In a 2-year period, we recruited 367 older patients attended at an orthopedic/traumatology unit in an acute hospital for fractures and/or arthroplasty. Patients were referred to a hospital-at-home integrated care unit or to standard hospital-based postacute orthogeriatric unit, based on their social support and availability of the resource. We compared home-based care versus hospital-based care for Relative Functional Gain (gain/loss of function measured by the Barthel Index), mean direct costs, and potential savings in terms of reduction of stay in the acute care hospital. No differences were found in Relative Functional Gain, median (Q25-Q75) = 0.92 (0.64-1.09) in the home-based group versus 0.93 (0.59-1) in the hospital-based group, P =.333. Total health service direct cost [mean (standard deviation)] was significantly lower for patients receiving home-based care: €7120 (3381) versus €12,149 (6322), P < .001. Length of acute hospital stay was significantly shorter in patients discharged to home-based care [10.1 (7)] than in patients discharged to the postacute orthogeriatric hospital-based unit [15.3 (12) days, P < .001]. The hospital-at-home integrated care program was suitable for managing older patients with orthopedic conditions who have good social support for home care. It provided clinical care comparable to the hospital-based model, and it seems to enable earlier acute hospital discharge and lower direct costs. Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Using in situ simulation to evaluate operational readiness of a children's hospital-based obstetrics unit.

PubMed

Ventre, Kathleen M; Barry, James S; Davis, Deborah; Baiamonte, Veronica L; Wentworth, Allen C; Pietras, Michele; Coughlin, Liza; Barley, Gwyn

2014-04-01

Relocating obstetric (OB) services to a children's hospital imposes demands on facility operations, which must be met to ensure quality care and a satisfactory patient experience. We used in situ simulations to prospectively and iteratively evaluate operational readiness of a children's hospital-based OB unit before it opened for patient care. This project took place at a 314-bed, university-affiliated children's hospital. We developed 3 full-scale simulation scenarios depicting a concurrent maternal and neonatal emergency. One scenario began with a standardized patient experiencing admission; the mannequin portrayed a mother during delivery. We ran all 3 scenarios on 2 dates scheduled several weeks apart. We ran 2 of the scenarios on a third day to verify the reliability of key processes. During the simulations, content experts completed equipment checklists, and participants identified latent safety hazards. Each simulation involved a unique combination of scheduled participants who were supplemented by providers from responding ancillary services. The simulations involved 133 scheduled participants representing OB, neonatology, and anesthesiology. We exposed and addressed operational deficiencies involving equipment availability, staffing, interprofessional communication, and systems issues such as transfusion protocol failures and electronic order entry challenges. Process changes between simulation days 1 to 3 decreased the elapsed time between transfusion protocol activation and blood arrival to the operating room and labor/delivery/recovery/postpartum setting. In situ simulations identified multiple operational deficiencies on the OB unit, allowing us to take corrective action before its opening. This project may guide other children's hospitals regarding care processes likely to require significant focus and possible modification to accommodate an OB service.

Examining Depression in Patients on Dialysis.

PubMed

Treadwell, Allison A

2017-01-01

This study measured the prevalence of depression in 39 patients on hemodialysis and peritoneal dialysis in two urban outpatient facilities in the southeastern United States. Additionally, it evaluated the number of patients who sought and scheduled a mental health evaluation after screening and education. The prevalence of mild to severely depressed individuals among participants in this study was 36%, affirming previous findings of depressive symptoms in the ESRD population. Results suggest that patients with ESRD are at a higher risk for depression than the general population. The effects of depression may exacerbate ESRD symptoms, affect treatment adherence, and increase hospitalizations and morbidity. It is likely that screening, diagnosing, and treating depression will be associated with improvement in quality and quantity of life. The practicality of using the screening procedure may improve the detection of depression in this population. However, only a fraction of identified patients in this study pursued further mental health evaluation within the 45-day period. Continued research is needed to identify barriers to seeking mental health consultation and treatment in this community. Copyright© by the American Nephrology Nurses Association.

Peritoneal Fluid Transport rather than Peritoneal Solute Transport Associates with Dialysis Vintage and Age of Peritoneal Dialysis Patients.

PubMed

Waniewski, Jacek; Antosiewicz, Stefan; Baczynski, Daniel; Poleszczuk, Jan; Pietribiasi, Mauro; Lindholm, Bengt; Wankowicz, Zofia

2016-01-01

During peritoneal dialysis (PD), the peritoneal membrane undergoes ageing processes that affect its function. Here we analyzed associations of patient age and dialysis vintage with parameters of peritoneal transport of fluid and solutes, directly measured and estimated based on the pore model, for individual patients. Thirty-three patients (15 females; age 60 (21-87) years; median time on PD 19 (3-100) months) underwent sequential peritoneal equilibration test. Dialysis vintage and patient age did not correlate. Estimation of parameters of the two-pore model of peritoneal transport was performed. The estimated fluid transport parameters, including hydraulic permeability (LpS), fraction of ultrasmall pores (α u), osmotic conductance for glucose (OCG), and peritoneal absorption, were generally independent of solute transport parameters (diffusive mass transport parameters). Fluid transport parameters correlated whereas transport parameters for small solutes and proteins did not correlate with dialysis vintage and patient age. Although LpS and OCG were lower for older patients and those with long dialysis vintage, αu was higher. Thus, fluid transport parameters--rather than solute transport parameters--are linked to dialysis vintage and patient age and should therefore be included when monitoring processes linked to ageing of the peritoneal membrane.

Key Factors for a High-Quality Peritoneal Dialysis Program — The Role of the PD Team and Continuous Quality Improvement

PubMed Central

Fang, Wei; Ni, Zhaohui; Qian, Jiaqi

2014-01-01

The proportion of end-stage renal disease (ESRD) patients on peritoneal dialysis (PD) has increased very fast in China over the last decade. Renji Hospital, affiliated with Shanghai Jiaotong University School of Medicine, is a recognized high-quality PD unit with a high PD utilization rate, excellent patient and technique survival (1-year and 5-year patient survival rate of 93% and 71%, and 1-year and 5-year technique survival of 96% and 82%, respectively), low peritonitis rate and a well-documented good quality of life of the treated patients. We believe that a dedicated and experienced PD team, a structured patient training program, continuous patient support, establishing and utilizing standardized protocols, starting PD with low dialysis dose, monitoring key performance indicators (KPIs), and continuous quality improvement (CQI) are the key factors underlying this successful PD program. PMID:24962961

Effects of physician payment reform on provision of home dialysis.

PubMed

Erickson, Kevin F; Winkelmayer, Wolfgang C; Chertow, Glenn M; Bhattacharya, Jay

2016-06-01

Patients with end-stage renal disease can receive dialysis at home or in-center. In 2004, CMS reformed physician payment for in-center hemodialysis care from a capitated to a tiered fee-for-service model, augmenting physician payment for frequent in-center visits. We evaluated whether payment reform influenced dialysis modality assignment. Cohort study of patients starting dialysis in the United States in the 3 years before and the 3 years after payment reform. We conducted difference-in-difference analyses comparing patients with traditional Medicare coverage (who were affected by the policy) to others with Medicare Advantage (who were unaffected by the policy). We also examined whether the policy had a more pronounced influence on dialysis modality assignment in areas with lower costs of traveling to dialysis facilities. Patients with traditional Medicare coverage experienced a 0.7% (95% CI, 0.2%-1.1%; P = .003) reduction in the absolute probability of home dialysis use following payment reform compared with patients with Medicare Advantage. Patients living in areas with larger dialysis facilities (where payment reform made in-center hemodialysis comparatively more lucrative for physicians) experienced a 0.9% (95% CI, 0.5%-1.4%; P < .001) reduction in home dialysis use following payment reform compared with patients living in areas with smaller facilities (where payment reform made in-center hemodialysis comparatively less lucrative for physicians). The transition from a capitated to a tiered fee-for-service payment model for in-center hemodialysis care resulted in fewer patients receiving home dialysis. This area of policy failure highlights the importance of considering unintended consequences of future physician payment reform efforts.

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs.

PubMed

Yu, Margaret K; O'Hare, Ann M; Batten, Adam; Sulc, Christine A; Neely, Emily L; Liu, Chuan-Fen; Hebert, Paul L

2015-08-07

The secular trend toward dialysis initiation at progressively higher levels of eGFR is not well understood. This study compared temporal trends in eGFR at dialysis initiation within versus outside the Department of Veterans Affairs (VA)-the largest non-fee-for-service health system in the United States. The study used linked data from the US Renal Data System, VA, and Medicare to compare temporal trends in eGFR at dialysis initiation between 2000 and 2009 (n=971,543). Veterans who initiated dialysis within the VA were compared with three groups who initiated dialysis outside the VA: (1) veterans whose dialysis was paid for by the VA, (2) veterans whose dialysis was not paid for by the VA, and (3) nonveterans. Logistic regression was used to estimate average predicted probabilities of dialysis initiation at an eGFR≥10 ml/min per 1.73 m(2). The adjusted probability of starting dialysis at an eGFR≥10 ml/min per 1.73 m(2) increased over time for all groups but was lower for veterans who started dialysis within the VA (0.31; 95% confidence interval [95% CI], 0.30 to 0.32) than for those starting outside the VA, including veterans whose dialysis was (0.36; 95% CI, 0.35 to 0.38) and was not (0.40; 95% CI, 0.40 to 0.40) paid for by the VA and nonveterans (0.39; 95% CI, 0.39 to 0.39). Differences in eGFR at initiation within versus outside the VA were most pronounced among older patients (P for interaction <0.001) and those with a higher risk of 1-year mortality (P for interaction <0.001). Temporal trends in eGFR at dialysis initiation within the VA mirrored those in the wider United States dialysis population, but eGFR at initiation was consistently lowest among those who initiated within the VA. Differences in eGFR at initiation within versus outside the VA were especially pronounced in older patients and those with higher 1-year mortality risk. Copyright © 2015 by the American Society of Nephrology.

Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs

PubMed Central

O’Hare, Ann M.; Batten, Adam; Sulc, Christine A.; Neely, Emily L.; Liu, Chuan-Fen; Hebert, Paul L.

2015-01-01

Background and objectives The secular trend toward dialysis initiation at progressively higher levels of eGFR is not well understood. This study compared temporal trends in eGFR at dialysis initiation within versus outside the Department of Veterans Affairs (VA)—the largest non–fee-for-service health system in the United States. Design, setting, participants, & measurements The study used linked data from the US Renal Data System, VA, and Medicare to compare temporal trends in eGFR at dialysis initiation between 2000 and 2009 (n=971,543). Veterans who initiated dialysis within the VA were compared with three groups who initiated dialysis outside the VA: (1) veterans whose dialysis was paid for by the VA, (2) veterans whose dialysis was not paid for by the VA, and (3) nonveterans. Logistic regression was used to estimate average predicted probabilities of dialysis initiation at an eGFR≥10 ml/min per 1.73 m2. Results The adjusted probability of starting dialysis at an eGFR≥10 ml/min per 1.73 m2 increased over time for all groups but was lower for veterans who started dialysis within the VA (0.31; 95% confidence interval [95% CI], 0.30 to 0.32) than for those starting outside the VA, including veterans whose dialysis was (0.36; 95% CI, 0.35 to 0.38) and was not (0.40; 95% CI, 0.40 to 0.40) paid for by the VA and nonveterans (0.39; 95% CI, 0.39 to 0.39). Differences in eGFR at initiation within versus outside the VA were most pronounced among older patients (P for interaction <0.001) and those with a higher risk of 1-year mortality (P for interaction <0.001). Conclusions Temporal trends in eGFR at dialysis initiation within the VA mirrored those in the wider United States dialysis population, but eGFR at initiation was consistently lowest among those who initiated within the VA. Differences in eGFR at initiation within versus outside the VA were especially pronounced in older patients and those with higher 1-year mortality risk. PMID:26206891

Recent Progress of Bypass Surgery to the Dialysis-Dependent Patients with Critical Limb Ischemia

PubMed Central

Azuma, Nobuyoshi; Kikuchi, Shinsuke; Okuda, Hiroko; Miyake, Keisuke; Koya, Atsuhiro

2017-01-01

According to expansion of dialysis-dependent population, more than half of patients with critical ischemic limbs are dialysis-dependent in Japan. Although patients with end-staged renal disease are well-known as poor life prognosis, well-managed dialysis patients in Japan can survive much longer compared to dialysis patients in the United States and Europe. Therefore, some dialysis patients can enjoy the long-term benefits of bypass surgery. To decide the indication of bypass surgery, patient’s general condition, nutrition status, and vein availability are more important rather than arterial disease anatomy. Ultrasound guided nerve block anesthesia blocking both sciatic and femoral nerve is contributing greatly to quick postoperative recovery of high risk patients. Preoperative ultrasound examination also contribute to not only vein mapping but also find out the graftable segment of artery. The selection of distal target should be decided based on the degree of arterial disease (luminal surface as well as wall calcification), and arterial run-off. Several tips regarding anastomosis to heavily calcified artery have been established including how to create bloodless operative field without arterial clamps. Adequate wound management after bypass surgery is also important. Detection of deep infection such as osteomyelitis and the adequate treatment may avoid major amputation of salvageable limbs. In the era of endovascular treatment, the evidences guiding how to select dialysis patients suitable for bypass surgery are awaiting. (This is a translation of Jpn J Vasc Surg 2017; 26: 33–39.) PMID:29147171

Patients' Perspectives on the Prevention and Treatment of Peritonitis in Peritoneal Dialysis: A Semi-Structured Interview Study.

PubMed

Campbell, Denise J; Craig, Jonathan C; Mudge, David W; Brown, Fiona G; Wong, Germaine; Tong, Allison

♦ BACKGROUND: Peritoneal dialysis (PD) is recommended for adults with residual kidney function and without significant comorbidities. However, peritonitis is a serious and common complication that is associated with hospitalization, pain, catheter loss, and death. This study aims to describe the beliefs, needs, and experiences of PD patients about peritonitis, to inform the training, support, and care of these patients. ♦ METHODS: Qualitative semi-structured interviews were conducted with 29 patients from 3 renal units in Australia who had previous or current experience of PD. The interviews were conducted between November 2014 and November 2015. Transcripts were analyzed thematically. ♦ RESULTS: We identified 4 themes: constant vigilance for prevention (conscious of vulnerability, sharing responsibility with family, demanding attention to detail, ambiguity of detecting infection, ineradicable inhabitation, jeopardizing PD success); invading harm (life-threatening, wreaking internal damage, debilitating pain, losing control and dignity); incapacitating lifestyle interference (financial strain, isolation and separation, exacerbating burden on family); and exasperation with hospitalization (dread of hospital admission, exposure to infection, gruelling follow-up schedule, exposure to harm). ♦ CONCLUSIONS: Patients perceived that peritonitis could threaten their health, treatment modality, and lifestyle, which motivated vigilance and attention to hygiene. They felt a loss of control due to debilitating symptoms including pain and having to be hospitalized, and they were uncertain about how to monitor for signs of peritonitis. Providing patients with education about the causes and signs of peritonitis and addressing their concerns about lifestyle impact, financial impact, hospitalization, and peritonitis-related anxieties may improve treatment satisfaction and outcomes for patients requiring PD. Copyright © 2016 International Society for Peritoneal Dialysis.

The value of 'life at any cost': Talk about stopping kidney dialysis

PubMed Central

Russ, Ann J.; Shim, Janet K.; Kaufman, Sharon R.

2007-01-01

With the trend toward an older, sicker dialysis population in the USA, discussions of ethical issues surrounding dialysis have shifted from concerns about access to and availability of the therapy, to growing unease about non-initiation and treatment discontinuation. Recent studies report treatment withdrawal as the leading cause of death among elderly dialysis patients. Yet, the actual activities that move patients toward stopping treatment often remain obscure, even to clinicians and patients themselves. This paper explores that paradox, drawing on anthropological research among patients over age 70, their families, and clinicians in two California renal dialysis units. It concludes that many older patients sacrifice a sense of choice about dialysis in the present to maintain “choice” as both value and possibility for the future. Yet, patients desire more information and communication, provided earlier in their illness, about prognosis, how long they can expect to be on dialysis, and what the impact of the treatment will be on their daily lives. That, with time, there is a transition to be made from dialysis as “treatment” to end of life care could be better explained and managed to alleviate patients’ confusion and unneeded isolation. PMID:17418924

Polycystic kidney disease at Howard University Hospital.

PubMed

Hosten, A O; Cummings, Y

1977-08-01

Adult polycystic kidney disease treatment at Howard University Hospital is summarized. The cases are taken from autopsies performed between January 1955 and November 1975 and from the Hospital's dialysis population. Polycystic kidney disease was identified in six adults and four infants. Only two dialysis patients were clinically thought to have the disease. A review of the major clinical features of the disease is presented.

Application of instant messaging software in the follow-up of patients using peritoneal dialysis, a randomised controlled trial.

PubMed

Cao, Fang; Li, Lanfei; Lin, Miao; Lin, Qinyu; Ruan, Yiping; Hong, Fuyuan

2018-04-20

This study aims to investigate the application value of Internet-based instant messaging software in the follow-up of patients using peritoneal dialysis. Peritoneal dialysis is an effective renal replacement treatment for end-stage renal disease. The clinical usefulness of Internet-based instant messaging software in the follow-up of peritoneal dialysis patients, including the incidence of peritonitis and exit-site infection, the levels of albumin and electrolytes and the degree of patients' satisfaction, remains unknown. Between January 2009-April 2016, a total of 160 patients underwent continuous peritoneal dialysis in the Department of Nephrology, Fujian Provincial Hospital were invited to participate voluntarily in this study. The patients were randomly assigned to the instant messenger (QQ) follow-up group (n = 80) and the traditional follow-up group (n = 80). The differences in death, hospitalisation, peritonitis, exit-site infection, and patients' satisfaction were investigated during 1 year of follow-up. The mean follow-up duration is 11.4 ± 1.5 months. Compared with the patients in the traditional follow-up group, patients in the QQ follow-up group showed higher levels of serum albumin (p = .009) and haemoglobin (p = .009), lower levels of phosphorus (p < .001) and calcium-phosphorus product (p = .001), and better degree of satisfaction (p < .001). Internet-based follow-up by instant messaging software appears to be a feasible and acceptable method of delivering peritoneal dialysis treatment for patients with end-stage renal disease. © 2018 John Wiley & Sons Ltd.

[Cost of intensive care in a German hospital: cost-unit accounting based on the InEK matrix].

PubMed

Martin, J; Neurohr, C; Bauer, M; Weiss, M; Schleppers, A

2008-05-01

The aim of this study was to determine the actual cost per intensive care unit (ICU) day in Germany based on routine data from an electronic patient data management system as well as analysis of cost-driving factors. A differentiation between days with and without mechanical ventilation was performed. On the ICU of a German focused-care hospital (896 beds, 12 anesthesiology ICU beds), cost per treatment day was calculated with or without mechanical ventilation from the perspective of the hospital. Costs were derived retrospectively with respect to the period between January and October 2006 by cost-unit accounting based on routine data collected from the ICU patients. Patients with a length of stay of at least 2 days on the ICU were included. Demographic, clinical and economical data were analyzed for patient characterization. Data of 407 patients (217 male and 190 female) were included in the analysis, of which 159 patients (100 male, 59 female) were completely or partially mechanically ventilated. The mean simplified acute physiology (SAPS) II score at the onset of ICU stay was 28.2. Average cost per ICU day was 1,265 EUR and costs for ICU days with and without mechanical ventilation amounted to 1,426 EUR and 1,145 EUR, respectively. Personnel costs (50%) showed the largest cost share followed by drugs plus medicinal products (18%) and infrastructure (16%). For the first time, a cost analysis of intensive care in Germany was performed with routine data based on the matrix of the institute for reimbursement in hospitals (InEK). The results revealed a higher resource use on the ICU than previously expected. The large share of personnel costs on the ICU was evident but is comparable to other medical departments in the hospital. The need for mechanical ventilation increases the daily costs of resources by approximately 25%.

Radiation decontamination unit for the community hospital.

PubMed

Waldron, R L; Danielson, R A; Shultz, H E; Eckert, D E; Hendricks, K O

1981-05-01

"Freestanding" radiation decontamination units including surgical capability can be developed and made operational in small/medium sized community hospitals at relatively small cost and with minimal plant reconstruction. Because of the development of nuclear power plants in relatively remote areas and widespread transportation of radioactive materials it is important for hospitals and physicians to be prepared to handle radiation accident victims. The Radiological Assistance Program of the United States Department of Energy and the Radiation Emergency Assistance Center Training Site of Oak Ridge Associated Universities are ready to support individual hospitals and physicians in this endeavor. Adequate planning rather than luck, should be used in dealing with potential radiation accident victims. The radiation emergency team is headed by a physician on duty in the hospital. It is important that the team leader be knowledgeable in radiation accident management and have personnel trained in radiation accident management as members of this team. The senior administrative person on duty is responsible for intramural and extramural communications. Rapid mobilization of the radiation decontamination unit is important. Periodic drills are necessary for this mobilization and the smooth operation of the unit.

Acute dialysis-associated peritonitis in children with D+ hemolytic uremic syndrome.

PubMed

Adragna, Marta; Balestracci, Alejandro; García Chervo, Laura; Steinbrun, Silvina; Delgado, Norma; Briones, Liliana

2012-04-01

Acute peritoneal dialysis (PD) is the preferred therapy for renal replacement in children with post-diarrheal hemolytic uremic syndrome (D+ HUS), but peritonitis remains a frequent complication of this procedure. We reviewed data from 149 patients with D+ HUS who had undergone acute PD with the aim of determining the prevalence and risk factors for the development of peritonitis. A total of 36 patients (24.2%) presented peritonitis. The median onset of peritonitis manifestations was 6 (range 2-18) days after the initiation of dialysis treatment, and Gram-positive microorganisms were the predominant bacterial type isolated (15/36 patients). The patients were divided into two groups: with or without peritonitis, respectively. Univariate analysis revealed that a longer duration of the oligoanuric period, more days of dialysis, catheter replacement, stay in the intensive care unit, and hypoalbuminemia were significantly associated to the development of peritonitis. The multivariate analysis, controlled by duration of PD, identified the following independent risk factors for peritonitis: catheter replacement [p = 0.037, odds ratio (OR) 1.33, 95% confidence interval (CI) 1.02-1.73], stay in intensive care unit (p = 0.0001, OR 2.62, 95% CI 1.65-4.19), and hypoalbuminemia (p = 0.0076, OR 1.45, 95% CI 1.10-1.91). Based on these findings, we conclude that the optimization of the aseptic technique during catheter manipulation and early nutritional support are targets for the prevention of peritonitis, especially in critically ill patients.

Dialysis Malnutrition and Malnutrition Inflammation Scores: screening tools for prediction of dialysis-related protein-energy wasting in Malaysia.

PubMed

Harvinder, Gilcharan Singh; Swee, Winnie Chee Siew; Karupaiah, Tilakavati; Sahathevan, Sharmela; Chinna, Karuthan; Ahmad, Ghazali; Bavanandan, Sunita; Goh, Bak Leong

2016-01-01

Malnutrition is highly prevalent in Malaysian dialysis patients and there is a need for a valid screening tool for early identification and management. This cross-sectional study aims to examine the sensitivity of the Dialysis Malnutrition Score (DMS) and Malnutrition Inflammation Score (MIS) tools in predicting protein-energy wasting (PEW) among Malaysian dialysis patients. A total of 155 haemodialysis (HD) and 90 peritoneal dialysis (PD) patients were screened for risk of malnutrition using DMS and MIS and comparisons were made with established guidelines by International Society of Renal Nutrition and Metabolism (ISRNM) for PEW. MIS cut-off score of >=5 indicated presence of malnutrition in all patients. A total of 59% of HD and 83% of PD patients had PEW by ISRNM criteria. Based on DMS, 73% of HD and 71% of PD patients exhibited moderate malnutrition, whilst using MIS, 88% and 90%, respectively were malnourished. DMS and MIS correlated significantly in HD (r2=0.552, p<0.001) and PD (r2=0.466, p<0.001) patients. DMS and MIS had higher sensitivity values in PD (81% and 82%, respectively) compared to HD (59% and 60%, respectively) patients. The MIS cut-off scores for malnutrition classification were established (score >=5) for use amongst Malaysian dialysis patients. Both DMS and MIS are valid tools to be used for nutrition screening of dialysis patients especially those undergoing peritoneal dialysis. The DMS may be a more practical and simpler tool to be utilized in the Malaysian dialysis settings as it does not require laboratory markers.

Depression in dialysis patients.

PubMed

King-Wing Ma, Terry; Kam-Tao Li, Philip

2016-08-01

Depression is the most common psychiatric illness in patients with end-stage renal disease (ESRD). The reported prevalence of depression in dialysis population varied from 22.8% (interview-based diagnosis) to 39.3% (self- or clinician-administered rating scales). Such differences were attributed to the overlapping symptoms of uraemia and depression. Systemic review and meta-analysis of observational studies showed that depression was a significant predictor of mortality in dialysis population. The optimal screening tool for depression in dialysis patients remains uncertain. The Beck Depression Inventory (BDI), Patient Health Questionnaire (PHQ) and Center for Epidemiologic Studies Depression Scale (CESD) have been validated for screening purposes. Patients who scored ≥14 using BDI should be referred to a psychiatrist for early evaluation. Structured Clinical Interview for DSM disorders (SCID) remains the gold standard for diagnosis. Non-pharmacological treatment options include cognitive behavioural therapy and exercise training programs. Although frequent haemodialysis may have beneficial effects on patients' physical and mental well-being, it cannot and should not be viewed as a treatment of depression. Selective serotonin reuptake inhibitors (SSRIs) are generally effective and safe in ESRD patients, but most studies were small, non-randomized and uncontrolled. The European Renal Best Practice (ERBP) guideline suggests a trial of SSRI for 8 to 12 weeks in dialysis patients who have moderate-major depression. The treatment effect should be re-evaluated after 12 weeks to avoid prolonging ineffective medication. This review will discuss the current understanding in the diagnosis and management of depression in dialysis patients. © 2016 Asian Pacific Society of Nephrology.

Effect of a Quality Improvement Program to Improve Guideline Adherence and Attainment of Clinical Standards in Dialysis Care: Report of Outcomes in Year 1.

PubMed

Youssouf, Sajeda; Nache, Azri; Wijesekara, Chandrakumaran; Middleton, Rachel J; Lewis, David; Shurrab, Aladdin E; O'Riordan, Edmond; Lappin, Lesley P; O'Donoghue, Donal; Kalra, Philip A; Hegarty, Janet

2017-01-01

Best practice in dialysis is synthesised in clear international guidelines. However, a large gap remains between the international guidelines and the actual delivery of care. In this paper, we report outcomes for the first year of a multifaceted dialysis improvement programme in our network. One year collaborative involving 3 haemodialysis units and a peritoneal dialysis (PD) programme involving 299 dialysis patients. Each unit addressed a different indicator (unit A - catheter-related bloodstream infection [CRBSI], unit B - pre-dialysis blood pressure [BP], unit C - dialysis dose, unit D - anaemia) with a shared aim to match the top 10% in the UK. Tailored multifaceted approaches include a modified collaborative methodology with an aim, framework, driver diagram, learning sessions, facilitated meetings, plan-do-study-act cycles and continuous measurement. Analysis of outcomes, costings, erythropoietin stimulating agent and iron use, and safety culture attributes. Unit A reduced CRBSI from 2.65 to 0.5 per 1,000 catheter days (p = 0.02). Unit B improved attainment of target BP from 37.5 to 67.2% (p = 0.003). Unit C improved attainment of target urea reduction ratio from 75.8 to 91.4% (p = 0.04). PD unit D improved attainment of target haemoglobin from 45.5 to 62.7% (p = 0.01), with no significant change in the indicators in a non-intervention unit. Safety culture attributes improved. Costs associated with admission for fluid overload and infection, erythropoietin, iron and thrombokinase use decreased 36% (£415,620-£264,143). Units that took part in this collaborative improved guideline adherence compared both to their own pre-intervention performance and a non-intervention unit. Such multifaceted interventions are a useful methodology to improve dialysis care. © 2017 S. Karger AG, Basel.

Effects of Oral Nutritional Supplements on Mortality, Missed Dialysis Treatments, and Nutritional Markers in Hemodialysis Patients.

PubMed

Benner, Debbie; Brunelli, Steven M; Brosch, Becky; Wheeler, Jane; Nissenson, Allen R

2018-05-01

Protein-energy wasting is common in end-stage renal disease patients undergoing dialysis and is strongly associated with mortality and adverse outcomes. Intradialytic oral nutritional supplements (ONS) reduce risk of mortality in these patients. Large studies characterizing the impact of ONS on other outcomes are lacking. We assessed the associations between administration of ONS and clinical and nutritional outcomes. Retrospective evaluation of a pilot program providing ONS to patients at a large dialysis organization in the United States. The pilot program provided ONS to in-center hemodialysis patients with serum albumin ≤3.5 g/dL at 408 facilities. ONS patients were compared to matched controls with serum albumin ≤3.5 g/dL, identified from facilities not participating in the ONS program (n = 3,374 per group). Receipt of ONS. Death, missed dialysis treatments, hospitalizations, serum albumin, normalized protein catabolic rate, and postdialysis body weight were abstracted from large dialysis organization electronic medical records. There was a 69% reduction in deaths (hazard ratio = 0.31; 95% confidence interval = 0.25-0.39), and 33% fewer missed dialysis treatments (incidence rate ratio = 0.77; 95% confidence interval = 0.73-0.82) among ONS patients compared to controls (P < .001 for both). The effects of ONS on nutritional indices were mixed: serum albumin was lower, whereas normalized protein catabolic rate values, a surrogate for dietary protein intake, and postdialysis body weights were higher for ONS patients compared to controls during follow-up. Our evaluation confirmed the beneficial effects of ONS in reducing mortality and improving some indices of nutritional status for hypoalbuminemic hemodialysis patients. We also report the novel finding that ONS can reduce the number of missed dialysis treatments. These results support the use of intradialytic ONS as an effective intervention to improve the outcomes in hemodialysis patients with

Factors Affecting Employment at Initiation of Dialysis

PubMed Central

Muehrer, Rebecca J.; Schatell, Dori; Witten, Beth; Gangnon, Ronald; Becker, Bryan N.

2011-01-01

Summary Background and objectives Half the individuals who reach ESRD are working age (<65 years old) and many are at risk for job loss. Factors that contribute to job retention among working-age patients with chronic kidney disease before ESRD are unknown. The purpose of the study is to understand factors associated with maintaining employment among working-age patients with advanced kidney failure. Design, setting, participants, & measurements In this retrospective study we reviewed the United States Renal Data System database (1992 through 2003) and selected all patients (n = 102,104) who were working age and employed 6 months before dialysis initiation. Factors that were examined for an association with maintaining employment status included demographics, comorbid conditions, ESRD cause, insurance, predialysis erythropoietin use, and dialysis modality. Results Maintaining employment at the same level during the final 6 months before dialysis was more likely among (1) white men ages 30 to 49 years; (2) patients with either glomerulonephritis, cystic, or urologic causes of renal failure; (3) patients choosing peritoneal dialysis for their first treatment; (4) those with employer group or other health plans; and (5) erythropoietin usage before ESRD. Maintaining employment status was less likely among patients with congestive heart failure, cardiovascular disease, cancer, and other chronic illnesses. Conclusions The rate of unemployment in working-age patients with chronic kidney disease and ESRD is high compared with that of the general population. Treating anemia with erythropoietin before kidney failure and educating patients about work-friendly home dialysis options might improve job retention. PMID:21393489

Peritoneal Fluid Transport rather than Peritoneal Solute Transport Associates with Dialysis Vintage and Age of Peritoneal Dialysis Patients

PubMed Central

Waniewski, Jacek; Antosiewicz, Stefan; Baczynski, Daniel; Poleszczuk, Jan; Pietribiasi, Mauro; Lindholm, Bengt; Wankowicz, Zofia

2016-01-01

During peritoneal dialysis (PD), the peritoneal membrane undergoes ageing processes that affect its function. Here we analyzed associations of patient age and dialysis vintage with parameters of peritoneal transport of fluid and solutes, directly measured and estimated based on the pore model, for individual patients. Thirty-three patients (15 females; age 60 (21–87) years; median time on PD 19 (3–100) months) underwent sequential peritoneal equilibration test. Dialysis vintage and patient age did not correlate. Estimation of parameters of the two-pore model of peritoneal transport was performed. The estimated fluid transport parameters, including hydraulic permeability (LpS), fraction of ultrasmall pores (α u), osmotic conductance for glucose (OCG), and peritoneal absorption, were generally independent of solute transport parameters (diffusive mass transport parameters). Fluid transport parameters correlated whereas transport parameters for small solutes and proteins did not correlate with dialysis vintage and patient age. Although LpS and OCG were lower for older patients and those with long dialysis vintage, αu was higher. Thus, fluid transport parameters—rather than solute transport parameters—are linked to dialysis vintage and patient age and should therefore be included when monitoring processes linked to ageing of the peritoneal membrane. PMID:26989432

National perspective on in-hospital emergency units in Iraq

PubMed Central

Lafta, Riyadh K.; Al-Nuaimi, Maha A.

2013-01-01

Background: Hospitals play a crucial role in providing communities with essential medical care during times of disasters. The emergency department is the most vital component of hospitals' inpatient business. In Iraq, at present, there are many casualties that cause a burden of work and the need for structural assessment, equipment updating and evaluation of process. Objective: To examine the current pragmatic functioning of the existing set-up of services of in-hospital emergency departments within some general hospitals in Baghdad and Mosul in order to establish a mechanism for future evaluation for the health services in our community. Methods: A cross-sectional study was employed to evaluate the structure, process and function of six major hospitals with emergency units: four major hospitals in Baghdad and two in Mosul. Results: The six surveyed emergency units are distinct units within general hospitals that serve (collectively) one quarter of the total population. More than one third of these units feature observation unit beds, laboratory services, imaging facilities, pharmacies with safe storage, and ambulatory entrance. Operation room was found only in one hospital's reception and waiting area. Consultation/track area, cubicles for infection control, and discrete tutorial rooms were not available. Patient assessment was performed (although without adequate privacy). The emergency specialist, family medicine specialist and interested general practitioner exist in one-third of the surveyed units. Psychiatrist, physiotherapists, occupational therapists, and social work links are not available. The shortage in medication, urgent vaccines and vital facilities is an obvious problem. Conclusions: Our emergency unit's level and standards of care are underdeveloped. The inconsistent process and inappropriate environments need to be reconstructed. The lack of drugs, commodities, communication infrastructure, audit and training all require effective build up. PMID

Knowledge Translation Interventions to Improve the Timing of Dialysis Initiation: Protocol for a Cluster Randomized Trial.

PubMed

Chau, Elaine M T; Manns, Braden J; Garg, Amit X; Sood, Manish M; Kim, S Joseph; Naimark, David; Nesrallah, Gihad E; Soroka, Steven D; Beaulieu, Monica; Dixon, Stephanie; Alam, Ahsan; Tangri, Navdeep

2016-01-01

Early initiation of chronic dialysis (starting dialysis with higher vs lower kidney function) has risen rapidly in the past 2 decades in Canada and internationally, despite absence of established health benefits and higher costs. In 2014, a Canadian guideline on the timing of dialysis initiation, recommending an intent-to-defer approach, was published. The objective of this study is to evaluate the efficacy and safety of a knowledge translation intervention to promote the intent-to-defer approach in clinical practice. This study is a multicenter, 2-arm parallel, cluster randomized trial. The study involves 55 advanced chronic kidney disease clinics across Canada. Patients older than 18 years who are managed by nephrologists for more than 3 months, and initiate dialysis in the follow-up period are included in the study. Outcomes will be measured at the patient-level and enumerated within a cluster. Data on characteristics of each dialysis start will be determined by linkages with the Canadian Organ Replacement Register. Primary outcomes include the proportion of patients who start dialysis early with an estimated glomerular filtration rate greater than 10.5 mL/min/1.73 m 2 and start dialysis in hospital as inpatients or in an emergency room setting. Secondary outcomes include the rate of change in early dialysis starts; rates of hospitalizations, deaths, and cost of predialysis care (wherever available); quarterly proportion of new starts; and acceptability of the knowledge translation materials. We randomized 55 multidisciplinary chronic disease clinics (clusters) in Canada to receive either an active knowledge translation intervention or no intervention for the uptake of the guideline on the timing of dialysis initiation. The active knowledge translation intervention consists of audit and feedback as well as patient- and provider-directed educational tools delivered at a comprehensive in-person medical detailing visit. Control clinics are only exposed to guideline

[Refusal of initiation of dialysis by elderly patients with chronic renal failure].

PubMed

Fujimaki, Hiroshi; Kasuya, Yutaka; Kawaguchi, Sachiko; Hara, Shino; Koga, Shiro; Takahashi, Tadao; Mizuno, Shoichi

2005-07-01

Refusal of dialysis is not uncommon in elderly patients with chronic renal failure. In this study, we retrospectively inspected our dealings with patients who refused our offer to initiate dialysis. In addition, we discussed how to grasp the meaning of this phenomenon. We treated 152 patients with advanced chronic renal failure aged 60 years and over at Tokyo Metropolitan Geriatric Hospital. The patients fulfilling the following two criteria were considered to be refusal cases. The first criterion was that an acceptance of the initiation of dialysis could not be obtained in spite of repeated counseling. The second criterion was that a definite outcome was precipitated by the development of severe uremic symptoms. In every refusal case, clinical characteristics and household members were surveyed. Verbal expressions of the reasons for refusal were retrieved from medical charts. The outcome was also studied. The two criteria were fulfilled in 7 cases. The male/female ratio was 5:2. The age was 78 +/- 7 years (mean +/- standard deviation). All but one cases were ambulatory, and all cases had normal cognitive function. Four cases were married, and the other cases had lost their partners. The number of household members was 3.9 +/- 1.8. We speculated that every case could maintain a good quality of life even after the initiation of dialysis. Representative expressions of the reasons for refusal were "I have already lived fully" and "I would prefer to accept death rather than dialysis". The outcome was urgent initiation of dialysis (five cases) and death (two cases). The time between initial counseling and the outcome was 115 +/- 37 days. Accepting or refusing dialysis therapy is a selection related to life or death. We must make an effort to obtain consent to initiating dialysis if patients are assessed as suitable for dialysis.

Effects of Different Models of Dialysis Care on Patient-Important Outcomes: A Systematic Review and Meta-Analysis.

PubMed

Ramar, Priya; Ahmed, Ahmed T; Wang, Zhen; Chawla, Sagar S; Suarez, Maria Lourdes Gonzalez; Hickson, LaTonya J; Farrell, Ann; Williams, Amy W; Shah, Nilay D; Murad, M Hassan; Thorsteinsdottir, Bjorg

2017-12-01

Ongoing payment reform in dialysis necessitates better patient outcomes and lower costs. Suggested improvements to processes of care for maintenance dialysis patients are abundant; however, their impact on patient-important outcomes is unclear. This systematic review included comparative randomized controlled trials or observational studies with no restriction on language, published from 2000 to 2014, involving at least 5 adult dialysis patients who received a minimum of 6 months of follow-up. The effect size was pooled and stratified by intervention strategy (multidisciplinary care [MDC], home dialysis, alternate dialysis settings, and electronic health record implementation). Heterogeneity (I 2 ) was used to assess the variability in study effects related to study differences rather than chance. Of the 1988 articles screened, 25 international studies with 74,833 maintenance dialysis patients were included. Interventions with MDC or home dialysis were associated with a lower mortality (hazard ratio [HR] = 0.72, 95% confidence interval [CI] 0.61, 0.84, I 2  = 41.6%; HR = 0.57, 95% CI 0.41, 0.81, I 2  = 89.0%; respectively) and hospitalizations (incidence rate ratio [IRR] = 0.68, 95% CI 0.51, 0.91, I 2  = NA; IRR = 0.88, 95% CI 0.64, 1.20, I 2  = 79.6%; respectively). Alternate dialysis settings also were associated with a reduction in hospitalizations (IRR = 0.41, 95% CI 0.25, 0.69, I 2  = 0.0%). This systematic review underscores the importance of multidisciplinary care, and also the value of telemedicine as a means to increase access to providers and enhance outcomes for those dialyzing at home or in alternate settings, including those with limited access to nephrology expertise because of travel distance.

Critical Care Dialysis System

NASA Technical Reports Server (NTRS)

1992-01-01

Organon Teknika Corporation's REDY 2000 dialysis machine employs technology originally developed under NASA contract by Marquardt Corporation. The chemical process developed during the project could be applied to removing toxic waste from used dialysis fluid. This discovery led to the development of a kidney dialysis machine using "sorbent" dialysis, a method of removing urea from human blood by treating a dialysate solution. The process saves electricity and, because the need for a continuous water supply is eliminated, the patient has greater freedom.

Phosphate Removal by Peritoneal Dialysis: The Effect of Transporter Status and Peritoneal Dialysis Prescription.

PubMed

Courivaud, Cecile; Davenport, Andrew

2016-01-01

♦ Interventional trials failed to demonstrate that increasing urea clearance improved peritoneal dialysis (PD) patient survival. Hyperphosphatemia is a well-recognized predictor of cardiovascular and all-cause mortality in PD patients. Simplification of PD small solute clearance targets focuses away from larger solutes, including phosphate. In the US and UK, increasing use of automated peritoneal dialysis (APD) cyclers with shorter dwell times could also potentially reduce peritoneal phosphate removal compared to continuous ambulatory peritoneal dialysis (CAPD). ♦ Total phosphate and peritoneal phosphate clearances were measured in a prospective observational cohort of 380 adult PD patients attending a tertiary university hospital between 1996 and 2013 for routine assessment of PD adequacy. ♦ Eighty-seven patients (22.9%) were hyperphosphatemic. Taking the mean 4-hour dialysate to plasma (D/P) ratio for phosphate, 193 (50.8%) were fast and fast-average transporters and 187 (49.2%) were slow and slow-average transporters (compared to 276 [72.6%] and 104 [27.4%], respectively, for peritoneal creatinine transporter status). Faster peritoneal phosphate transporter status was associated with over-hydration (odds ratio [OR] = 2.45 [1.43 - 4.20], p = 0.001). Whereas the 4-hour D/P creatinine and peritoneal weekly creatinine clearance did not differ between those who were hyperphosphatemic or not, the hyperphosphatemic patients had lower 4-hour D/P phosphate and lower peritoneal weekly phosphate clearance (p = 0.019, and p = 0.06 respectively). We found greater peritoneal phosphate clearance for patients choosing CAPD compared to APD, irrespective of the peritoneal phosphate transporter status. ♦ Peritoneal creatinine transporter status and creatinine clearance cannot be used as surrogate markers of peritoneal phosphate transport and clearance. Hyperphosphatemia was more common in PD patients with slower peritoneal transporter status and lower peritoneal phosphate

Physical performance and clinical outcomes in dialysis patients: a secondary analysis of the EXCITE trial.

PubMed

Torino, Claudia; Manfredini, Fabio; Bolignano, Davide; Aucella, Filippo; Baggetta, Rossella; Barillà, Antonio; Battaglia, Yuri; Bertoli, Silvio; Bonanno, Graziella; Castellino, Pietro; Ciurlino, Daniele; Cupisti, Adamasco; D'Arrigo, Graziella; De Paola, Luciano; Fabrizi, Fabrizio; Fatuzzo, Pasquale; Fuiano, Giorgio; Lombardi, Luigi; Lucisano, Gaetano; Messa, Piergiorgio; Rapanà, Renato; Rapisarda, Francesco; Rastelli, Stefania; Rocca-Rey, Lisa; Summaria, Chiara; Zuccalà, Alessandro; Tripepi, Giovanni; Catizone, Luigi; Zoccali, Carmine; Mallamaci, Francesca

2014-01-01

Scarce physical activity predicts shorter survival in dialysis patients. However, the relationship between physical (motor) fitness and clinical outcomes has never been tested in these patients. We tested the predictive power of an established metric of motor fitness, the Six-Minute Walking Test (6MWT), for death, cardiovascular events and hospitalization in 296 dialysis patients who took part in the trial EXCITE (ClinicalTrials.gov Identifier: NCT01255969). During follow up 69 patients died, 90 had fatal and non-fatal cardiovascular events, 159 were hospitalized and 182 patients had the composite outcome. In multivariate Cox models - including the study allocation arm and classical and non-classical risk factors - an increase of 20 walked metres during the 6MWT was associated to a 6% reduction of the risk for the composite end-point (P=0.001) and a similar relationship existed between the 6MWT, mortality (P<0.001) and hospitalizations (P=0.03). A similar trend was observed for cardiovascular events but this relationship did not reach statistical significance (P=0.09). Poor physical performance predicts a high risk of mortality, cardiovascular events and hospitalizations in dialysis patients. Future studies, including phase-2 EXCITE, will assess whether improving motor fitness may translate into better clinical outcomes in this high risk population. © 2014 S. Karger AG, Basel.

Factors influencing access to education, decision making, and receipt of preferred dialysis modality in unplanned dialysis start patients.

PubMed

Machowska, Anna; Alscher, Mark Dominik; Reddy Vanga, Satyanarayana; Koch, Michael; Aarup, Michael; Qureshi, Abdul Rashid; Lindholm, Bengt; Rutherford, Peter A

2016-01-01

Unplanned dialysis start (UPS) leads to worse clinical outcomes than planned start, and only a minority of patients ever receive education on this topic and are able to make a modality choice, particularly for home dialysis. This study aimed to determine the predictive factors for patients receiving education, making a decision, and receiving their preferred modality choice in UPS patients following a UPS educational program (UPS-EP). The Offering Patients Therapy Options in Unplanned Start (OPTiONS) study examined the impact of the implementation of a specific UPS-EP, including decision support tools and pathway improvement on dialysis modality choice. Linear regression models were used to examine the factors predicting three key steps: referral and receipt of UPS-EP, modality decision making, and actual delivery of preferred modality choice. A simple economic assessment was performed to examine the potential benefit of implementing UPS-EP in terms of dialysis costs. The majority of UPS patients could receive UPS-EP (214/270 patients) and were able to make a decision (177/214), although not all patients received their preferred choice (159/177). Regression analysis demonstrated that the initial dialysis modality was a predictive factor for referral and receipt of UPS-EP and modality decision making. In contrast, age was a predictor for referral and receipt of UPS-EP only, and comorbidity was not a predictor for any step, except for myocardial infarction, which was a weak predictor for lower likelihood of receiving preferred modality. Country practices predicted UPS-EP receipt and decision making. Economic analysis demonstrated the potential benefit of UPS-EP implementation because dialysis modality costs were associated with modality distribution driven by patient preference. Education and decision support can allow UPS patients to understand their options and choose dialysis modality, and attention needs to be focused on ensuring equity of access to educational

Risk of dementia in peritoneal dialysis patients compared with hemodialysis patients.

PubMed

Wolfgram, Dawn F; Szabo, Aniko; Murray, Anne M; Whittle, Jeff

2015-01-01

Compared with similarly aged controls, patients with end-stage renal disease (ESRD) have a higher prevalence of cognitive impairment and more rapid cognitive decline, which is not explained by traditional risk factors alone. Since previous small studies suggest an association of cognitive impairment with dialysis modality, we compared incident dementia among patients initiating hemodialysis (HD) vs peritoneal dialysis (PD) in a large national cohort. This is a retrospective cohort study of incident dialysis patients in the United States from 2006 to 2008 with no diagnosis of dementia prior to beginning dialysis. We evaluated the effect of initial dialysis modality on incidence of dementia, diagnosed by Medicare claims data, adjusted for baseline demographic and clinical data from the USRDS registry. Our analysis included 121,623 patients, of whom 8,663 initiated dialysis on PD. The mean age of our cohort was 69.2 years. Patients who initiated PD had a lower cumulative incidence of dementia than those who initiated HD (1.0% vs 2.7%, 2.5% vs 5.3%, and 3.9% vs 7.3% at 1, 2, and 3 years, respectively). The risk of dementia for patients who started on PD was lower compared with those who started on HD, with a hazard ratio (HR) = 0.46 [0.41, 0.53], in an unadjusted model and HR 0.74 [0.64, 0.86] in a matched model. Dialysis modality is associated with incident dementia in a cohort of older ESRD patients. This finding warrants further investigation of the effect of dialysis modality on cognitive function and evaluation for possible mechanisms. Copyright © 2015 International Society for Peritoneal Dialysis.

Propensity-Matched Mortality Comparison of Incident Hemodialysis and Peritoneal Dialysis Patients

PubMed Central

Weinhandl, Eric D.; Gilbertson, David T.; Arneson, Thomas J.; Snyder, Jon J.; Collins, Allan J.

2010-01-01

Contemporary comparisons of mortality in matched hemodialysis and peritoneal dialysis patients are lacking. We aimed to compare survival of incident hemodialysis and peritoneal dialysis patients by intention-to-treat analysis in a matched-pair cohort and in subsets defined by age, cardiovascular disease, and diabetes. We matched 6337 patient pairs from a retrospective cohort of 98,875 adults who initiated dialysis in 2003 in the United States. In the primary intention-to-treat analysis of survival from day 0, cumulative survival was higher for peritoneal dialysis patients than for hemodialysis patients (hazard ratio 0.92; 95% CI 0.86 to 1.00, P = 0.04). Cumulative survival probabilities for peritoneal dialysis versus hemodialysis were 85.8% versus 80.7% (P < 0.01), 71.1% versus 68.0% (P < 0.01), 58.1% versus 56.7% (P = 0.25), and 48.4% versus 47.3% (P = 0.50) at 12, 24, 36, and 48 months, respectively. Peritoneal dialysis was associated with improved survival compared with hemodialysis among subgroups with age <65 years, no cardiovascular disease, and no diabetes. In a sensitivity analysis of survival from 90 days after initiation, we did not detect a difference in survival between modalities overall (hazard ratio 1.05; 95% CI 0.96 to 1.16), but hemodialysis was associated with improved survival among subgroups with cardiovascular disease and diabetes. In conclusion, despite hazard ratio heterogeneity across patient subgroups and nonconstant hazard ratios during the follow-up period, the overall intention-to-treat mortality risk after dialysis initiation was 8% lower for peritoneal dialysis than for matched hemodialysis patients. These data suggest that increased use of peritoneal dialysis may benefit incident ESRD patients. PMID:20133483

Campylobacter jejuni: A rare agent in a child with peritoneal dialysis-related peritonitis.

PubMed

Tural Kara, Tugce; Yilmaz, Songul; Ozdemir, Halil; Birsin Ozcakar, Zeynep; Derya Aysev, Ahmet; Ciftci, Ergin; Ince, Erdal

2016-10-01

Peritonitis is a serious problem in children receiving peritoneal dialysis. Campylobacter jejuni is an unusual cause of peritonitis. A 10-year-old boy who had end stage renal failure due to atypical hemolytic uremic syndrome was admitted to our hospital with abdominal pain and fever. Peritoneal dialysis fluid was cloudy and microscopic examination showed abundant leukocytes. Intraperitoneal cefepime treatment was started. Campylobacter jejuni was isolated from peritoneal dialysis fluid culture and oral clarithromycin was added to the treatment. At the end of therapy, peritoneal fluid culture was negative. To our knowledge, C. jejuni peritonitis was not reported in children previously. Although C. jejuni peritonitis is rarely encountered in children, it should be considered as an etiologic factor for peritonitis. Sociedad Argentina de Pediatría.

Hemorrhagic Cholecystitis in a Patient on Maintenance Dialysis

PubMed Central

Shishida, Masayuki; Ikeda, Masahiro; Karakuchi, Nozomi; Ono, Kosuke; Tsukiyama, Naofumi; Shimomura, Manabu; Oishi, Koichi; Miyamoto, Kazuaki; Toyota, Kazuhiro; Sadamoto, Seiji; Takahashi, Tadateru

2017-01-01

The present paper describes a case of hemorrhagic cholecystitis in a patient on maintenance dialysis. The patient presented with right upper quadrant abdominal pain. Computed tomography revealed swelling of the gallbladder, high- and isodensity contents of the gallbladder, and high-density stone in the gallbladder neck. He was hospitalized for suspected acute cholecystitis. After hospitalization, his levels of total bilirubin, aspartate aminotransferase, and alanine aminotransferase increased. T2-weighted magnetic resonance imaging showed low-intensity contents expanded to include a wide area from the common bile duct to the cystic duct and gallbladder neck. Endoscopic retrograde cholangiopancreatography revealed clotting from the duodenal papilla. After cannulation of the bile duct, old blood and pus began to flow from the mammary papilla, and an endoscopic nasobiliary drainage tube was placed. After his liver function had improved, the patient underwent laparoscopic cholecystectomy. His sample revealed that the gallbladder was filled with blood clots and stones. His postoperative course was uneventful and he was discharged on day 19 after the procedure. Although hemorrhagic cholecystitis is rare, it should be considered as a differential diagnosis for patients on dialysis who have acute abdominal symptoms. PMID:29033767

Epidemiology and mortality of liver abscess in end-stage renal disease dialysis patients: Taiwan national cohort study.

PubMed

Hong, Chon-Seng; Chung, Kun-Ming; Huang, Po-Chang; Wang, Jhi-Joung; Yang, Chun-Ming; Chu, Chin-Chen; Chio, Chung-Ching; Chang, Fu-Lin; Chien, Chih-Chiang

2014-01-01

To determine the incidence rates and mortality of liver abscess in ESRD patients on dialysis. Using Taiwan's National Health Insurance Research Database, we collected data from all ESRD patients who initiated dialysis between 2000 and 2006. Patients were followed until death, end of dialysis, or December 31, 2008. Predictors of liver abscess and mortality were identified using Cox models. Of the 53,249 incident dialysis patients identified, 447 were diagnosed as having liver abscesses during the follow-up period (224/100,000 person-years). The cumulative incidence rate of liver abscess was 0.3%, 1.1%, and 1.5% at 1 year, 5 years, and 7 years, respectively. Elderly patients and patients on peritoneal dialysis had higher incidence rates. The baseline comorbidities of diabetes mellitus, polycystic kidney disease, malignancy, chronic liver disease, biliary tract disease, or alcoholism predicted development of liver abscess. Overall in-hospital mortality was 10.1%. The incidence of liver abscess is high among ESRD dialysis patients. In addition to the well known risk factors of liver abscess, two other important risk factors, peritoneal dialysis and polycystic kidney disease, were found to predict liver abscess in ESRD dialysis patients.

Being-in-dialysis: The experience of the machine-body for home dialysis users.

PubMed

Shaw, Rhonda

2015-05-01

New Zealand leads the world in rates of home dialysis use, yet little is known about the experience of home dialysis from the patient's perspective. This article contributes to the literature on the self-care of dialysis patients by examining the relevance of the concept of the machine-body and cyborg embodiment for the lived experience of people with end-stage renal failure. The article, which presents a discussion of 24 in-depth interviews undertaken between 2009 and 2012, shows that although dialysis therapy is disruptive of being and time, study participants experience home dialysis in terms of flexibility, control and independence. While they do not use the term machine-body as a descriptor, the concept resonates with felt experience. Data also indicate that positive experience of home dialysis is relative to socio-economic positioning and the lived relation of patients to others, necessitating further research to examine these factors. © The Author(s) 2014.

Hospital based emergency department visits attributed to child physical abuse in United States: predictors of in-hospital mortality.

PubMed

Allareddy, Veerajalandhar; Asad, Rahimullah; Lee, Min Kyeong; Nalliah, Romesh P; Rampa, Sankeerth; Speicher, David G; Rotta, Alexandre T; Allareddy, Veerasathpurush

2014-01-01

To describe nationally representative outcomes of physical abuse injuries in children necessitating Emergency Department (ED) visits in United States. The impact of various injuries on mortality is examined. We hypothesize that physical abuse resulting in intracranial injuries are associated with worse outcome. We performed a retrospective analysis of the Nationwide Emergency Department Sample (NEDS), the largest all payer hospital based ED database, for the years 2008-2010. All ED visits and subsequent hospitalizations with a diagnosis of "Child physical abuse" (Battered baby or child syndrome) due to various injuries were identified using ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) codes. In addition, we also examined the prevalence of sexual abuse in this cohort. A multivariable logistic regression model was used to examine the association between mortality and types of injuries after adjusting for a multitude of patient and hospital level factors. Of the 16897 ED visits that were attributed to child physical abuse, 5182 (30.7%) required hospitalization. Hospitalized children were younger than those released treated and released from the ED (1.9 years vs. 6.4 years). Male or female partner of the child's parent/guardian accounted for >45% of perpetrators. Common injuries in hospitalized children include- any fractures (63.5%), intracranial injuries (32.3%) and crushing/internal injuries (9.1%). Death occurred in 246 patients (13 in ED and 233 following hospitalization). Amongst the 16897 ED visits, 1.3% also had sexual abuse. Multivariable analyses revealed each 1 year increase in age was associated with a lower odds of mortality (OR = 0.88, 95% CI = 0.81-0.96, p < 0.0001). Females (OR = 2.39, 1.07-5.34, p = 0.03), those with intracranial injuries (OR = 65.24, 27.57-154.41, p<0.0001), or crushing/internal injury (OR = 4.98, 2.24-11.07, p<0.0001) had higher odds of mortality compared to their male counterparts. In this

Reviewing and comparing self-concept in patients undergoing hemodialysis and peritoneal dialysis

PubMed Central

Shahgholian, Nahid; Tajdari, Setareh; Nasiri, Mahmoud

2012-01-01

Background: Chronic renal disease is a health problem in today’s world. In the end-stages of renal disease patients depend upon alternative therapies including dialysis for their survival. However, dialysis causes several stressors on physical, mental and social performance of patients. The present study aimed to review and compare the self-concept in patients undergoing hemodialysis and peritoneal dialysis. Materials and Methods: This was a case-control study including two groups of patients, undergoing hemodialysis and peritoneal dialysis, who referred to Al-Zahra and Ali Asghar Hospitals, which are affiliated to Isfahan University of Medical Sciences. These groups were compared to the control group. Data were collected through completing the form of demographic characteristics and a questionnaire, written by the researcher, pertaining to the self-concept which was collected by the samples. The data were analyzed by the Software SPSS version 18. Findings: ANOVA (analysis of variance) showed that statistically there was a significant difference between mean score of self-concept in the three physical (body-image), psychological, and social self aspects in the two groups of hemodialysis and peritoneal dialysis with the control group; however, Duncan’s post-hoc analysis showed no significant difference between mean score of self-concept in the three mentioned aspects in the two groups of hemodialysis and peritoneal dialysis. Furthermore, ANOVA (analysis of variance) showed that there was no significant difference between mean score of the spiritual aspect of the self-concept in the two groups of hemodialysis and peritoneal dialysis with the control group. Duncan’s post-hoc analysis also showed no significant difference in this aspect between the two groups of hemodialysis and peritoneal dialysis. Conclusions: Patients undergoing dialysis have many psychological disorders and the type of dialysis is not of much importance in this regard; therefore, adequate

Can dialysis patients be accurately identified using healthcare claims data?

PubMed

Taneja, Charu; Berger, Ariel; Inglese, Gary W; Lamerato, Lois; Sloand, James A; Wolff, Greg G; Sheehan, Michael; Oster, Gerry

2014-01-01

While health insurance claims data are often used to estimate the costs of renal replacement therapy in patients with end-stage renal disease (ESRD), the accuracy of methods used to identify patients receiving dialysis - especially peritoneal dialysis (PD) and hemodialysis (HD) - in these data is unknown. The study population consisted of all persons aged 18 - 63 years in a large US integrated health plan with ESRD and dialysis-related billing codes (i.e., diagnosis, procedures) on healthcare encounters between January 1, 2005, and December 31, 2008. Using billing codes for all healthcare encounters within 30 days of each patient's first dialysis-related claim ("index encounter"), we attempted to designate each study subject as either a "PD patient" or "HD patient." Using alternative windows of ± 30 days, ± 90 days, and ± 180 days around the index encounter, we reviewed patients' medical records to determine the dialysis modality actually received. We calculated the positive predictive value (PPV) for each dialysis-related billing code, using information in patients' medical records as the "gold standard." We identified a total of 233 patients with evidence of ESRD and receipt of dialysis in healthcare claims data. Based on examination of billing codes, 43 and 173 study subjects were designated PD patients and HD patients, respectively (14 patients had evidence of PD and HD, and modality could not be ascertained for 31 patients). The PPV of codes used to identify PD patients was low based on a ± 30-day medical record review window (34.9%), and increased with use of ± 90-day and ± 180-day windows (both 67.4%). The PPV for codes used to identify HD patients was uniformly high - 86.7% based on ± 30-day review, 90.8% based on ± 90-day review, and 93.1% based on ± 180-day review. While HD patients could be accurately identified using billing codes in healthcare claims data, case identification was much more problematic for patients receiving PD. Copyright �

Home-based versus hospital-based postnatal care: a randomised trial.

PubMed

Boulvain, Michel; Perneger, Thomas V; Othenin-Girard, Véronique; Petrou, Stavros; Berner, Michel; Irion, Olivier

2004-08-01

To compare a shortened hospital stay with midwife visits at home to usual hospital care after delivery. Randomised controlled trial. Maternity unit of a Swiss teaching hospital. Four hundred and fifty-nine women with a single uncomplicated pregnancy at low risk of caesarean section. Women were randomised to either home-based (n= 228) or hospital-based postnatal care (n= 231). Home-based postnatal care consisted of early discharge from hospital (24 to 48 hours after delivery) and home visits by a midwife; women in the hospital-based care group were hospitalised for four to five days. Breastfeeding 28 days postpartum, women's views of their care and readmission to hospital. Women in the home-based care group had shorter hospital stays (65 vs 106 hours, P < 0.001) and more midwife visits (4.8 vs 1.7, P < 0.001) than women in the hospital-based care group. Prevalence of breastfeeding at 28 days was similar between the groups (90%vs 87%, P= 0.30), but women in the home-based care group reported fewer problems with breastfeeding and greater satisfaction with the help received. There were no differences in satisfaction with care, women's hospital readmissions, postnatal depression scores and health status scores. A higher percentage of neonates in the home-based care group were readmitted to hospital during the first six months (12%vs 4.8%, P= 0.004). In low risk pregnancies, early discharge from hospital and midwife visits at home after delivery is an acceptable alternative to a longer duration of care in hospital. Mothers' preferences and economic considerations should be taken into account when choosing a policy of postnatal care.

An education initiative modifies opinions of hemodialysis nurses towards home dialysis.

PubMed

Phillips, Matthew; Wile, Colleen; Bartol, Carolyn; Stockman, Cynthia; Dhir, Minakshi; Soroka, Steven D; Hingwala, Jay; Bargman, Joanne M; Chan, Christopher T; Tennankore, Karthik K

2015-01-01

It has been shown that in-center hemodialysis (HD) nurses prefer in-center HD for patients with certain characteristics; however it is not known if their opinions can be changed. To determine if an education initiative modified the perceptions of in-center HD nurses towards home dialysis. Cross-sectional survey of in-center HD nurses before and after a three hour continuing nursing education (CNE) initiative. Content of the CNE initiative included a didactic review of benefits of home dialysis, common misconceptions about patient eligibility, cost comparisons of different modalities and a home dialysis patient testimonial video. All in-center HD nurses (including those working in satellite dialysis units) affiliated with a single academic institution. Survey themes included perceived barriers to home dialysis, preferred modality (home versus in-center HD), ideal modality distribution in the local program, awareness of home dialysis and patient education about home modalities. Paired comparisons of responses before and after the CNE initiative. Of the 115 in-center HD nurses, 100 registered for the CNE initiative and 89 completed pre and post surveys (89% response rate). At baseline, in-center HD nurses perceived that impaired cognition, poor motor strength and poor visual acuity were barriers to peritoneal dialysis and home HD. In-center HD was preferred for availability of multidisciplinary care and medical personnel in case of catastrophic events. After the initiative, perceptions were more in favor of home dialysis for all patient characteristics, and most patient/system factors. Home dialysis was perceived to be underutilized both at baseline and after the initiative. Finally, in-center HD nurses were more aware of home dialysis, felt better informed about its benefits and were more comfortable teaching in-center HD patients about home modalities after the CNE session. Single-center study. CNE initiatives can modify the opinions of in-center HD nurses towards

Haemodialysis in a rural area: a demanding form of treatment.

PubMed

Brammah, A; Young, G; Allan, A; Robertson, S; Norrie, J; Isles, C

2001-09-01

To determine distances travelled and time spent waiting for transport among hospital haemodialysis patients living in a rural area. Cross sectional survey comparing the subregional dialysis unit in south west Scotland with 12 of the other 13 Scottish Adult Renal Units. Forty three Dumfries and Galloway patients and 935 other Scottish patients receiving hospital haemodialysis in November 1999. At the time of the survey 8/43 (19%) Dumfries patients travelled in excess of 100 miles per dialysis day (15,000 miles per year) solely for the purpose of dialysis, compared to 20/935 (2%) elsewhere in Scotland (p < 0.001). Twenty seven (63%) Dumfries and 594 (64%) patients in other Scottish Units relied on hospital car, Patient Transport Service bus or ambulance for the journey home after treatment. Dumfries patients who travelled by Patient Transport Service or hospital ambulance had to wait twice as long before they left the renal unit as patients using a dedicated hospital car or private car. Haemodialysis in a rural area has every reason to be considered a demanding form of treatment. Greater promotion of home based treatment would improve the quality of life for many of these patients, while dedicated hospital cars would reduce 'car to needle time' for those who remain on hospital haemodialysis.

Challenges of hemodialysis in Vietnam: experience from the first standardized district dialysis unit in Ho Chi Minh City.

PubMed

Duong, Cuong Minh; Olszyna, Dariusz Piotr; Nguyen, Phong Duy; McLaws, Mary-Louise

2015-08-01

Hemodialysis is an increasingly common treatment in Vietnam as the diagnosis of end stage renal disease continues to rise. To provide appropriate hemodialysis treatment for end-stage renal disease patients, we conducted a 1-year cross-sectional study to measure the prevalence of bloodborne infection and factors associated with non-compliant behaviors in hemodialysis patients. One hundred forty-two patients were tested for hepatitis B virus (HBV) surface antigen and hepatitis C virus (HCV) core antigen. They provided demographic, medical and dialysis information. Non-compliant behaviors were obtained from their medical records. Overall, 99 % of patients reused their dialyzers and 46 % had arteriovenous fistula on admission. Both HBV and HCV equally accounted for 8 % of patients and concurrent infection accounted for 1 %. Non-compliance rates of dietary and medication were 39 and 27 % respectively. 42 % of patients missed hemodialysis session, 8 % were verbally or physically abusive and 9 % were non-cooperative. Of the 54 % catheterized patients, 7 % improperly cared for their dialysis access. Dietary non-adherence was associated with male patients (p = 0.03) and medication non-adherence was associated with younger age (p = 0.05). Duration between diagnosis of chronic kidney disease and initiation of hemodialysis was associated with improper care of dialysis access (p = 0.04). Time on hemodialysis was associated with missed hemodialysis session (p = 0.007) and verbal or physical abuse (p = 0.01). Health services need to provide safe practice for dialyzer reuse given the endemicity of hepatitis. We believe a national survey similar to ours about seroprevalence and infection control challenges would prepare Vietnam for providing safer satellite treatment units. Safe hemodialysis services should also comprise patient preparedness, education and counseling.

Organizational effects on patient satisfaction in hospital medical-surgical units.

PubMed

Bacon, Cynthia Thornton; Mark, Barbara

2009-05-01

The purpose of this study was to examine the relationships between hospital context, nursing unit structure, and patient characteristics and patients' satisfaction with nursing care in hospitals. Although patient satisfaction has been widely researched, our understanding of the relationship between hospital context and nursing unit structure and their impact on patient satisfaction is limited. The data source for this study was the Outcomes Research in Nursing Administration Project, a multisite organizational study conducted to investigate relationships among nurse staffing, organizational context and structure, and patient outcomes. The sample for this study was 2,720 patients and 3,718 RNs in 286 medical-surgical units in 146 hospitals. Greater availability of nursing unit support services and higher levels of work engagement were associated with higher levels of patient satisfaction. Older age, better health status, and better symptom management were also associated with higher levels of patient satisfaction. Organizational factors in hospitals and nursing units, particularly support services on the nursing unit and mechanisms that foster nurses' work engagement and effective symptom management, are important influences on patient satisfaction.

Design, Planning and Management of the Hospital Custody Unit at Hospital Universitario Fundación Alcorcón.

PubMed

Fuente-Martín, C de la; Fuente Martín, B de la; Grifol-Clar, E

2017-12-01

The design and management of a Hospital Custody Unit at Hospital Universitario Fundación Alcorcón, to focus the aim of this study on specialized medical care for extra-penitentiary patients who have suffered from a disease. We are building a new space to facilitate their daily lives at hospital and we want to offer a double function to the patients that consists of a custody space and a health rehabilitation space. We carried out a scientific literature search on the international and national databases, about Hospital Custody Units or Restricted Access Units. The language of the reviews that we checked was English and Spanish. We wrote the Action Guide of the Hospital Custody Unit for the design, planning and management of the Hospital Custody Unit at Hospital Universitario Fundación Alcorcón. (We included complementary bibliographic material and the Quick Guide in the Unit). The Hospital Custody Unit will be compatible with medical activity, occupational safety and the custody of patients that are in prison. We thus require consensus with police departments about custody protocols along with assistance from the clinicians' teams at penitentiary centers and referral hospitals. Furthermore, it is important to step up special care for mental health and to promote telemedicine and new technologies to streamline medical care along with coordination with healthcare professionals.

Peritoneal dialysis: a primary care perspective.

PubMed

Saxena, Ramesh; West, Cheryl

2006-01-01

As the population of chronic kidney disease (CKD) and end-stage renal disease (ESRD) grows at an alarming rate, primary care physicians will increasingly be involved in the management of these patients. Early recognition of CKD and timely referral to a nephrologist when glomerular filtration rate approaches 30 mL/min/1.73 m(2) is extremely important to improve ESRD outcome and appropriate selection of dialysis modality. Peritoneal dialysis (PD) remains a viable treatment option for ESRD patients. PD is less expensive dialysis modality and may provide a survival advantages over hemodialysis in first 2 to 4 years of treatment. Preserving residual renal function (RRF) is of paramount importance to prolong the survival outcomes in PD patients. Thus preservation of RRF is an important goal in the management of PD patients. Every effort should be made to avoid nephrotoxic drugs like aminoglycosides and nonsteroidal anti-inflammatory drugs, and limit the use of radiocontrast agents in PD patients with RRF. Judicious use of prophylactic antibiotics to prevent peritonitis would further help to reduce morbidity from PD. Protecting peritoneal membrane from long-term toxic and metabolic effects of the conventional glucose-based solutions is another objective to further improve PD outcome. Development of new, more biocompatible PD solutions holds promise for the future. One such solution, icodextrin, is now approved for use in the United States. Although extremely safe to use, it is associated with unique metabolic effects that may concern primary care physicians. They include false elevation of blood glucose, a reversible increase in serum alkaline phosphatase and a false decline in serum amylase. Monitoring of glycemia by assays that use glucose dehydrogenase pyrroloquinoline quinone enzymes should be avoided and serum amylase alone should not be relied on in diagnosing pancreatitis in patients on icodextrin.

Darbepoetin alfa therapeutic interchange protocol for anemia in dialysis.

PubMed

Brophy, Donald F; Ripley, Elizabeth Bd; Kockler, Denise R; Lee, Seina; Proeschel, Lori A

2005-11-01

Erythropoiesis-stimulating proteins, such as erythropoietin alfa and darbepoetin alfa, have positively impacted anemia management. These medications improve patient outcomes and quality of life. Their costs, however, remain a major barrier for health systems. To evaluate the development, implementation, and cost-effectiveness of an inpatient therapeutic interchange protocol for erythropoiesis-stimulating proteins at a large, tertiary care, university-affiliated health system. Virginia Commonwealth University Health System (VCUHS) developed and implemented a therapeutic interchange program to convert therapy for all inpatients undergoing dialysis from erythropoietin alfa to darbepoetin alfa for treatment of chronic kidney disease-related anemia. An evaluation of the economic impact of this program on drug expenditures over a fiscal quarter (2003) was conducted using historical comparator data (2002). Preliminary evaluation of the program demonstrated cost-savings and reduced drug utilization of erythropoiesis-stimulating proteins in hospitalized dialysis patients. For the first quarter of 2003 compared with the first quarter of 2002, VCUHS realized a cost-savings of nearly 10,000 US dollars, which was related to the program's aggressive screening procedure. When these data were normalized for equal numbers of patients in each group receiving one of the drugs, the actual cost-savings was over 2000 US dollars. These cost-savings are largely due to reduced utilization of these expensive biotechnology products with implementation of a dosing protocol. VCUHS has successfully developed and implemented a darbepoetin alfa therapeutic interchange protocol for hospitalized dialysis patients. This has translated into reduced use of erythropoiesis-stimulating proteins, resulting in cost-savings for the health system.

Peritoneal dialysis vs. haemodialysis in the management of paediatric acute kidney injury in Kano, Nigeria: a cost analysis.

PubMed

Obiagwu, Patience N; Abdu, Aliyu

2015-01-01

To determine the cost of the dialytic management of paediatric acute kidney injury in a low-income country. All children under the age of 15 years, who had either peritoneal dialysis or haemodialysis for acute kidney injury in Aminu Kano Teaching Hospital over a 1-year period, were studied. The average cost of each dialysis modality was estimated. Of 20 children, who had dialysis for acute kidney injury, 12 (60%) had haemodialysis and 8 (40%) had peritoneal dialysis. The mean cost for haemodialysis exceeded that of peritoneal dialysis ($363.33 vs. $311.66, t = 1.04, P = 0.313) with the mean cost of consumables significantly accounting for most of the cost variation ($248.49 vs. $164.73, t = 2.91, P = 0.009). Mean costs of nephrologist visit and nursing were not found to be significant. Peritoneal dialysis is the less costly alternative for managing acute kidney injury in children in our environment. © 2014 John Wiley & Sons Ltd.

Risk factors for unplanned and crash dialysis starts: a protocol for a systematic review and meta-analysis.

PubMed

Molnar, Amber O; Hiremath, Swapnil; Brown, Pierre A; Akbari, Ayub

2016-07-19

Many patients with kidney failure "crash" onto dialysis or initiate dialysis in an unplanned fashion. There are varying definitions, but essentially, a patient is labeled as having a crash dialysis start if he or she has little to no care by a nephrologist prior to starting dialysis. A patient is labeled as having an unplanned dialysis start when he or she starts dialysis with a catheter or during a hospitalization. Given the high prevalence and poor outcomes associated with crash and unplanned dialysis starts, it is important to establish a better understanding of patient risk factors. We will conduct a systematic review and meta-analysis with a focus on both crash and unplanned dialysis starts. The first objective will be to determine patient risk factors for crash and unplanned dialysis starts. Secondary objectives will be to determine the most common criteria used to define both crash and unplanned dialysis starts and to determine outcomes associated with crash and unplanned dialysis starts. We will search MEDLINE, EMBASE and Cochrane Library from inception to the present date for all studies that report the characteristics and outcomes of patients who have crash vs. non-crash dialysis starts or unplanned vs. planned dialysis starts. We will also extract from included studies the criteria used to define crash and unplanned dialysis starts. If there are any eligible randomized controlled trials, quality assessment will be performed using the Cochrane Risk of Bias Assessment Tool. Observational studies will be evaluated using the Newcastle-Ottawa Scale. Data will be pooled in meta-analysis if deemed appropriate. The results of this review will inform the design of strategies to help reduce the incidence of crash and unplanned dialysis starts. Prospero CRD42016032916.

Cognitive Impairment in Non-Dialysis-Dependent CKD and the Transition to Dialysis: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study.

PubMed

Harhay, Meera N; Xie, Dawei; Zhang, Xiaoming; Hsu, Chi-Yuan; Vittinghoff, Eric; Go, Alan S; Sozio, Stephen M; Blumenthal, Jacob; Seliger, Stephen; Chen, Jing; Deo, Rajat; Dobre, Mirela; Akkina, Sanjeev; Reese, Peter P; Lash, James P; Yaffe, Kristine; Tamura, Manjula Kurella

2018-05-02

Advanced chronic kidney disease is associated with elevated risk for cognitive impairment. However, it is not known whether and how cognitive impairment is associated with planning and preparation for end-stage renal disease. Retrospective observational study. 630 adults participating in the CRIC (Chronic Renal Insufficiency Cohort) Study who had cognitive assessments in late-stage CKD, defined as estimated glome-rular filtration rate ≤ 20mL/min/1.73m 2 , and subsequently initiated maintenance dialysis therapy. Predialysis cognitive impairment, defined as a score on the Modified Mini-Mental State Examination lower than previously derived age-based threshold scores. Covariates included age, race/ethnicity, educational attainment, comorbid conditions, and health literacy. Peritoneal dialysis (PD) as first dialysis modality, preemptive permanent access placement, venous catheter avoidance at dialysis therapy initiation, and preemptive wait-listing for a kidney transplant. Multivariable-adjusted logistic regression. Predialysis cognitive impairment was present in 117 (19%) participants. PD was the first dialysis modality among 16% of participants (n=100), 75% had preemptive access placed (n=473), 45% avoided using a venous catheter at dialysis therapy initiation (n=279), and 20% were preemptively wait-listed (n=126). Predialysis cognitive impairment was independently associated with 78% lower odds of PD as the first dialysis modality (adjusted OR [aOR], 0.22; 95% CI, 0.06-0.74; P=0.02) and 42% lower odds of venous catheter avoidance at dialysis therapy initiation (aOR, 0.58; 95% CI, 0.34-0.98; P=0.04). Predialysis cognitive impairment was not independently associated with preemptive permanent access placement or wait-listing. Potential unmeasured confounders; single measure of cognitive function. Predialysis cognitive impairment is associated with a lower likelihood of PD as a first dialysis modality and of venous catheter avoidance at dialysis therapy

Improving adjustment to chronic illness through strategic self-presentation: an experimental study on a renal dialysis unit.

PubMed

Leake, R; Friend, R; Wadhwa, N

1999-01-01

Laboratory studies show that strategic self-presentations strongly influence private self-evaluations. The present study experimentally manipulated self-presentations of dialysis patients' coping skills in order to influence their adjustment. In all, 42 renal dialysis patients matched for diabetes, gender, and dialysis years were randomly assigned to 3 conditions; adjustment was assessed at baseline, post-intervention, and 1 month follow-up. Patients in a self-presentation condition selectively presented themselves as successful copers in a videotaped interview, ostensibly as part of a training program for new patients. Patients in a problem disclosure condition discussed problems with managing their illness. Control group patients viewed a medical videotape about adjusting to dialysis. Patients in the self-presentation condition reported better adjustment, fewer physical symptoms, and more coping skills 1 month later, compared with patients in the other 2 conditions. In addition, coping skills were shown to mediate the relationship between strategic self-presentation and adjustment.

[Why hospitalize stroke patients in a specialized unit?].

PubMed

Jaillard, A; Hommel, M

1999-01-30

A PUBLIC HEALTH CHALLENGE: Cerebral vascular events are the third most frequent cause of death in the adult population and the number one cause of disabilities, a public health challenge both in terms of health care service and health care expenditures. Structured health care facilities, particularly specialized hospital units, can lower mortality, limit residual disability and reduce the need for long-term institutionalization. Specialized research and teaching units are paradigmatic of the impact of health care organization. The limited number of such specialized units in France raises important ethical considerations about effective access to health care. Functioning units could be a useful criteria for auditing quality of hospital facilities.

Epidemiology and Mortality of Liver Abscess in End-Stage Renal Disease Dialysis Patients: Taiwan National Cohort Study

PubMed Central

Huang, Po-Chang; Wang, Jhi-Joung; Yang, Chun-Ming; Chu, Chin-Chen; Chio, Chung-Ching; Chang, Fu-Lin; Chien, Chih-Chiang

2014-01-01

Background and Objectives To determine the incidence rates and mortality of liver abscess in ESRD patients on dialysis. Design, Setting, Participants, & Measurements Using Taiwan’s National Health Insurance Research Database, we collected data from all ESRD patients who initiated dialysis between 2000 and 2006. Patients were followed until death, end of dialysis, or December 31, 2008. Predictors of liver abscess and mortality were identified using Cox models. Results Of the 53,249 incident dialysis patients identified, 447 were diagnosed as having liver abscesses during the follow-up period (224/100,000 person-years). The cumulative incidence rate of liver abscess was 0.3%, 1.1%, and 1.5% at 1 year, 5 years, and 7 years, respectively. Elderly patients and patients on peritoneal dialysis had higher incidence rates. The baseline comorbidities of diabetes mellitus, polycystic kidney disease, malignancy, chronic liver disease, biliary tract disease, or alcoholism predicted development of liver abscess. Overall in-hospital mortality was 10.1%. Conclusions The incidence of liver abscess is high among ESRD dialysis patients. In addition to the well known risk factors of liver abscess, two other important risk factors, peritoneal dialysis and polycystic kidney disease, were found to predict liver abscess in ESRD dialysis patients. PMID:24551077

[News in peritoneal dialysis].

PubMed

Ryckelynck, Jean-Philippe; Lobbedez, Thierry; Ficheux, Maxence; Bonnamy, Cécile; El Haggan, Waël; Henri, Patrick; Chatelet, Valérie; Levaltier, Béatrice; Hurault de Ligny, Bruno

2007-12-01

Peritoneal dialysis, like hemodialysis, is a first-line therapy for patients with end-stage renal disease. Progress in medical devices and materials has reduced infectious complications such as peritonitis and catheter exit-site infections and thus decreased morbidity. Peritoneal dialysis fluids are increasingly biocompatible, result in fewer glucose degradation products, protect the peritoneal membrane better and thus improve tolerance. The maintenance of residual renal function, together with better comfort and no pain, help control the fluid and sodium balance. Automated peritoneal dialysis can be performed each night, either autonomously or assisted by a visiting nurse twice a day (to prepare, connect, and disconnect the machine). This treatment can thus be provided to most patients, regardless of their age. Peritoneal dialysis is indicated principally for young people waiting for a kidney transplantation (to preserve their vascular network), elderly patients who wish to remain either at home or in an institution, and patients with cardiac insufficiency, because of the better hemodynamic tolerance. Numerous obstacles, mainly nonmedical, still impede the development of peritoneal dialysis. Patients seen in emergencies start hemodialysis without necessarily receiving any information about peritoneal dialysis. Indeed, neither physicians nor patients receive adequate information.

Predicting Early Death Among Elderly Dialysis Patients: Development and Validation of a Risk Score to Assist Shared Decision Making for Dialysis Initiation.

PubMed

Thamer, Mae; Kaufman, James S; Zhang, Yi; Zhang, Qian; Cotter, Dennis J; Bang, Heejung

2015-12-01

A shared decision-making tool could help elderly patients with advanced chronic kidney disease decide about initiating dialysis therapy. Because mortality may be high in the first few months after initiating dialysis therapy, incorporating early mortality predictors in such a tool would be important for an informed decision. Our objective is to derive and validate a predictive risk score for early mortality after initiating dialysis therapy. Retrospective observational cohort, with development and validation cohorts. US Renal Data System and claims data from the Centers for Medicare & Medicaid Services for 69,441 (aged ≥67 years) patients with end-stage renal disease with a previous 2-year Medicare history who initiated dialysis therapy from January 1, 2009, to December 31, 2010. Demographics, predialysis care, laboratory data, functional limitations, and medical history. All-cause mortality in the first 3 and 6 months. Predicted mortality by logistic regression. The simple risk score (total score, 0-9) included age (0-3 points), low albumin level, assistance with daily living, nursing home residence, cancer, heart failure, and hospitalization (1 point each), and showed area under the receiver operating characteristic curve (AUROC)=0.69 in the validation sample. A comprehensive risk score with additional predictors was also developed (with AUROC=0.72, high concordance between predicted vs observed risk). Mortality probabilities were estimated from these models, with the median score of 3 indicating 12% risk in 3 months and 20% in 6 months, and the highest scores (≥8) indicating 39% risk in 3 months and 55% in 6 months. Patients who did not choose dialysis therapy and did not have a 2-year Medicare history were excluded. Routinely available information can be used by patients with chronic kidney disease, families, and their nephrologists to estimate the risk of early mortality after dialysis therapy initiation, which may facilitate informed decision making

Comparing clinical and demographic characteristics of people with mental illness in hospital- and community-based residential rehabilitation units in Queensland.

PubMed

Meehan, Tom; Stedman, Terry; Parker, Stephen; Curtis, Bretine; Jones, Donna

2017-05-01

Objective The aim of the present study was to examine care pathways and characteristics of mental health consumers participating in both hospital- and community-based residential rehabilitation programs. Methods An audit of consumers (n=240) in all publicly funded residential rehabilitation units in Queensland was performed on the same day in 2013. Data collection focused on demographic characteristics, clinical information and measures of consumer functioning. Results Significant differences emerged for consumers in community- and hospital-based services with regard to age, length of stay, functioning, Mental Health Act status, guardianship status, family contact and risk of violence. Consumers in hospital-based programs have more severe and complex problems. Conclusions Consumers in residential rehabilitation units have high levels of disability, poor physical health and high levels of vulnerability. Nonetheless, it is likely that a sizeable proportion of consumers occupying rehabilitation beds in Queensland could be discharged if more 'step-down' options to move patients on were available. What is known about the topic? A small subgroup of people with severe and complex mental health problems is likely to require time in a residential rehabilitation program. This group is characterised by failure to respond to treatment, severe negative symptoms and some degree of cognitive impairment. What does this paper add? Patients currently occupying residential rehabilitation beds in Queensland have high levels of disability, poor physical health and high levels of vulnerability. Patients in hospital-based programs are more severely disabled than those in community-based programs. What are the implications for practitioners? It is likely that a sizeable proportion of patients occupying rehabilitation beds in Queensland could be discharged if more 'step-down' options were available. Future planning initiatives need to focus on developing a greater array of community

Enhanced H-filter based on Fåhræus-Lindqvist effect for efficient and robust dialysis without membrane

PubMed Central

Zheng, Wei-Chao; Xie, Rui; He, Li-Qun; Xi, Yue-Heng; Liu, Ying-Mei; Meng, Zhi-Jun; Wang, Wei; Ju, Xiao-Jie; Chen, Gang; Chu, Liang-Yin

2015-01-01

A novel microfluidic device for highly efficient and robust dialysis without membrane is highly desired for the development of portable or wearable microdialyzer. Here we report an enhanced H-filter with pillar array based on Fåhræus-Lindqvist effect (F-L effect) for highly efficient and robust membraneless dialysis of simplified blood for the first time. The H-filter employs two fluids laminarly flowing in the microchannel for continuously membraneless dialysis. With pillar array in the microchannel, the two laminar flows, with one containing blood cells and small molecules and another containing dialyzate solution, can form a cell-free layer at the interface as selective zones for separation. This provides enhanced mixing yet extremely low shear for extraction of small molecules from the blood-cell-containing flow into the dialyzate flow, resulting in robust separation with reduced cell loss and improved efficiency. We demonstrate this by first using Chlorella pyrenoidosa as model cells to quantitatively study the separation performances, and then using simplified human blood for dialysis. The advanced H-filter, with highly efficient and robust performance for membraneless dialysis, shows great potential as promising candidate for rapid blood analysis/separation, and as fundamental structure for portable dialyzer. PMID:26339313

Enhanced H-filter based on Fåhræus-Lindqvist effect for efficient and robust dialysis without membrane.

PubMed

Zheng, Wei-Chao; Xie, Rui; He, Li-Qun; Xi, Yue-Heng; Liu, Ying-Mei; Meng, Zhi-Jun; Wang, Wei; Ju, Xiao-Jie; Chen, Gang; Chu, Liang-Yin

2015-07-01

A novel microfluidic device for highly efficient and robust dialysis without membrane is highly desired for the development of portable or wearable microdialyzer. Here we report an enhanced H-filter with pillar array based on Fåhræus-Lindqvist effect (F-L effect) for highly efficient and robust membraneless dialysis of simplified blood for the first time. The H-filter employs two fluids laminarly flowing in the microchannel for continuously membraneless dialysis. With pillar array in the microchannel, the two laminar flows, with one containing blood cells and small molecules and another containing dialyzate solution, can form a cell-free layer at the interface as selective zones for separation. This provides enhanced mixing yet extremely low shear for extraction of small molecules from the blood-cell-containing flow into the dialyzate flow, resulting in robust separation with reduced cell loss and improved efficiency. We demonstrate this by first using Chlorella pyrenoidosa as model cells to quantitatively study the separation performances, and then using simplified human blood for dialysis. The advanced H-filter, with highly efficient and robust performance for membraneless dialysis, shows great potential as promising candidate for rapid blood analysis/separation, and as fundamental structure for portable dialyzer.

Pro: Higher serum bicarbonate in dialysis patients is protective.

PubMed

Misra, Madhukar

2016-08-01

Chronic metabolic acidosis is common in dialysis patients. Bicarbonate administration via the dialysate helps maintain the acid-base balance in these patients. Serum bicarbonate level in dialysis patients is determined by several factors that include dietary protein intake, nutritional status and dialysis prescription, etc. Additionally, a meaningful interpretation of serum bicarbonate in dialysis patients requires an understanding of complexities involving its measurement. Both very low as well very high levels of serum bicarbonate have been associated with adverse outcomes in observational studies. However, recent observational data, when adjusted for the confounding effects of nutritional status, do not associate higher predialysis serum bicarbonate with adverse consequences. At this time, there are no prospective studies available that have examined the association of serum bicarbonate with hard outcomes in dialysis patients. The ideal level of serum bicarbonate in dialysis patients is therefore unknown. This article examines the available data with regard to the benefits of higher predialysis serum bicarbonate. © The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Systems Thinking and Leadership: How Nephrologists Can Transform Dialysis Safety to Prevent Infections.

PubMed

Wong, Leslie P

2018-04-06

Infections are the second leading cause of death for patients with ESKD. Despite multiple efforts, nephrologists have been unable to prevent infections in dialysis facilities. The American Society of Nephrology and the Centers for Disease Control and Prevention have partnered to create Nephrologists Transforming Dialysis Safety to promote nephrologist leadership and engagement in efforts to "Target Zero" preventable dialysis infections. Because traditional approaches to infection control and prevention in dialysis facilities have had limited success, Nephrologists Transforming Dialysis Safety is reconceptualizing the problem in the context of the complexity of health care systems and organizational behavior. By identifying different parts of a problem and attempting to understand how these parts interact and produce a result, systems thinking has effectively tackled difficult problems in dynamic settings. The dialysis facility is composed of different physical and human elements that are interconnected and affect not only behavior but also, the existence of a culture of safety that promotes infection prevention. Because dialysis infections result from a complex system of interactions between caregivers, patients, dialysis organizations, and the environment, attempts to address infections by focusing on one element in isolation often fail. Creating a sense of urgency and commitment to eradicating dialysis infections requires leadership and motivational skills. These skills are not taught in the standard nephrology or medical director curriculum. Effective leadership by medical directors and engagement in infection prevention by nephrologists are required to create a culture of safety. It is imperative that nephrologists commit to leadership training and embrace their potential as change agents to prevent infections in dialysis facilities. This paper explores the systemic factors contributing to the ongoing dialysis infection crisis in the United States and the role

Peritoneal dialysis for older people: overcoming the barriers.

PubMed

Brown, E A

2008-04-01

The proportion of older dialysis patients on peritoneal dialysis (PD) is considerably lower than that of younger patients. This is despite the fact that clinical outcome studies show that older patients cope at least as well as younger patients with PD, and that many older patients do not cope well with hemodialysis (HD). Barriers to PD include medical and social factors, physician bias, late referral, and education not tailored to the needs of older patients. The development of assisted PD can overcome some of the barriers and enable frail older patients to have home-based dialysis treatment.

Multidirectional approach to study peritoneal dialysis fluid biocompatibility in a chronic peritoneal dialysis model in the rat.

PubMed

Wieczorowska-Tobis, K; Polubinska, A; Wisniewska, J; Pawlaczyk, K; Kuzlan-Pawlaczyk, M; Filas, V; Breborowicz, A; Oreopoulos, D G

2001-03-01

Peritoneal dialysis causes the functional and morphological changes in the peritoneum that result from the bioincompatibility of dialysis solutions. We present a model of chronic peritoneal dialysis in the rat that can be used for testing the biocompatibility of dialysis fluids. Methods and Results. Long-term exposure of the peritoneum to dialysis solutions can be performed in rats with implanted peritoneal catheters. Sampling of the dialysate allows the evaluation of intraperitoneal inflammation by examining cell differential and dialysate cytokine levels. Peritoneal permeability can be evaluated at designed time intervals with the peritoneal equilibration test (PET). At the end of dialysis, peritoneal histology is studied with light and electron microscopy. Such a multidirectional approach is an effective way to test biocompatibility of dialysis solutions.

Glycemic Control Modifies Difference in Mortality Risk Between Hemodialysis and Peritoneal Dialysis in Incident Dialysis Patients With Diabetes

PubMed Central

Lee, Mi Jung; Kwon, Young Eun; Park, Kyoung Sook; Kee, Youn Kyung; Yoon, Chang-Yun; Han, In Mee; Han, Seung Gyu; Oh, Hyung Jung; Park, Jung Tak; Han, Seung Hyeok; Yoo, Tae-Hyun; Kim, Yong-Lim; Kim, Yon Su; Yang, Chul Woo; Kim, Nam-Ho; Kang, Shin-Wook

2016-01-01

Abstract Although numerous studies have tried to elucidate the best dialysis modality in end-stage renal disease patients with diabetes, results were inconsistent and varied with the baseline characteristics of patients. Furthermore, none of the previous studies on diabetic dialysis patients accounted for the impact of glycemic control. We explored whether glycemic control had modifying effect on mortality between hemodialysis (HD) and peritoneal dialysis (PD) in incident dialysis patients with diabetes. A total of 902 diabetic patients who started dialysis between August 2008 and December 2013 were included from a nationwide prospective cohort in Korea. Based on the interaction analysis between hemoglobin A1c (HbA1c) and dialysis modalities for patient survival (P for interaction = 0.004), subjects were stratified into good and poor glycemic control groups (HbA1c< or ≥8.0%). Differences in survival rates according to dialysis modalities were ascertained in each glycemic control group after propensity score matching. During a median follow-up duration of 28 months, the relative risk of death was significantly lower in PD compared with HD in the whole cohort and unmatched patients (whole cohort, hazard ratio [HR] = 0.65, 95% confidence interval [CI] = 0.47–0.90, P = 0.01; patients with available HbA1c [n = 773], HR = 0.64, 95% CI = 0.46–0.91, P = 0.01). In the good glycemic control group, there was a significant survival advantage of PD (HbA1c <8.0%, HR = 0.59, 95% CI = 0.37–0.94, P = 0.03). However, there was no significant difference in survival rates between PD and HD in the poor glycemic control group (HbA1c ≥8.0%, HR = 1.21, 95% CI = 0.46–2.76, P = 0.80). This study demonstrated that the degree of glycemic control modified the mortality risk between dialysis modalities, suggesting that glycemic control might partly contribute to better survival of PD in incident dialysis patients with diabetes

Introduction of Renal Key Performance Indicators Associated with Increased Uptake of Peritoneal Dialysis in a Publicly Funded Health Service.

PubMed

Toussaint, Nigel D; McMahon, Lawrence P; Dowling, Gregory; Holt, Stephen G; Smith, Gillian; Safe, Maria; Knight, Richard; Fair, Kathleen; Linehan, Leanne; Walker, Rowan G; Power, David A

2017-01-01

♦ BACKGROUND: Increased demand for treatment of end-stage kidney disease has largely been accommodated by a costly increase in satellite hemodialysis (SHD) in most jurisdictions. In the Australian State of Victoria, a marked regional variation in the uptake of home-based dialysis suggests that use of home therapies could be increased as an alternative to SHD. An earlier strategy based solely on increased remuneration had failed to increase uptake of home therapies. Therefore, the public dialysis funder adopted the incidence and prevalence of home-based dialysis therapies as a key performance indicator (KPI) for its health services to encourage greater uptake of home therapies. ♦ METHODS: A KPI data collection and bench-marking program was established in 2012 by the Victorian Department of Health and Human Services, with data provided monthly by all renal units in Victoria using a purpose-designed website portal. A KPI Working Group was responsible for analyzing data each quarter and ensuring indicators remained accurate and relevant and each KPI had clear definitions and targets. We present a prospective, observational study of all dialysis patients in Victoria over a 4-year period following the introduction of the renal KPI program, with descriptive analyses to evaluate the proportion of patients using home therapies as well as home dialysis modality survival. ♦ RESULTS: Following the introduction of the KPI program, the net growth of dialysis patient numbers in Victoria remained stable over 4 years, at 75 - 80 per year (approximately 4%). However, unlike the previous decade, about 40% of this growth was through an increase in home dialysis, which was almost exclusively peritoneal dialysis (PD). The increase was identified particularly in the young (20 - 49) and the elderly (> 80). Disappointingly, however, 67% of these incident patients ceased PD within 2 years of commencement, 46% of whom transferred to SHD. ♦ CONCLUSIONS: Introduction of a KPI program

Dialysis Provision and Implications of Health Economics on Peritoneal Dialysis Utilization: A Review from a Malaysian Perspective

PubMed Central

Seong Hooi, Lai; Bavanandan, Sunita

2017-01-01

End-stage renal disease (ESRD) is managed by either lifesaving hemodialysis (HD) and peritoneal dialysis (PD) or a kidney transplant. In Malaysia, the prevalence of dialysis-treated ESRD patients has shown an exponential growth from 504 per million population (pmp) in 2005 to 1155 pmp in 2014. There were 1046 pmp patients on HD and 109 pmp patients on PD in 2014. Kidney transplants are limited due to lack of donors. Malaysia adopts public-private financing model for dialysis. Majority of HD patients were treated in the private sector but almost all PD patients were treated in government facilities. Inequality in access to dialysis is visible within geographical regions where majority of HD centres are scattered around developed areas. The expenditure on dialysis has been escalating in recent years but economic evaluations of dialysis modalities are scarce. Evidence shows that health policies and reimbursement strategies influence dialysis provision. Increased uptake of PD can produce significant economic benefits and improve patients' access to dialysis. As a result, some countries implemented a PD-First or Favored Policy to expand PD use. Thus, a current comparative costs analysis of dialysis is strongly recommended to assist decision-makers to establish a more equitable and economically sustainable dialysis provision in the future. PMID:29225970

Dialysis Provision and Implications of Health Economics on Peritoneal Dialysis Utilization: A Review from a Malaysian Perspective.

PubMed

Abdul Manaf, Mohd Rizal; Surendra, Naren Kumar; Abdul Gafor, Abdul Halim; Seong Hooi, Lai; Bavanandan, Sunita

2017-01-01

End-stage renal disease (ESRD) is managed by either lifesaving hemodialysis (HD) and peritoneal dialysis (PD) or a kidney transplant. In Malaysia, the prevalence of dialysis-treated ESRD patients has shown an exponential growth from 504 per million population (pmp) in 2005 to 1155 pmp in 2014. There were 1046 pmp patients on HD and 109 pmp patients on PD in 2014. Kidney transplants are limited due to lack of donors. Malaysia adopts public-private financing model for dialysis. Majority of HD patients were treated in the private sector but almost all PD patients were treated in government facilities. Inequality in access to dialysis is visible within geographical regions where majority of HD centres are scattered around developed areas. The expenditure on dialysis has been escalating in recent years but economic evaluations of dialysis modalities are scarce. Evidence shows that health policies and reimbursement strategies influence dialysis provision. Increased uptake of PD can produce significant economic benefits and improve patients' access to dialysis. As a result, some countries implemented a PD-First or Favored Policy to expand PD use. Thus, a current comparative costs analysis of dialysis is strongly recommended to assist decision-makers to establish a more equitable and economically sustainable dialysis provision in the future.

Families' and physicians' predictions of dialysis patients' preferences regarding life-sustaining treatments in Japan.

PubMed

Miura, Yasuhiko; Asai, Atsushi; Matsushima, Masato; Nagata, Shizuko; Onishi, Motoki; Shimbo, Takuro; Hosoya, Tatsuo; Fukuhara, Shunichi

2006-01-01

Substituted judgment traditionally has been used often for patient care in Japan regardless of the patient's competency. It has been believed that patient preferences are understood intuitively by family and caregivers. However, there are no data to support this assumption. A questionnaire survey was administered to 450 dialysis patients in 15 hospitals to determine their preferences for cardiopulmonary resuscitation (CPR) and dialysis therapy under various circumstances. Simultaneously, we asked family members and physicians of these patients about patient preferences to evaluate their ability to predict what their patients would want. The accuracy of families' and physicians' judgments was assessed by means of kappa coefficient. Three hundred ninety-eight pairs, consisting of a patient, 1 of his or her family members, and the physician in charge, participated from 15 hospitals in Japan, with a response rate of 88%. Sixty-eight percent of family members correctly predicted patients' current preferences for CPR, 67% predicted patients' preferences for dialysis when they were severely demented, and 69% predicted patients' preferences for dialysis when they had terminal cancer. Corresponding figures for physicians were 60%, 68%, and 66%. When using kappa coefficient analysis, those results indicated that neither family members nor physicians more accurately predicted their patients' wishes about life-sustaining treatments than expected by chance alone. (All kappa coefficients <0.4.) Our study suggests that patients who want to spend their end-of-life period as they want should leave better advance directives.

Management of a rapidly growing peritoneal dialysis population at the First Affiliated Hospital of Sun Yat-sen University.

PubMed

Yu, Xueqing; Yang, Xiao; Huang, Naya

2014-06-01

Managing a rapidly growing peritoneal dialysis program with more than 1000 patients involves multiple challenges, labor constraints, logistics, and excessive geographic distance. This paper describes how Sun Yat-sen University, Guangzhou, China, manages those issues, while simultaneously improving quality of the care and, subsequently, clinical outcomes. Copyright © 2014 International Society for Peritoneal Dialysis.

Trends in Acute Ischemic Stroke Hospitalizations in the United States.

PubMed

Ramirez, Lucas; Kim-Tenser, May A; Sanossian, Nerses; Cen, Steven; Wen, Ge; He, Shuhan; Mack, William J; Towfighi, Amytis

2016-05-11

Population-based studies have revealed declining acute ischemic stroke (AIS) hospitalization rates in the United States, but no study has assessed recent temporal trends in race/ethnic-, age-, and sex-specific AIS hospitalization rates. Temporal trends in hospitalization for AIS from 2000 to 2010 were assessed among adults ≥25 years using the Nationwide Inpatient Sample. Age-, sex-, and race/ethnic-specific and age-adjusted stroke hospitalization rates were calculated using the weighted number of hospitalizations and US census data. From 2000 to 2010, age-adjusted stroke hospitalization rates decreased from 250 to 204 per 100 000 (overall rate reduction 18.4%). Age-specific AIS hospitalization rates decreased for individuals aged 65 to 84 years (846 to 605 per 100 000) and ≥85 years (2077 to 1618 per 100 000), but increased for individuals aged 25 to 44 years (16 to 23 per 100 000) and 45 to 64 years (149 to 156 per 100 000). Blacks had the highest age-adjusted yearly hospitalization rates, followed by Hispanics and whites (358, 170, and 155 per 100 000 in 2010). Age-adjusted AIS hospitalization rates increased for blacks but decreased for Hispanics and whites. Age-adjusted AIS hospitalization rates were lower in women and declined more steeply compared to men (272 to 212 per 100 000 in women versus 298 to 245 per 100 000 in men). Although overall stroke hospitalizations declined in the United States, the reduction was more pronounced among older individuals, women, Hispanics, and whites. Renewed efforts at targeting risk factor control among vulnerable individuals may be warranted. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Adoption of Alcohol-Based Handrub by United States Hospitals: A National Survey

PubMed Central

Mody, Lona; Saint, Sanjay; Kaufman, Samuel R.; Kowalski, Christine; Krein, Sarah L.

2009-01-01

The extent to which the use of alcohol-based handrub for hand hygiene has been adopted by US hospitals is unknown. A survey of infection control coordinators (response rate, 516 [72%] of 719) revealed that most hospitals (436 [84%] of 516) have adopted alcohol-based handrub. Leadership support and staff receptivity play a significant role in its adoption. PMID:18986300

Centre characteristics associated with the risk of peritonitis in peritoneal dialysis: a hierarchical modelling approach based on the data of the French Language Peritoneal Dialysis Registry.

PubMed

Béchade, Clémence; Guillouët, Sonia; Verger, Christian; Ficheux, Maxence; Lanot, Antoine; Lobbedez, Thierry

2017-06-01

This study investigated the centre effect on the risk of peritonitis in peritoneal dialysis (PD) patients. This was a retrospective cohort study based on data from the French Language Peritoneal Dialysis Registry. We analysed 5017 incident patients starting PD between January 2008 and December 2012 in 127 PD centres. The end of the observation period was 1 January 2014. The event of interest was the first peritonitis episode. The analysis was performed with a multilevel Cox model and a Fine and Gray model. Among the 5017 patients, 3190 peritonitis episodes occurred in 1796 patients. There was significant heterogeneity between centres (variance of the random effect: 0.11). The variance of the centre effect was reduced by 9% after adjusting for patient characteristics and by 35% after adjusting on centre covariate. In the multivariate analysis with a multilevel Cox model, centre with a nurse specialized in PD or centre providing home visits before dialysis initiation decreased the centre effect on peritonitis. Patients treated in centres with a nurse specialized in PD or in centres providing home visits before dialysis initiation had a lower risk of peritonitis [cause-specific hazard ratio (cs-HR): 0.75 (95% confidence interval, CI, 0.67-0.83) and cs-HR: 0.87 (95% CI 0.76-0.97), respectively]. The data show that neither centre type nor centre volume influenced peritonitis risk. In the competing risk analysis, centre with a nurse specialized in PD and centre with home visits had a protective effect on peritonitis [sub-distribution HR (sd-HR): 0.77 (95% CI 0.70-0.85) and sd-HR: 0.85 (95% CI 0.77-0.94), respectively]. There is a significant centre effect on the risk of peritonitis that can be decreased by home visits before dialysis initiation and by the presence of a nurse specialized in PD. © The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Dose of dialysis based on body surface area is markedly less in younger children than in older adolescents.

PubMed

Daugirdas, John T; Hanna, Melisha G; Becker-Cohen, Rachel; Langman, Craig B

2010-05-01

BACKGROUND AND OBSERVATIONS: The current denominator for dosing dialysis is the urea distribution volume (V). Normalizing Kt/V to body surface area (S) has been proposed, but the implications of doing this in children have not been examined. Dialysis dose given to children and adolescents was calculated in terms of conventional V-based scaling and surface-area-normalized standard Kt/V (SAN-stdKt/V) calculated as stdKt/V x (Vant/S)/17.5, where Vant was an anthropometric estimate of V calculated using the Morgenstern equation. Formal 2-pool modeling was used to compute all dialysis adequacy outputs. In 34 children (11 girls, 23 boys) dialyzed 3 times a week, age range 1.4 to 18 years, the mean delivered equilibrated Kt/V (eKt/V) was 1.40, and the mean stdKt/V was 2.49, both of which tended to be higher in younger children. The ratio of Vant to S was 15.6 +/- 2.69 and was strongly associated with age between ages 2 and 16. SAN-stdKt/V averaged 2.21 and was strongly correlated with age between ages 2 and 16. If one considers a desired target for SAN-stdKt/V to be 2.45, all children less than 10 years of age were below target, despite having relatively high values of eKt/V and stdKt/V. If a surface-area-based denominator were to be adopted for dialysis dosing, most children under 10 years of age would receive markedly less dialysis than adolescent patients and would require 6- to 8-hour hemodialysis sessions or, for the youngest children, treatments given more frequently than 3 times/wk.

Burnout Syndrome Among Hemodialysis and Peritoneal Dialysis Nurses.

PubMed

Karakoc, Ayten; Yilmaz, Murvet; Alcalar, Nilufer; Esen, Bennur; Kayabasi, Hasan; Sit, Dede

2016-11-01

Burnout, a syndrome with 3 dimensions of emotional exhaustion, depersonalization, and reduction of personal accomplishment, is very common among hemodialysis nurses, while data are scarce regarding the prevalence of burnout syndrome (BS) among peritoneal dialysis (PD) nurses. This study aimed to assess and compare demographic and professional characteristics and burnout levels in hemodialysis and PD nurses, and to investigate factors that increase the level of burnout in dialysis nurses. A total of 171 nurses from 44 dialysis centers in Turkey were included in a cross-sectional survey study. Data were collected using a questionnaire defining the social and demographic characteristics and working conditions of the nurses as well as the Maslach Burnout Inventory for assessment of burnout level. There was no significant difference in the level of burnout between the hemodialysis and PD nurses groups. Emotional exhaustion and depersonalization scores were higher among the shift workers, nurses who had problems in interactions with the other team members, and those who wanted to leave the unit, as well as the nurses who would not attend training programs. In addition, male sex, younger age, limited working experience, more than 50 hours of working per week, and working in dialysis not by choice were associated with higher depersonalization scores. Personal accomplishment score was lower among the younger nurses who had problems in their interactions with the doctors, who would not regularly attend training programs, and who felt being medically inadequate. Improving working conditions and relations among colleagues, and also providing further dialysis education are necessary for minimizing burnout syndrome. Burnout reduction programs should mainly focus on younger professionals.

Psychiatric units in Brazilian general hospitals: a growing philanthropic field.

PubMed

Botega, Neury José

2002-06-01

Some countries, mainly in North America and Europe, have adopted psychiatric wards in the general hospital as an alternative to the classic psychiatric hospital. In Brazil there are 6,169 general hospitals, 1.3% of which with a psychiatric unit. This service strategy is scarcely developed in the country and comprises only 4% of all psychiatric admissions. There was no information on the facilities and functioning of the psychiatric units in general hospitals. To determine the main characteristics of psychiatric units in Brazilian general hospitals and to assess the current trends in the services provided. A mailing survey assessed all 94 Brazilian general hospitals which made psychiatric admissions. A two-page questionnaire was designed to determine the main characteristics of each institution and of the psychiatric unit. Seventy-nine (84%) questionnaires were returned. In contrast to the 1970s and 1980s, in the last decade the installation of psychiatric units has spread to smaller philanthropic institutions that are not linked to medical schools. A fifth of hospitals admit psychiatric patients to medical wards because there is no specialist psychiatric ward. They try to meet all the local emergency demands, usually alcohol-dependent patients who need short term admission. This could signal the beginning of a program through which mental health professionals may become an integral part of general health services. The inauguration of psychiatric wards in philanthropic hospitals, as well as the admission of psychiatric patients in their medical wards, is a phenomenon peculiar to this decade. The installation of psychiatric services in these and other general hospitals would overcome two of major difficulties encountered: prejudice and a lack of financial resources.

Administration of chemotherapy in patients on dialysis.

PubMed

Kuo, James C; Craft, Paul S

2015-08-01

The prevalence of patients on dialysis has increased and these patients present a challenge for chemotherapy administration when diagnosed with cancer. A consensus on the dosage and timing of different chemotherapeutic agents in relation to dialysis has not been established. We describe the pattern of care and treatment outcome for cancer patients on dialysis in our institution. The dataset from the Australia and New Zealand Dialysis and Transplant Registry of patients on dialysis who had a diagnosis of cancer was obtained and matched to the pharmacy records in our institution to identify patients who had received chemotherapy while on dialysis. Relevant clinical information including details of the dialysis regimen, chemotherapy administration and adverse events was extracted for analysis. Between July 1999 and July 2014, 21 patients on dialysis were included for analysis. Five (23.8%) received chemotherapy, most of which was administered before dialysis sessions. As a result of adverse events, one patient discontinued treatment; two other patients required dose reduction or treatment delay. Chemotherapy administration was feasible in cancer patients on dialysis, but chemotherapy usage was low. Better understanding of the altered pharmacokinetics in patients on dialysis may improve chemotherapy access and practice.

Automatic adaptive system dialysis for hemodialysis-associated hypotension and intolerance: a noncontrolled multicenter trial.

PubMed

Colì, Luigi; La Manna, Gaetano; Comai, Giorgia; Ursino, Mauro; Ricci, Davide; Piccari, Matteo; Locatelli, Francesco; Di Filippo, Salvatore; Cristinelli, Luciano; Bacchi, Massimo; Balducci, Alessandro; Aucella, Filippo; Panichi, Vincenzo; Ferrandello, Francesco Paolo; Tarchini, Renzo; Lambertini, Domenica; Mura, Carlo; Marinangeli, Giancarlo; Di Loreto, Ermanno; Quarello, Francesco; Forneris, Giacomo; Tancredi, Maurizio; Morosetti, Massimo; Palombo, Giuditta; Di Luca, Marina; Martello, Mauro; Emiliani, Giuseppe; Bellazzi, Roberto; Stefoni, Sergio

2011-07-01

Hemodialysis is complicated by a high incidence of intradialytic hypotension and disequilibrium symptoms caused by hypovolemia and a decrease in extracellular osmolarity. Automatic adaptive system dialysis (AASD) is a proprietary dialysis system that provides automated elaboration of dialysate and ultrafiltration profiles based on the prescribed decrease in body weight and sodium content. A noncontrolled (single arm), multicenter, prospective, clinical trial. 55 patients with intradialytic hypotension or disequilibrium syndrome in 15 dialysis units were studied over a 1-month interval using standard treatment (642 sessions) followed by 6 months using AASD (2,376 sessions). AASD (bicarbonate dialysis with dialysate sodium concentration and ultrafiltration rate profiles determined by the automated procedure). Primary and major secondary outcomes were the frequency of intradialytic hypotension and symptoms (hypotensive events, headache, nausea, vomiting, and cramps), respectively. More stable intradialytic systolic and diastolic blood pressures with lower heart rate were found using AASD compared with standard treatment. Sessions complicated by hypotension decreased from 58.7% ± 7.3% to 0.9% ± 0.6% (P < 0.001). The incidence of other disequilibrium syndrome symptoms was lower in patients receiving AASD. There were no differences in end-session body weight, interdialytic weight gain, or presession natremia between the standard and AASD treatment periods. A noncontrolled (single arm) study, no crossover from AASD to standard treatment. This study shows the long-term clinical efficacy of AASD for intradialytic hypotension and disequilibrium symptoms in a large number of patients and dialysis sessions. Copyright © 2011 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

A randomised controlled trial of domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital.

PubMed Central

Gladman, J R; Lincoln, N B; Barer, D H

1993-01-01

This study compared the functional ability and perceived health status of stroke patients treated by a domiciliary rehabilitation team or by routine hospital-based services after discharge from hospital. Patients discharged from two acute and three rehabilitation hospitals in Nottingham were randomly allocated in three strata (Health Care of the Elderly, General Medical and Stroke Unit) to receive domiciliary or hospital-based care after discharge. Functional recovery was assessed by the Extended Activities of Daily Living (ADL) scale three and six months after discharge and perceived health at six months was measured by the Nottingham Health Profile. A total of 327 eligible patients of 1119 on a register of acute stroke admissions were recruited over 16 months. Overall there were no differences between the groups in their Extended ADL scores at three or six months, or their Nottingham Health Profile scores at six months. In the Stroke Unit stratum, patients treated by the domiciliary team had higher household (p = 0.02) and leisure activity (p = 0.04) scores at six months than those receiving routine care. In the Health Care of the Elderly stratum, death or a move into long-term institutional care at six months occurred less frequently in patients allocated to the routine service, about half of whom attended a geriatric day hospital. Overall there was no difference in the effectiveness of the domiciliary and hospital-based services, although younger stroke unit patients appeared to do better with home therapy while some frail elderly patients might have benefited from day hospital attendance. PMID:8410035

A Comparison of the Regional Circulation in the Feet between Dialysis and Non-Dialysis Patients using Indocyanine Green Angiography.

PubMed

Nishizawa, M; Igari, K; Kudo, T; Toyofuku, T; Inoue, Y; Uetake, H

2017-09-01

Peripheral artery disease in dialysis cases is more prone to critical limb ischemia compared to non-dialysis cases, with a significantly high rate of major amputation of the lower limbs. Lesions are distributed on the more distal side in dialysis critical limb ischemia cases. The aim of this study was to investigate the usefulness of indocyanine green angiography to determine differences in the regional circulation in the foot between dialysis and non-dialysis patients. The subjects included 62 cases, among which 20 were dialysis patients and 42 were non-dialysis patients. We compared the indocyanine green angiography parameters for regions of interest in the dialysis and non-dialysis groups, which included the magnitude of intensity from indocyanine green onset to maximum intensity (Imax), the time from indocyanine green onset to maximum intensity (Tmax), the time elapsed from the fluorescence onset to half the maximum intensity (T1/2), and the time from maximum intensity to declining to 90% of the maximum intensity (Td90%). These indocyanine green angiography parameters were measured at region of interest 1 (the Chopart joint), region of interest 2 (the Lisfranc joint), and region of interest 3 (the distal region of the first metatarsal bone). In the comparison between the dialysis and non-dialysis groups, a significant difference was observed regarding Tmax, T1/2, and Td90%, especially in region of interest 3. In this study, we show that regional tissue perfusion is more deteriorated in dialysis patients compared with non-dialysis patients using indocyanine green angiography. Tmax, T1/2, and Td90% could be useful clinical parameters to compare ischemic severity of the lower limb between dialysis and non-dialysis patients.

Initiating Maintenance Dialysis Before Living Kidney Donor Transplantation When a Donor Candidate Evaluation Is Well Underway.

PubMed

Habbous, Steven; McArthur, Eric; Dixon, Stephanie N; McKenzie, Susan; Garcia-Ochoa, Carlos; Lam, Ngan N; Lentine, Krista L; Dipchand, Christine; Litchfield, Kenneth; Begen, Mehmet A; Sarma, Sisira; Garg, Amit X

2018-07-01

Preemptive kidney transplants result in better outcomes and patient experiences than transplantation after dialysis onset. It is unknown how often a person initiates maintenance dialysis before living kidney donor transplantation when their donor candidate evaluation is well underway. Using healthcare databases, we retrospectively studied 478 living donor kidney transplants from 2004 to 2014 across 5 transplant centers in Ontario, Canada, where the recipients were not receiving dialysis when their donor's evaluation was well underway. We also explored some factors associated with a higher likelihood of dialysis initiation before transplant. A total of 167 (35%) of 478 persons with kidney failure initiated dialysis in a median of 9.7 months (25th-75th percentile, 5.4-18.7 months) after their donor candidate began their evaluation and received dialysis for a median of 8.8 months (3.6-16.9 months) before kidney transplantation. The total cohort's dialysis cost was CAD $8.1 million, and 44 (26%) of 167 recipients initiated their dialysis urgently in hospital. The median total donor evaluation time (time from evaluation start to donation) was 10.6 months (6.4-21.6 months) for preemptive transplants and 22.4 months (13.1-38.7 months) for donors whose recipients started dialysis before transplant. Recipients were more likely to start dialysis if their donor was female, nonwhite, lived in a lower-income neighborhood, and if the transplant center received the recipient referral later. One third of persons initiated dialysis before receiving their living kidney donor transplant, despite their donor's evaluation being well underway. Future studies should consider whether some of these events can be prevented by addressing inappropriate delays to improve patient outcomes and reduce healthcare costs.

Does Selection and Management of Patients with Chronic Kidney Disease In Government Run and Private Hospitals Differ?

PubMed

Gowda, Anoop; Dutt, Aswini Raghavendra; Bangera, Shobith

2017-08-01

Globally, incidence of Chronic Kidney Disease (CKD) is rapidly rising with huge burden on the life expectancy of the patients. Regular haemodialysis improves the quality of life in these patients. They get treatment at either government run or private sector hospitals. A difference in disease pattern, comorbidity, patient management and number of access failures can be observed in these set ups. The present study was carried out to find out selection, management and disease pattern of CKD patients admitted for dialysis in government run and private hospital. A cross-sectional study on patients (18-90 years) admitted and undergoing dialysis at government run (N=129) and private hospital (N=182) was undertaken in Karnataka, India. Parameters like comorbidity (diabetes), number of dialysis per week, number of access failures, and follow up visits were compared between these patients. Chi- squared test was used to compare the data. All tests were two-tailed and p< 0.05 was considered as significant. More number of younger patients and associated comorbidity, were seen in patients admitted in government run hospital (p<0.001), with no gender bias in selection of patients for dialysis between the two hospitals. Similarly, follow-ups with nephrologist, number of dialysis done per week and erythropoietin supplements administered were significantly more among private hospital patients (p<0.001). Number of dialysis sessions and mean haemoglobin level was less in government run hospital patients, as compared to those in private hospital. No statistical difference was seen with access failure in both these setups. No bias in management of CKD patient was seen among the two sets of hospitals though available facilities seemed to vary.

Facility Practice Variation to Help Understand the Effects of Public Policy: Insights from the Dialysis Outcomes and Practice Patterns Study (DOPPS).

PubMed

Fuller, Douglas S; Robinson, Bruce M

2017-01-06

Recent Centers for Medicare & Medicaid Services policies have used dialysis facility practice variation to develop public ratings and adjust payments. In the Dialysis Facility Compare star rating system (DFC SRS), facility-relative rates of performance-based clinical measures varied nearly two-fold for mortality (standardized mortality ratio; 10th/90th percentiles: 0.71, 1.34) and hospitalization (standardized hospitalization ratio; 10th/90th percentiles: 0.64, 1.37), and nearly four-fold for transfusion (standardized transfusion ratio; 10th/90th percentiles: 0.43, 1.65). Medicare claims data (from July of 2014) demonstrate that facility variation for the proportions of patients on hemodialysis hospitalized (10th/90th percentiles: 27%, 50%) and transfused (10th/90th percentiles: 3%, 17%) within 6 months that far exceeds relatively modest recent overall longitudinal trends. DFC SRS-rated facility variation is also substantial for fistula (10th/90th percentiles: 50%, 78%) and catheter use >90 days (10th/90th percentiles: 3%, 19%). By contrast, DFC SRS-rated facility distributions for adult hemodialysis Kt/V>1.2 (10th/90th percentiles: 84%, 97%) and total serum calcium >10.2 mg/dl (median, 1%; 75th/90th percentiles: 3%, 5%) are quite narrow and may be of questionable value. Likewise, variation in the US Dialysis Outcomes and Practice Patterns Study is over two-fold for facility median serum parathyroid hormone (10th/90th percentiles: 290 pg/ml, 629 pg/ml) and ferritin (10th/90th percentiles: 469 ng/ml, 1143 ng/ml) levels, and facility mean treatment time varies by 30 minutes (10th/90th percentiles: 204 minutes, 234 minutes). Rising serum parathyroid hormone and ferritin levels, and generally short dialysis treatment time, represent areas unchecked by existing policy; both overall trends and facility variation in these values may reflect unintended consequences of policy or reimbursement pressures and therefore raise concern. Additionally, outcomes in the transition

Response to inadequate dialysis in chronic peritoneal dialysis patients. Results from the 2000 Centers for Medicare and Medicaid (CMS) ESRD Peritoneal Dialysis Clinical Performance Measures (PD-CPM) Project.

PubMed

Rocco, Michael V; Frankenfield, Diane L; Prowant, Barbara; Frederick, Pamela; Flanigan, Michael J

2003-04-01

It is not known if patient prescriptions are being changed if patients are receiving an inadequate dose of peritoneal dialysis. Data from the 2000 Centers for Medicare and Medicaid were used to obtain data on dialysis adequacy and dialysis prescriptions. A total of 359 of 1,268 (28%) adult peritoneal dialysis patients had a total weekly Kt/V urea (twKt/V) less than 2.0 and 436 of 1,245 (35%) patients had a total weekly creatinine clearance (twCrCl) less than 60 L/wk/1.73 m2, defined as "inadequate dialysis." Among chronic ambulatory peritoneal dialysis (CAPD) patients, 81 of 188 (43%) patients had inadequate dialysis and a change in the peritoneal dialysis prescription within 6 months of the initial adequacy value. Among cycler patients, 106 of 197 (54%) patients had inadequate dialysis and a change in the prescription. Thirty-six of 46 (78%) CAPD patients and 48 of 56 (86%) cycler patients had an improvement in twKt/V after the prescription was revised. Thirty-two of 42 (76%) CAPD patients and 45 of 57 (79%) cycler patients had an improvement in twCrCl after the prescription was changed. For these patients, twKt/V increased from 1.6 +/- 0.3 to 2.1 +/- 0.5, with an increase in the peritoneal Kt/V urea from 1.5 +/- 0.3 to 1.9 +/- 0.4. Similarly, twCrCl increased from 46.3 +/- 7.5 to 59.1 +/- 10.6 L/wk/1.73 m2 with an increase in the peritoneal CrCl dose from 42.0 +/- 9.1 to 52.7 +/- 9.9 L/wk/1.73 m2. About half of peritoneal dialysis patients with inadequate dialysis did not have a prescription change and could benefit from modifications in their dialysis prescription.

Recovery of renal function in dialysis patients

PubMed Central

Agraharkar, Mahendra; Nair, Vasudevan; Patlovany, Matthew

2003-01-01

Background Although recovery of renal functions in dialysis dependent patients is estimated to be greater than 1%, there are no indicators that actually suggest such revival of renal function. Residual renal function in dialysis patients is unreliable and seldom followed. Therefore renal recovery (RR) in dialysis dependent patients may remain unnoticed. We present a group of dialysis dependent patients who regained their renal functions. The aim of this project is to determine any indicators that may identify the recovery of renal functions in dialysis dependent patients. Methods All the discharges from the chronic dialysis facilities were identified. Among these discharges deaths, transplants, voluntary withdrawals and transfers either to another modality or another dialysis facility were excluded in order to isolate the patients with RR. The dialysis flow sheets and medical records of these patients were subsequently reviewed. Results Eight patients with a mean age of 53.8 ± 6.7 years (± SEM) were found to have RR. Dialysis was initiated due to uremic symptoms in 6 patients and fluid overload in the remaining two. The patients remained dialysis dependent for 11.1 ± 4.2 months. All these patients had good urine output and 7 had symptoms related to dialysis. Their mean pre-initiation creatinine and BUN levels were 5.21 ± 0.6 mg/dl and 72.12 ± 11.12 mg/dl, respectively. Upon discontinuation, they remained dialysis free for 19.75 ± 5.97 months. The mean creatinine and BUN levels after cessation of dialysis were 2.85 ± 0.57 mg/dl and 29.62 ± 5.26 mg/dl, respectively, while the mean creatinine clearance calculated by 24-hour urine collection was 29.75 ± 4.78 ml/min. One patient died due to HIV complications. One patient resumed dialysis after nine months. Remaining continue to enjoy a dialysis free life. Conclusion RR must be considered in patients with good urine output and unresolved acute renal failure. Dialysis intolerance may be an indicator of RR among

Chemistry Testing on Plasma Versus Serum Samples in Dialysis Patients: Clinical and Quality Improvement Implications.

PubMed

Carey, Roger Neill; Jani, Chinu; Johnson, Curtis; Pearce, Jim; Hui-Ng, Patricia; Lacson, Eduardo

2016-09-07

Plasma samples collected in tubes containing separator gels have replaced serum samples for most chemistry tests in many hospital and commercial laboratories. Use of plasma samples for blood tests in the dialysis population eliminates delays in sample processing while waiting for clotting to complete, laboratory technical issues associated with fibrin formation, repeat sample collection, and patient care issues caused by delay of results because of incompletely clotted specimens. Additionally, a larger volume of plasma is produced than serum for the same amount of blood collected. Plasma samples are also acceptable for most chemical tests involved in the care of patients with ESRD. This information becomes very important when United States regulatory requirements for ESRD inadvertently limit the type of sample that can be used for government reporting, quality assessment, and value-based payment initiatives. In this narrative, we summarize the renal community experience and how the subsequent resolution of the acceptability of phosphorus levels measured from serum and plasma samples may have significant implications in the country's continued development of a value-based Medicare ESRD Quality Incentive Program. Copyright © 2016 by the American Society of Nephrology.

Incremental cost-utility of sevelamer relative to calcium carbonate for treatment of hyperphosphatemia among pre-dialysis chronic kidney disease patients.

PubMed

Nguyen, Hai V; Bose, Saideep; Finkelstein, Eric

2016-04-28

Sevelamer is an alternative to calcium carbonate for the treatment of hyperphosphatemia among non-dialysis dependent patients with chronic kidney disease (CKD). Although some studies show that it may reduce mortality and delay the onset of dialysis when compared to calcium carbonate, it is also significantly more expensive. Prior studies looking at the incremental cost-effectiveness of sevelamer versus calcium carbonate in pre-dialysis patients are based on data from a single clinical trial. The goal of our study is to use a wider range of clinical data to achieve a more contemporary and robust cost-effectiveness analysis. We used a Markov model to estimate the lifetime costs and quality-adjusted life years (QALYs) gained for treatment with sevelamer versus calcium carbonate. The model simulated transitions among three health states (CKD not requiring dialysis, end-stage renal disease, and death). Data on transition probabilities and utilities were obtained from the published literature. Costs were calculated from a third party payer perspective and included medication, hospitalization, and dialysis. Sensitivity analyses were also run to encompass a wide range of assumptions about the dose, costs, and effectiveness of sevelamer. Over a lifetime, the average cost per patient treated with sevelamer is S$180,724. The estimated cost for patients treated with calcium carbonate is S$152,988. A patient treated with sevelamer gains, on average, 6.34 QALYs relative to no treatment, whereas a patient taking calcium carbonate gains 5.81 QALYs. Therefore, sevelamer produces an incremental cost-effectiveness ratio (ICER) of S$51,756 per QALY gained relative to calcium carbonate. Based on established benchmarks for cost-effectiveness, sevelamer is cost effective relative to calcium carbonate for the treatment of hyperphosphatemia among patients with chronic kidney disease initially not on dialysis.

High rates of death and hospitalization follow bone fracture among hemodialysis patients.

PubMed

Tentori, Francesca; McCullough, Keith; Kilpatrick, Ryan D; Bradbury, Brian D; Robinson, Bruce M; Kerr, Peter G; Pisoni, Ronald L

2014-01-01

Altered bone structure and function contribute to the high rates of fractures in dialysis patients compared to the general population. Fracture events may increase the risk of subsequent adverse clinical outcomes. Here we assessed the incidence of post-fracture morbidity and mortality in an international cohort of 34,579 in-center hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). We estimated country-specific rates of fractures requiring a hospital admission and associated length of stay in the hospital. Incidence rates of death and of a composite event of death/rehospitalization were estimated for 1 year after fracture. Overall, 3% of participants experienced a fracture. Fracture incidence varied across countries, from 12 events/1000 patient-years (PY) in Japan to 45/1000 PY in Belgium. In all countries, fracture rates were higher in the hemodialysis group compared to those reported for the general population. Median length of stay ranged from 7 to 37 days in the United States and Japan, respectively. In most countries, postfracture mortality rates exceeded 500/1000 PY and death/rehospitalization rates exceeded 1500/1000 PY. Fracture patients had higher unadjusted rates of death (3.7-fold) and death/rehospitalization (4.0-fold) compared to the overall DOPPS population. Mortality and hospitalization rates were highest in the first month after the fracture and declined thereafter. Thus, the high frequency of fractures and increased adverse outcomes following a fracture pose a significant health burden for dialysis patients. Fracture prevention strategies should be identified and applied broadly in nephrology practices.

Games policy makers and providers play: introducing case-mix-based payment to hospital chronic care units in Japan.

PubMed

Ikegami, Naoki

2009-06-01

Case-mix-based payment was developed for hospital chronic care units in Japan to replace the flat per diem rate and encourage the admission of patients with higher medical acuity and was part of a policy initiative to make the tariff more evidence based. However, although the criteria for grouping patients were developed from a statistical analysis of resource use, the tariff was subsequently set below costs, particularly for the groups with the lowest medical acuity, both because of the prime minister's decision to decrease total health expenditures and because of the health ministry's decision to target the reductions on chronic care units. Providers quickly adapted to the new payment system mainly by reclassifying their patients to higher medical acuity groups. Some hospitals reported high prevalence rates of urinary tract infections and pressure ulcers. The government responded by issuing directives to providers to calculate the prevalence rates and document the care that has been mandated for the patients at risk. However, in order to monitor compliance and to evaluate whether the patient is being billed for the appropriate case-mix group, the government must invest in developing a comprehensive patient-level database and in training staff for making on-site inspections.

Survival among older adults with kidney failure is better in the first three years with chronic dialysis treatment than not.

PubMed

Tam-Tham, Helen; Quinn, Robert R; Weaver, Robert G; Zhang, Jianguo; Ravani, Pietro; Liu, Ping; Thomas, Chandra; King-Shier, Kathryn; Fruetel, Karen; James, Matt T; Manns, Braden J; Tonelli, Marcello; Murtagh, Fliss E M; Hemmelgarn, Brenda R

2018-05-23

Comparisons of survival between dialysis and nondialysis care for older adults with kidney failure have been limited to those managed by nephrologists, and are vulnerable to lead and immortal time biases. So we compared time to all-cause mortality among older adults with kidney failure treated vs. not treated with chronic dialysis. Our retrospective cohort study used linked administrative and laboratory data to identify adults aged 65 or more years of age in Alberta, Canada, with kidney failure (2002-2012), defined by two or more consecutive outpatient estimated glomerular filtration rates less than 10 mL/min/1.73m 2 , spanning 90 or more days. We used marginal structural Cox models to assess the association between receipt of dialysis and all-cause mortality by allowing control for both time-varying and baseline confounders. Overall, 838 patients met inclusion criteria (mean age 79.1; 48.6% male; mean estimated glomerular filtration rate 7.8 mL/min/1.73m 2 ). Dialysis treatment (vs. no dialysis) was associated with a significantly lower risk of death for the first three years of follow-up (hazard ratio 0.59 [95% confidence interval 0.46-0.77]), but not thereafter (1.22 [0.69-2.17]). However, dialysis was associated with a significantly higher risk of hospitalization (1.40 [1.16-1.69]). Thus, among older adults with kidney failure, treatment with dialysis was associated with longer survival up to three years after reaching kidney failure, though with a higher risk of hospital admissions. These findings may assist shared decision-making about treatment of kidney failure. Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.

Patient and hospital characteristics on the variance of perioperative outcomes for pancreatic resection in the United States: a plea for outcome-based and not volume-based referral guidelines.

PubMed

Teh, Swee H; Diggs, Brian S; Deveney, Clifford W; Sheppard, Brett C

2009-08-01

There is an effect of patient and hospital characteristics on perioperative outcomes for pancreatic resection in the United States. Retrospective cohort study. Academic research. Patient data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project from January 1988 to January 2003. In-hospital mortality, perioperative complications, and mortality following a major complication. A total of 103 222 patients underwent major pancreatic surgery. The annual number of pancreatic resections increased 15.0% during the 16-year study period. Resection for benign pancreatic disease increased 26.8%. Overall in-hospital mortality, perioperative complications, and mortality following a major complication were 6.5%, 35.6%, and 15.6%, respectively. Multivariate analysis demonstrated that significant independent predictors for these 3 perioperative outcomes were advancing age, male sex, medical comorbidity, and hospital volume for each type of pancreatic resection. The in-hospital mortality for pancreatoduodenectomy increases with age and ranges from 1.7% to 13.8% (P < .001). After adjusting for other confounders, the odds of in-hospital mortality for pancreatoduodenectomy, distal pancreatectomy, and total pancreatectomy in those 65 years or older were 4.78-fold, 3.84-fold, and 2.60-fold, respectively, lower in the high-volume hospitals compared with those in the lower-volume hospitals. Perioperative complications derived from this population-based study were higher than those reported in many case series. A significant disparity was noted in perioperative outcomes among surgical centers across the United States. An outcome-based referral guideline may have an immediate effect on improving the quality of care in patients who undergo pancreatic resection for benign and malignant disease.

Adherence to peritoneal dialysis training schedule.

PubMed

Chow, Kai Ming; Szeto, Cheuk Chun; Leung, Chi Bon; Law, Man Ching; Kwan, Bonnie Ching-Ha; Li, Philip Kam-Tao

2007-02-01

Shortening behaviour during peritoneal dialysis training can be easily measured, and likened to the skipping behaviour in haemodialysis subjects, although its effect on peritoneal dialysis outcomes is now well understood. We studied the clinical impact of failing to adhere to a peritoneal dialysis training programme among incident dialysis patients. This study included 159 consecutive inception peritoneal dialysis patients in a single centre from September 1999 through November 2002. We evaluated the effects of behavioural compliance quantified by the per cent time arriving late for scheduled peritoneal dialysis training. The patients were categorized by whether they arrived late in >20% of their peritoneal dialysis training sessions. Of the 159 incident peritoneal dialysis patients (mean age 57 +/- 13 years) who attended peritoneal dialysis training, 70 subjects (44%) arrived late in >20% of the sessions. They were younger by 5 years than patients who arrived late < or =20%. Mean peritonitis-free time for subjects who arrived late for training in >20% the of sessions was 30.9 months, as compared with 41.8 months in subjects with < or =20% late attendance behaviour (log rank test, P = 0.038). Multivariable Cox proportional hazards analysis showed that late attendance behaviour and baseline serum albumin were the only independent risk factors for the time to a first peritonitis after adjustment for diabetes mellitus and relevant coexisting medical factors. Late arrival in >20% of the peritoneal dialysis training sessions was associated with >50% increased likelihood of subsequent peritonitis, with an adjusted risk ratio of 1.56 (95% confidence interval, 1.02-2.39; P = 0.04). These findings show that the behavioural measure of late attendance for peritoneal dialysis training has a crucial role in predicting peritonitis. It may therefore represent a practical strategy for identifying poor adherence or predicting medical outcomes.

[Patients in pre-dialysis: decision taking and free choice of treatment].

PubMed

Sarrias Lorenz, X; Bardón Otero, E; Vila Paz, M L

2008-01-01

treatment. Because of the impossibility of establishing universal rules of proportionality, it is necessary to make a personal judgment of conscience in each specific case. Recommendations for initiation or not of dialysis: Taking shared decisions between the patient (or relatives and/or advisors) and the physician. These shared decisions will be documented with signing of the proposed informed consent or rejection of the treatment. The medical team should always be sure that the patients has fully understood the consequences of the decision taken. Explanation of the modalities should include: - Types of dialysis treatment available. - Not to initiate dialysis and continue with conservative treatment until death. This situation may cause many problems if we do not have the help of the palliative care service. - Try dialysis for a limited time. - Stop dialysis and receive medical care until death. - Evaluate the prognosis of renal disease and concomitant diseases, life expectancy and family support. Resolution of conflicts: Conflicts may occur: - Between nephrologist and patient/family. - Between members of the nephrological team. - Between nephrologist and other physicians. When conflicts persist and the need for initiation of dialysis is urgent, it is necessary to initiate treatment and continue it until the resolution of these conflicts, making a record of this decision. In such cases, the Hospital Ethics Care Committee can help with appropriate advice to solve the discrepancies. Decisions taken in advance may be useful in this type of patients. Patients with advanced chronic kidney disease with criteria for Noninclusion or withdrawal of dialysis. - Severe or irreversible dementia. - conditions of permanent unconsciousness. - advanced tumors with metastasis. - terminal disease of another nontransplantable organ. - severe physical and/or mental disabilities. (Strength of Recommendation C)

Timing of Initiation of Maintenance Dialysis

PubMed Central

Wong, Susan P. Y.; Vig, Elizabeth K.; Taylor, Janelle S.; Burrows, Nilka R.; Liu, Chuan-Fen; Williams, Desmond E.; Hebert, Paul L.; O’Hare, Ann M.

2016-01-01

IMPORTANCE There is often considerable uncertainty about the optimal time to initiate maintenance dialysis in individual patients and little medical evidence to guide this decision. OBJECTIVE To gain a better understanding of the factors influencing the timing of initiation of dialysis in clinical practice. DESIGN, SETTING, AND PARTICIPANTS A qualitative analysis was conducted using the electronic medical records from the Department of Veterans Affairs (VA) of a national random sample of 1691 patients for whom the decision to initiate maintenance dialysis occurred in the VA between January 1, 2000, and December 31, 2009. Data analysis took place from June 1 to November 30, 2014. MAIN OUTCOMES AND MEASURES Central themes related to the timing of initiation of dialysis as documented in patients’ electronic medical records. RESULTS Of the 1691 patients, 1264 (74.7%) initiated dialysis as inpatients and 1228 (72.6%) initiated dialysis with a hemodialysis catheter. Cohort members met with a nephrologist during an outpatient clinic visit a median of 3 times (interquartile range, 0–6) in the year prior to initiation of dialysis. The mean (SD) estimated glomerular filtration rate at the time of initiation for cohort members was 10.4 (5.7) mL/min/1.73m2. The timing of initiation of dialysis reflected the complex interplay of at least 3 interrelated and dynamic processes. The first was physician practices, which ranged from practices intended to prepare patients for dialysis to those intended to forestall the need for dialysis by managing the signs and symptoms of uremia with medical interventions. The second process was sources of momentum. Initiation of dialysis was often precipitated by clinical events involving acute illness or medical procedures. In these settings, the imperative to treat often seemed to override patient choice. The third process was patient-physician dynamics. Interactions between patients and physicians were sometimes adversarial, and physician

Dose of Dialysis Based on Body Surface Area Is Markedly Less in Younger Children Than in Older Adolescents

PubMed Central

Hanna, Melisha G.; Becker-Cohen, Rachel; Langman, Craig B.

2010-01-01

Background and observations: The current denominator for dosing dialysis is the urea distribution volume (V). Normalizing Kt/V to body surface area (S) has been proposed, but the implications of doing this in children have not been examined. Design, setting, participants, & measurements: Dialysis dose given to children and adolescents was calculated in terms of conventional V-based scaling and surface-area-normalized standard Kt/V (SAN-stdKt/V) calculated as stdKt/V·(Vant/S)/17.5, where Vant was an anthropometric estimate of V calculated using the Morgenstern equation. Formal 2-pool modeling was used to compute all dialysis adequacy outputs. Results: In 34 children (11 girls, 23 boys) dialyzed 3 times a week, age range 1.4 to 18 years, the mean delivered equilibrated Kt/V (eKt/V) was 1.40, and the mean stdKt/V was 2.49, both of which tended to be higher in younger children. The ratio of Vant to S was 15.6 ± 2.69 and was strongly associated with age between ages 2 and 16. SAN-stdKt/V averaged 2.21 and was strongly correlated with age between ages 2 and 16. If one considers a desired target for SAN-stdKt/V to be 2.45, all children less than 10 years of age were below target, despite having relatively high values of eKt/V and stdKt/V. Conclusions: If a surface-area-based denominator were to be adopted for dialysis dosing, most children under 10 years of age would receive markedly less dialysis than adolescent patients and would require 6- to 8-hour hemodialysis sessions or, for the youngest children, treatments given more frequently than 3 times/wk. PMID:20299373

The Communication and Bioethical Training (CoBiT) Program for assisting dialysis decision-making in Spanish ACKD units.

PubMed

García-Llana, Helena; Bajo, Maria-Auxiliadora; Barbero, Javier; Selgas, Rafael; Del Peso, Gloria

2017-04-01

Healthcare professionals currently working in Advanced Chronic Kidney Disease (ACKD) units must cope with difficult situations regarding assisting patients with the dialysis decision-making process, and they are often untrained for these conversations. Although we have evidence from the literature that these skills can be learned, few professionals feel confident in this area. A Communication and Bioethical Training (CoBiT) Program for ACKD staff (physicians, nurses and allied health professionals) was developed to improve their ability and self-confidence in conducting these conversations. A four-stage study was conducted: (1) development of the CoBiT program, beginning with the creation of an interdisciplinary focus group (N = 10); (2) design of a questionnaire to assess self-confidence based on the areas identified by the focus group. The face validity of the instrument was tested using an inter-judge methodology (N = 6); (3) design of the format and contents of the program; (4) piloting the program. Thirty-six health professionals took an 8-h workshop based on role-playing methodology. Participants assessed their self-confidence in their communication skills before and after the program using self-report measures. The results show that after the program, participants reported significantly higher levels of self-confidence measured with a five-point Likert scale (p < 0.001). Participants felt that communication with colleagues of other professions significantly increased after the workshop (p = 0.004). The CoBiT program improves ACKD Unit healthcare professionals' self-confidence in their ability to perform a specific communication task.

Epidemiological perspective on infections in chronic dialysis patients.

PubMed

Bloembergen, W E; Port, F K

1996-07-01

Infectious complications are a source of substantial morbidity and a common cause of death among dialysis patients. This article considers the magnitude and impact of the problem of infection among patients treated with hemodialysis (HD) and peritoneal dialysis (PD) using data from national registries and large cohort studies of patients with end-stage renal disease (ESRD). United States Renal Data System (USRDS) data indicate that in the United States for years 1991 to 1992, infection accounted for 12% of all deaths among HD patients and 15% of all deaths among PD patients. Septicemia was the underlying cause in 76% of these infectious deaths among HD patients, of which the vascular access, peritonitis, peripheral vascular disease, and other causes accounted for 12%, 5%, 24%, and 59% respectively. Among PD patients, septicemia accounted for 79% of infectious deaths. Of these deaths attributable to septicemia, peritonitis, peripheral vascular disease, and other causes were reported as the cause in 35%, 23%, and 41% respectively. Infection is also a major cause of morbidity in the dialysis population. Among HD patients, an average of 7.6 bacteremic episodes per 100 patient years (0.076 per year) has been described, of which 48% were associated with access infections. Among PD patients, studies have reported peritonitis rates ranging from 1 in 7.6 to 21.5 months (0.56 to 1.58 per patient year) and exit and/or tunnel infections occurring at a rate of 0.6 episodes per year. The known predictors of infectious complications among these populations are reviewed.

Does Selection and Management of Patients with Chronic Kidney Disease In Government Run and Private Hospitals Differ?

PubMed Central

Gowda, Anoop; Bangera, Shobith

2017-01-01

Introduction Globally, incidence of Chronic Kidney Disease (CKD) is rapidly rising with huge burden on the life expectancy of the patients. Regular haemodialysis improves the quality of life in these patients. They get treatment at either government run or private sector hospitals. A difference in disease pattern, comorbidity, patient management and number of access failures can be observed in these set ups. Aim The present study was carried out to find out selection, management and disease pattern of CKD patients admitted for dialysis in government run and private hospital. Materials and Methods A cross-sectional study on patients (18–90 years) admitted and undergoing dialysis at government run (N=129) and private hospital (N=182) was undertaken in Karnataka, India. Parameters like comorbidity (diabetes), number of dialysis per week, number of access failures, and follow up visits were compared between these patients. Chi- squared test was used to compare the data. All tests were two-tailed and p< 0.05 was considered as significant. Results More number of younger patients and associated comorbidity, were seen in patients admitted in government run hospital (p<0.001), with no gender bias in selection of patients for dialysis between the two hospitals. Similarly, follow-ups with nephrologist, number of dialysis done per week and erythropoietin supplements administered were significantly more among private hospital patients (p<0.001). Number of dialysis sessions and mean haemoglobin level was less in government run hospital patients, as compared to those in private hospital. No statistical difference was seen with access failure in both these setups. Conclusion No bias in management of CKD patient was seen among the two sets of hospitals though available facilities seemed to vary. PMID:28969180

Weekend Compared with Weekday Presentations of Peritoneal Dialysis-Associated Peritonitis

PubMed Central

Johnson, David W.; Clayton, Philip; Cho, Yeoungjee; Badve, Sunil V.; Hawley, Carmel M.; McDonald, Stephen; Boudville, Neil; Wiggins, Kathryn J.; Bannister, Kym; Brown, Fiona

2012-01-01

♦ Objective: Management of peritoneal dialysis (PD)-associated peritonitis requires timely intervention by experienced staff, which may not be uniformly available throughout the week. The aim of the present study was to examine the effects of weekend compared with weekday presentation on peritonitis outcomes. ♦ Methods: The study, which used data from the Australia and New Zealand Dialysis and Transplant Registry, included all Australian patients receiving PD between 1 October 2003 and 31 December 2008. The independent predictors of weekend presentation and subsequent peritonitis outcomes were assessed by multivariate logistic regression. ♦ Results: Peritonitis presentation rates were significantly lower on Saturdays [0.46 episodes per year; 95% confidence interval (CI): 0.42 to 0.49 episodes per year] and on Sundays (0.43 episodes per year; 95% CI: 0.40 to 0.47 episodes per year) than all other weekdays; they peaked on Mondays (0.76 episodes per year; 95% CI: 0.72 to 0.81 episodes per year). Weekend presentation with a first episode of peritonitis was independently associated with lower body mass index and residence less than 100 km away from the nearest PD unit. Patients presenting with peritonitis on the weekend were significantly more likely to be hospitalized [adjusted odds ratio (OR): 2.32; 95% CI: 1.85 to 2.90], although microbial profiles and empiric antimicrobial treatments were comparable between the weekend and weekday groups. Antimicrobial cure rates were also comparable (79% vs 79%, p = 0.9), with the exception of cure rates for culture-negative peritonitis, which were lower on the weekend (80% vs 88%, p = 0.047). Antifungal prophylaxis was less likely to be co-prescribed for first peritonitis episodes presenting on weekdays (OR: 0.68; 95% CI: 0.05 to 0.89). ♦ Conclusions: Patients on PD are less likely to present with peritonitis on the weekend. Nevertheless, the microbiology, treatment, and outcomes of weekend and weekday PD peritonitis

Measuring patient experience in dialysis: a new paradigm of quality assessment.

PubMed

Rhee, Connie M; Brunelli, Steven M; Subramanian, Lalita; Tentori, Francesca

2018-04-01

Patients' experience of care (PEC) is as an important dimension in quality of care. As a distinct entity from patient satisfaction and patient health-related quality of life, PEC is defined as patients' perceptions of the range of interactions they have with the health care system, including care from providers, facilities, and health plans. While traditionally PEC may be ascertained via informal assessments, in recent years, especially in the United States, there has been a shift towards standardized surveillance of PEC amongst dialysis patients in order to: (1) set a normative expectation regarding the importance of PEC; (2) standardize the components of patients' experience that are assessed to minimize potential "blind spots"; (3) provide a direct "voice" to the patient in communicating perceptions of their care; (4) facilitate comparisons of quality across facilities; and (5) broaden accountability for PEC to the entire multidisciplinary dialysis care team. In this review, we will discuss the significance of PEC as a quality of care metric in dialysis patients; the history of PEC assessment across other health care arenas; the development of the In-Center Hemodialysis Consumer Assessment of Healthcare Provider and Systems survey as a means to standardize PEC assessment among US dialysis patients; experiences in PEC assessment across international dialysis populations; and future areas of research needed to refine the ascertainment of PEC and its impact upon patient outcomes.

Evaluation of Bacteriological and Chemical Quality of Dialysis Water and Fluid in Isfahan, Central Iran

PubMed Central

SHAHRYARI, Ali; NIKAEEN, Mahnaz; HATAMZADEH, Maryam; VAHID DASTJERDI, Marzieh; HASSANZADEH, Akbar

2016-01-01

Background: Chemical and microbial quality of water used in hemodialysis play key roles in a number of dialysis-related complications. In order to avoid the complications and to guarantee safety and health of patients therefore, vigorous control of water quality is essential. The objective of present study was to investigate the chemical and bacteriological characteristics of water used in dialysis centers of five hospitals in Isfahan, central Iran. Methods: A total of 30 water samples from the input of dialysis purification system and dialysis water were analyzed for chemical parameters. Heterotrophic plate count and endotoxin concentration of drinking water, dialysis water and dialysis fluid of 40 machines were also monitored over a 5-month period in 2011–2012. Results: Concentration of the determined chemicals (copper, zinc, sulfate, fluoride, chloramines and free chlorine) did not exceed the recommended concentration by the Association for the Advancement of Medical Instrumentation (AAMI) exclude lead, nitrate, aluminum and calcium. Furthermore, the magnesium; cadmium and chromium concentration exceeded the maximum level in some centers. No contamination with heterotrophic bacteria was observed in all samples, while the AMMI standard for endotoxin level in dialysis fluid (<2 EU/ml) was achieved in 95% of samples. Conclusion: Dialysis water and fluid failed to meet the all chemical and bacteriological requirements for hemodialysis. To minimize the risk of contaminants for hemodialysis patients therefore, a water quality management program including monitoring, maintenance and development of water treatment system in hemodialysis centers is extremely important. In addition, an appropriate disinfection program is needed to guarantee better control of bacterial growth and biofilm formation. PMID:27398338

CHILDREN HOSPITALIZED WITH LOWER EXTREMITY FRACTURES IN THE UNITED STATES IN 2006: A POPULATION-BASED APPROACH

PubMed Central

Gao, Yubo

2011-01-01

OBJECTIVE The purpose of this study was to examine the demographic and hospitalization characteristics of children hospitalized with lower extremity fractures in the United States in 2006. METHODS Children aged 0 to 20 years with a diagnosis of lower extremity fracture in the 2006 Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID) were included. Lower extremity fractures were defined by International Classification of Diseases, 9th Revision, Clinical Modification codes 820-829 under “Injury and Poisoning (800-999).” Patient demographic and hospitalization-related data were analyzed by chi-square testing and unbalanced analysis of variance. RESULTS There were more boys than girls with lower extremity fractures and 53% had private insurance as their primary payer. About one half of the children were between the ages of 13 and 20 years, but all ages were represented from age 0 to 20. White children accounted for 56%. Urban hospitalizations accounted for 93% of cases and 66 percent of admissions were to teaching hospitals. All patients had an average length of stay (LOS) 4.04 days, and infant patients had the longest average LOS of 5.46 days. The average number of diagnoses per patient was 3.07, and the average number of procedures per patient was 2.21. The average charge per discharge was $35,236, and the oldest patients had the largest average charge of $41,907. The average number of comorbidities increased with increasing patient age. There was a 55.6% greater mortality risk in non-teaching hospitals than in teaching hospitals and there was at least ten times the mortality risk in rural hospitals than in urban hospitals. CONCLUSIONS This study provides an understanding of the demographic and hospitalization characteristics of children with lower extremity fractures in the United States in 2006. This information may be useful in implementing measures to help prevent similar injuries in the future. Further research is required to determine

Children hospitalized with lower extremity fractures in the United States in 2006: a population-based approach.

PubMed

Gao, Yubo

2011-01-01

The purpose of this study was to examine the demographic and hospitalization characteristics of children hospitalized with lower extremity fractures in the United States in 2006. Children aged 0 to 20 years with a diagnosis of lower extremity fracture in the 2006 Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) were included. Lower extremity fractures were defined by International Classification of Diseases, 9th Revision, Clinical Modification codes 820-829 under "Injury and Poisoning (800-999)." Patient demographic and hospitalization-related data were analyzed by chi-square testing and unbalanced analysis of variance. There were more boys than girls with lower extremity fractures and 53% had private insurance as their primary payer. About one half of the children were between the ages of 13 and 20 years, but all ages were represented from age 0 to 20. White children accounted for 56%. Urban hospitalizations accounted for 93% of cases and 66 percent of admissions were to teaching hospitals. All patients had an average length of stay (LOS) 4.04 days, and infant patients had the longest average LOS of 5.46 days. The average number of diagnoses per patient was 3.07, and the average number of procedures per patient was 2.21. The average charge per discharge was $35,236, and the oldest patients had the largest average charge of $41,907. The average number of comorbidities increased with increasing patient age. There was a 55.6% greater mortality risk in non-teaching hospitals than in teaching hospitals and there was at least ten times the mortality risk in rural hospitals than in urban hospitals. This study provides an understanding of the demographic and hospitalization characteristics of children with lower extremity fractures in the United States in 2006. This information may be useful in implementing measures to help prevent similar injuries in the future. Further research is required to determine causality of the associations found including

Influence of safety warnings on ESA prescribing among dialysis patients using an interrupted time series

PubMed Central

2013-01-01

Background In March, 2007, a black box warning was issued by the Food and Drug Administration (FDA) to use the lowest possible erythropoiesis-stimulating agents (ESA) doses for treatment of anemia associated with renal disease. The goal is to determine if a change in ESA use was observed following the warning among US dialysis patients. Methods ESA therapy was examined from September 2004 through August 2009 (thirty months before and after the FDA black box warning) among adult Medicare hemodialysis patients. An interrupted time series model assessed the impact of the warnings. Results The FDA black box warning did not appear to influence ESA prescribing among the overall dialysis population. However, significant declines in ESA therapy after the FDA warnings were observed for selected populations. Patients with a hematocrit ≥36% had a declining month-to-month trend before (−164 units/week, p = <0.0001) and after the warnings (−80 units/week, p = .001), and a large drop in ESA level immediately after the black box (−4,744 units/week, p = <.0001). Not-for-profit facilities had a declining month-to-month trend before the warnings (−90 units/week, p = .009) and a large drop in ESA dose immediately afterwards (−2,487 units/week, p = 0.015). In contrast, for-profit facilities did not have a significant change in ESA prescribing. Conclusions ESA therapy had been both profitable for providers and controversial regarding benefits for nearly two decades. The extent to which a FDA black box warning highlighting important safety concerns influenced use of ESA therapy among nephrologists and dialysis providers was unknown. Our study found no evidence of changes in ESA prescribing for the overall dialysis population resulting from a FDA black box warning. PMID:23927675

The impact of peritoneal dialysis-related peritonitis on mortality in peritoneal dialysis patients.

PubMed

Ye, Hongjian; Zhou, Qian; Fan, Li; Guo, Qunying; Mao, Haiping; Huang, Fengxian; Yu, Xueqing; Yang, Xiao

2017-06-05

Results concerning the association between peritoneal dialysis-related peritonitis and mortality in peritoneal dialysis patients are inconclusive, with one potential reason being that the time-dependent effect of peritonitis has rarely been considered in previous studies. This study aimed to evaluate whether peritonitis has a negative impact on mortality in a large cohort of peritoneal dialysis patients. We also assessed the changing impact of peritonitis on patient mortality with respect to duration of follow-up. This retrospective cohort study included incident patients who started peritoneal dialysis from 1 January 2006 to 31 December 2011. Episodes of peritonitis were recorded at the time of onset, and peritonitis was parameterized as a time-dependent variable for analysis. We used the Cox regression model to assess whether peritonitis has a negative impact on mortality. A total of 1321 patients were included. The mean age was 48.1 ± 15.3 years, 41.3% were female, and 23.5% with diabetes mellitus. The median (interquartile) follow-up time was 34 (21-48) months. After adjusting for confounders, peritonitis was independently associated with 95% increased risk of all-cause mortality (hazard ratio, 1.95; 95% confidence interval: 1.46-2.60), 90% increased risk of cardiovascular mortality (hazard ratio, 1.90; 95% confidence interval: 1.28-2.81) and near 4-fold increased risk of infection-related mortality (hazard ratio, 4.94; 95% confidence interval: 2.47-9.86). Further analyses showed that peritonitis was not significantly associated with mortality within 2 years of peritoneal dialysis initiation, but strongly influenced mortality in patients dialysed longer than 2 years. Peritonitis was independently associated with higher risk of all-cause, cardiovascular and infection-related mortality in peritoneal dialysis patients, and its impact on mortality was more significant in patients with longer peritoneal dialysis duration.

Patient and family perspectives on peritoneal dialysis at home: findings from an ethnographic study.

PubMed

Baillie, Jessica; Lankshear, Annette

2015-01-01

To discuss findings from an ethnographic study, considering the experiences of patients and families, using peritoneal dialysis at home in the United Kingdom. Peritoneal dialysis is a daily, life-preserving treatment for end-stage renal disease, undertaken in the patient's home. With ever-growing numbers of patients requiring treatment for this condition, the increased use of peritoneal dialysis is being promoted. While it is known that quality of life is reduced when using dialysis, few studies have sought to explore experiences of peritoneal dialysis specifically. No previous studies were identified that adopted an ethnographic approach. A qualitative design was employed, utilising ethnographic methodology. Ethical and governance approvals were gained in November 2010 and data were generated in 2011. Patients (n = 16) and their relatives (n = 9) were interviewed and observed using peritoneal dialysis in their homes. Thematic analysis was undertaken using Wolcott's (1994) three stage process: Description, Analysis and Interpretation. This article describes four themes: initiating peritoneal dialysis; the constraints of peritoneal dialysis due to medicalisation of the home environment and the imposition of rigid timetables; the uncertainty of managing crises and inevitable deterioration; and seeking freedom through creativity and hope of a kidney transplant. This study highlights the culture of patients and their families living with peritoneal dialysis. Despite the challenges posed by the treatment, participants were grateful they were able to self-manage at home. Furthermore, ethnographic methods offer an appropriate and meaningful way of considering how patients live with home technologies. Participants reported confusion about kidney transplantation and also how to identify peritonitis, and ongoing education from nurses and other healthcare professionals is thus vital. Opportunities for sharing experiences of peritoneal dialysis were valued by participants and

Microbiological surveillance and state of the art technological strategies for the prevention of dialysis water pollution.

PubMed

Bolasco, Piergiorgio; Contu, Antonio; Meloni, Patrizia; Vacca, Dorio; Galfrè, Andrea

2012-08-01

The present report attempts to illustrate the positive impact on the microbiological quality of dialysis patients over a 15-year period through the progressive implementation of state-of-the-art technological strategies and the optimization of microbiological surveillance procedures in five dialysis units in Sardinia. Following on better microbiological, quality controls of dialysis water and improvement of procedures and equipment, a drastic improvement of microbiological water quality was observed in a total of 945 samples. The main aim was to introduce the use of microbiological culture methods as recommended by the most important guidelines. The microbiological results obtained have led to a progressive refining of controls and introduction of new materials and equipment, including two-stage osmosis and piping distribution rings featuring a greater capacity to prevent biofilm adhesion. The actions undertaken have resulted in unexpected quality improvements. Dialysis water should be viewed by the nephrologist as a medicinal product exerting a demonstrable positive impact on microinflammation in dialysis patients. A synergic effort between nephrologists and microbiologists undoubtedly constitutes the most effective means of preventing dialysis infections.

Microbiological Surveillance and State of the Art Technological Strategies for the Prevention of Dialysis Water Pollution

PubMed Central

Bolasco, Piergiorgio; Contu, Antonio; Meloni, Patrizia; Vacca, Dorio; Galfrè, Andrea

2012-01-01

Methods: The present report attempts to illustrate the positive impact on the microbiological quality of dialysis patients over a 15-year period through the progressive implementation of state-of-the-art technological strategies and the optimization of microbiological surveillance procedures in five dialysis units in Sardinia. Results: Following on better microbiological, quality controls of dialysis water and improvement of procedures and equipment, a drastic improvement of microbiological water quality was observed in a total of 945 samples. The main aim was to introduce the use of microbiological culture methods as recommended by the most important guidelines. The microbiological results obtained have led to a progressive refining of controls and introduction of new materials and equipment, including two-stage osmosis and piping distribution rings featuring a greater capacity to prevent biofilm adhesion. The actions undertaken have resulted in unexpected quality improvements. Conclusions: Dialysis water should be viewed by the nephrologist as a medicinal product exerting a demonstrable positive impact on microinflammation in dialysis patients. A synergic effort between nephrologists and microbiologists undoubtedly constitutes the most effective means of preventing dialysis infections. PMID:23066395

Reiki and related therapies in the dialysis ward: an evidence-based and ethical discussion to debate if these complementary and alternative medicines are welcomed or banned.

PubMed

Ferraresi, Martina; Clari, Roberta; Moro, Irene; Banino, Elena; Boero, Enrico; Crosio, Alessandro; Dayne, Romina; Rosset, Lorenzo; Scarpa, Andrea; Serra, Enrica; Surace, Alessandra; Testore, Alessio; Colombi, Nicoletta; Piccoli, Barbara Giorgina

2013-06-21

Complementary and Alternative Medicines (CAMs) are increasingly practiced in the general population; it is estimated that over 30% of patients with chronic diseases use CAMs on a regular basis. CAMs are also used in hospital settings, suggesting a growing interest in individualized therapies. One potential field of interest is pain, frequently reported by dialysis patients, and seldom sufficiently relieved by mainstream therapies. Gentle-touch therapies and Reiki (an energy based touch therapy) are widely used in the western population as pain relievers.By integrating evidence based approaches and providing ethical discussion, this debate discusses the pros and cons of CAMs in the dialysis ward, and whether such approaches should be welcomed or banned. In spite of the wide use of CAMs in the general population, few studies deal with the pros and cons of an integration of mainstream medicine and CAMs in dialysis patients; one paper only regarded the use of Reiki and related practices. Widening the search to chronic pain, Reiki and related practices, 419 articles were found on Medline and 6 were selected (1 Cochrane review and 5 RCTs updating the Cochrane review). According to the EBM approach, Reiki allows a statistically significant but very low-grade pain reduction without specific side effects. Gentle-touch therapy and Reiki are thus good examples of approaches in which controversial efficacy has to be balanced against no known side effect, frequent free availability (volunteer non-profit associations) and easy integration with any other pharmacological or non pharmacological therapy. While a classical evidence-based approach, showing low-grade efficacy, is likely to lead to a negative attitude towards the use of Reiki in the dialysis ward, the ethical discussion, analyzing beneficium (efficacy) together with non maleficium (side effects), justice (cost, availability and integration with mainstream therapies) and autonomy (patients' choice) is likely to lead to a

Reiki and related therapies in the dialysis ward: an evidence-based and ethical discussion to debate if these complementary and alternative medicines are welcomed or banned

PubMed Central

2013-01-01

Background Complementary and Alternative Medicines (CAMs) are increasingly practiced in the general population; it is estimated that over 30% of patients with chronic diseases use CAMs on a regular basis. CAMs are also used in hospital settings, suggesting a growing interest in individualized therapies. One potential field of interest is pain, frequently reported by dialysis patients, and seldom sufficiently relieved by mainstream therapies. Gentle-touch therapies and Reiki (an energy based touch therapy) are widely used in the western population as pain relievers. By integrating evidence based approaches and providing ethical discussion, this debate discusses the pros and cons of CAMs in the dialysis ward, and whether such approaches should be welcomed or banned. Discussion In spite of the wide use of CAMs in the general population, few studies deal with the pros and cons of an integration of mainstream medicine and CAMs in dialysis patients; one paper only regarded the use of Reiki and related practices. Widening the search to chronic pain, Reiki and related practices, 419 articles were found on Medline and 6 were selected (1 Cochrane review and 5 RCTs updating the Cochrane review). According to the EBM approach, Reiki allows a statistically significant but very low-grade pain reduction without specific side effects. Gentle-touch therapy and Reiki are thus good examples of approaches in which controversial efficacy has to be balanced against no known side effect, frequent free availability (volunteer non-profit associations) and easy integration with any other pharmacological or non pharmacological therapy. While a classical evidence-based approach, showing low-grade efficacy, is likely to lead to a negative attitude towards the use of Reiki in the dialysis ward, the ethical discussion, analyzing beneficium (efficacy) together with non maleficium (side effects), justice (cost, availability and integration with mainstream therapies) and autonomy (patients�

Inertia in health care organizations: A case study of peritoneal dialysis services.

PubMed

Wang, Virginia; Lee, Shoou-Yih D; Maciejewski, Matthew L

2015-01-01

Change is difficult for health care organizations where adoption of new practices is notoriously slow. Inertial behavior may reflect organizations' rational, strategic nonresponse to its environment or latent, institutionalizing preservation of dominant organizational routines and norms. Such strategic and selective influences of organizational inertia have different implications on the efficacy of policy to induce intended change. The aim of this study was to examine whether strategic and selective factors were associated with the provision of peritoneal dialysis (PD) services in outpatient dialysis facilities in the United States between 1995 and 2003. We conducted a longitudinal retrospective study of all outpatient end-stage renal disease dialysis facilities, using 1995-2003 administrative data from the U.S. Renal Data System. Less than half of U.S. dialysis facilities offered PD, and this pattern was stable despite substantial growth of dialysis facilities entering the market. We found little support for strategic influences and some evidence that selective factors were predictive of dialysis facilities' PD provision. Although the design of many policy and health care reform efforts widely accepts the strategic perspective of altering incentives and the environment to induce change, the presence of selective inertial influences raises concerns about the efficacy of policy intervention in the face of institutionalized organizational behavior that may be less amenable to policy intervention. Incentives recently introduced by Medicare to increase facility provision of PD may be less effective than might be expected.

Nervous system disorders in dialysis patients.

PubMed

Bansal, Vinod K; Bansal, Seema

2014-01-01

Neurologic complications are frequently encountered in dialysis patients. These may be due to the uremic state or to dialysis therapy, and require careful assessment. With longer survival of dialysis patients, these neurologic complications may significantly affect morbidity, mortality, and patients' well-being. Central nervous system involvement includes uremic encephalopathy as well as dialysis disequilibrium disorder. Both are rarely seen because of current improved understanding of their pathogenesis and treatment. Manifestations of atherosclerosis, stroke, and other neuropathies are present in this population and are not significantly altered by dialysis therapy. In recent years, increasing numbers of sleep disorders are being recognized. Peripheral nervous system involvement is also noted, including myopathy and related categories. In this chapter, we address clinical and pathophysiologic aspects of nervous system disorders in dialysis patients while discussing available therapeutic options to address the neurologic involvement. © 2014 Elsevier B.V. All rights reserved.

Differences in survival on peritoneal dialysis between oriental Asians and Caucasians: one center's experience.

PubMed

Wang, Tao; Tziviskou, Effie; Chu, Maggie; Bargman, Joanne; Jassal, Vanita; Vas, Stephen; Oreopoulos, Dimitrios G

2003-01-01

Recently it has been suggested that the survival of dialysis patients may differ among different races. Both registry data and data from Asian countries indicates that Asians on peritoneal dialysis may survive longer than their Caucasian counterparts. In the present study, we performed a detailed analysis of survival differences between oriental Asians and Caucasians on peritoneal dialysis in our multiethnic, multicultural program. Retrospectively we analyzed the survival data for patients who started peritoneal dialysis after January 1, 1996 and before December 31, 1999, in our hospital. They were followed for at least for two years. Excluded from the present analysis were those who survived for less than three months on peritoneal dialysis. The patient demographic characteristics, comorbidities, and residual renal function at the start of dialysis were collected. Indices for adequacy of dialysis were collected 1-3 months after the initiation of dialysis. Actuarial survival rates were determined by the Kaplan-Meier method. The Cox proportional hazards model was used to classify risk factors for a high mortality. There were 87 Caucasians and 29 Oriental Asian peritoneal dialysis patients. No differences were found in age, gender, primary renal disease, and residual renal function between the two groups. The Caucasians had significantly higher body surface area and urea volume and higher incidence of cardiovascular diseases. Even with slightly higher dialysis dose, the peritoneal creatinine clearance was significantly lower among the Caucasians than among Asians. There was no difference in the peritoneal D/P value between the two groups. However, compared to the Caucasians, the 24hr peritoneal fluid removal and total fluid removal volumes were significantly lower in the Asian patients. The one, two, three and four year survival rates were 95.8%, 91%, 86% and 80% for Asians and 91.3%, 78.1%, 64.7% and 54.1% for Caucasians. Significant predictors for a higher

Efficacy and safety of a very-low-protein diet when postponing dialysis in the elderly: a prospective randomized multicenter controlled study.

PubMed

Brunori, Giuliano; Viola, Battista F; Parrinello, Giovanni; De Biase, Vincenzo; Como, Giovanna; Franco, Vincenzo; Garibotto, Giacomo; Zubani, Roberto; Cancarini, Giovanni C

2007-05-01

A supplemented very-low-protein diet (sVLPD) seems to be safe when postponing dialysis therapy. Prospective multicenter randomized controlled study designed to assess the noninferiority of diet versus dialysis in 1-year mortality assessed by using intention-to-treat and per-protocol analysis. Italian uremic patients without diabetes older than 70 years with glomerular filtration rate of 5 to 7 mL/min (0.08 to 0.12 mL/s). Randomization to an sVLPD (diet group) or dialysis. The sVLPD is a vegan diet (35 kcal; proteins, 0.3 g/kg body weight daily) supplemented with keto-analogues, amino acids, and vitamins. Patients following an sVLPD started dialysis therapy in the case of malnutrition, intractable fluid overload, hyperkalemia, or appearance of uremic symptoms. Mortality, hospitalization, and metabolic markers. 56 patients were randomly assigned to each group, median follow-up was 26.5 months (interquartile range, 40), and patients in the diet group spent a median of 10.7 months (interquartile range, 11) following an sVLPD. Forty patients in the diet group started dialysis treatment because of either fluid overload or hyperkalemia. There were 31 deaths (55%) in the dialysis group and 28 deaths (50%) in the diet group. One-year observed survival rates at intention to treat were 83.7% (95% confidence interval [CI], 74.5 to 94.0) in the dialysis group versus 87.3% (95% CI, 78.9 to 96.5) in the diet group (log-rank test for noninferiority, P < 0.001; for superiority, P = 0.6): the difference in survival was -3.6% (95% CI, -17 to +10; P = 0.002). The hazard ratio for hospitalization was 1.50 for the dialysis group (95% CI, 1.11 to 2.01; P < 0.01). The unblinded nature of the study, exclusion of patients with diabetes, and incomplete enrollment. An sVLPD was effective and safe when postponing dialysis treatment in elderly patients without diabetes.

Discontinuation of dialysis.

PubMed

Motes, C E

1989-10-01

With the evolution and recognition of a legal right to self-determination and right to privacy, it is inevitable that some competent end stage renal disease patients opt to discontinue dialysis. Although justified as a constitutional right, there are other issues that must be considered in resolving their decision to forego dialysis treatment. This article addresses pertinent moral, ethical, and legal issues pertaining to this right.

Rebasing the Medicare Payment for Dialysis: Rationale, Challenges, and Opportunities

PubMed Central

Johnson, Doug

2014-01-01

After Medicare’s implementation of the bundled payment for dialysis in 2011, there has been a predictable decrease in the use of intravenous drugs included in the bundle. The change in use of erythropoiesis-stimulating agents, which decreased by 37% between 2007, when its allowance in the bundle was calculated, and 2012, was because of both changes in the Food and Drug Administration labeling for erythropoiesis-stimulating agents in 2011 and cost-containment efforts at the facility level. Legislation in 2012 required Medicare to decrease (rebase) the bundled payment for dialysis in 2014 to reflect this decrease in intravenous drug use, which amounted to a cut of 12% or $30 per treatment. Medicare subsequently decided to phase in this decrease in payment over several years to offset the increase in dialysis payment that would otherwise have occurred with inflation. A 3% reduction from the rebasing would offset an approximately 3% increase in the market basket that determines a facility’s costs for 2014 and 2015. Legislation in March of 2014 provides that the rebasing will result in a 1.25% decrease in the market basket adjustment in 2016 and 2017 and a 1% decrease in the market basket adjustment in 2018 for an aggregate rebasing of 9.5% spread over 5 years. Adjusting to this payment decrease in inflation-adjusted dollars will be challenging for many dialysis providers in an industry that operates at an average 3%–4% margin. Closure of facilities, decreases in services, and increased consolidation of the industry are possible scenarios. Newer models of reimbursement, such as ESRD seamless care organizations, offer dialysis providers the opportunity to align incentives between themselves, nephrologists, hospitals, and other health care providers, potentially improving outcomes and saving money, which will be shared between Medicare and the participating providers. PMID:25189926

Outcome of Early Initiation of Peritoneal Dialysis in Patients with End-Stage Renal Failure

PubMed Central

Oh, Kook-Hwan; Hwang, Young-Hwan; Cho, Jung-Hwa; Kim, Mira; Ju, Kyung Don; Joo, Kwon Wook; Kim, Dong Ki; Kim, Yon Su; Ahn, Curie

2012-01-01

Recent studies reported that early initiation of hemodialysis may increase mortality. However, studies that assessed the influence of early initiation of peritoneal dialysis (PD) yielded controversial results. In the present study, we evaluated the prognosis of early initiation of PD on the various outcomes of end stage renal failure patients by using propensity-score matching methods. Incident PD patients (n = 491) who started PD at SNU Hospital were enrolled. The patients were divided into 'early starters (n = 244)' and 'late starters (n = 247)' on the basis of the estimated glomerular filtration rate (eGFR) at the start of dialysis. The calculated propensity-score was used for one-to-one matching. After propensity-score-based matching (n = 136, for each group), no significant differences were observed in terms of all-cause mortality (P = 0.17), technique failure (P = 0.62), cardiovascular event (P = 0.96) and composite event (P = 0.86) between the early and late starters. Stratification analysis in the propensity-score quartiles (n = 491) exhibited no trend toward better or poorer survival in terms of all-cause mortality. In conclusion, early commencement of PD does not reduce the mortality risk and other outcomes. Although the recent guidelines suggest that initiation of dialysis at higher eGFR, physicians should not determine the time to initiate PD therapy simply rely on the eGFR alone. PMID:22323864

Standardized Prevalence Ratios for Atrial Fibrillation in Adult Dialysis Patients in Japan.

PubMed

Ohsawa, Masaki; Tanno, Kozo; Okamura, Tomonori; Yonekura, Yuki; Kato, Karen; Fujishima, Yosuke; Obara, Wataru; Abe, Takaya; Itai, Kazuyoshi; Ogasawara, Kuniaki; Omama, Shinichi; Turin, Tanvir Chowdhury; Miyamatsu, Naomi; Ishibashi, Yasuhiro; Morino, Yoshihiro; Itoh, Tomonori; Onoda, Toshiyuki; Kuribayashi, Toru; Makita, Shinji; Yoshida, Yuki; Nakamura, Motoyuki; Tanaka, Fumitaka; Ohta, Mutsuko; Sakata, Kiyomi; Okayama, Akira

2016-05-05

While it is assumed that dialysis patients in Japan have a higher prevalence of atrial fibrillation (AF) than the general population, the magnitude of this difference is not known. Standardized prevalence ratios (SPRs) for AF in dialysis patients (n = 1510) were calculated compared to data from the general population (n = 26 454) living in the same area. The prevalences of AF were 3.8% and 1.6% in dialysis patients and the general population, respectively. In male subjects, these respective values were 4.9% and 3.3%, and in female subjects they were 1.6% and 0.6%. The SPRs for AF were 2.53 (95% confidence interval [CI], 1.88-3.19) in all dialysis patients, 1.80 (95% CI, 1.30-2.29) in male dialysis patients, and 2.13 (95% CI, 0.66-3.61) in female dialysis patients. The prevalence of AF in dialysis patients was twice that in the population-based controls. Since AF strongly contributes to a higher risk of cardiovascular mortality and morbidity in the general population, further longitudinal studies should be conducted regarding the risk of several outcomes attributable to AF among Japanese dialysis patients.

The pattern of choosing dialysis modality and related mortality outcomes in Korea: a national population-based study

PubMed Central

Kim, Hyung Jong; Park, Jung Tak; Han, Seung Hyeok; Yoo, Tae-Hyun; Park, Hyeong-Cheon; Kang, Shin-Wook; Kim, Kyoung Hoon; Ryu, Dong-Ryeol; Kim, Hyunwook

2017-01-01

Background/Aims Since comorbidities are major determinants of modality choice, and also interact with dialysis modality on mortality outcomes, we examined the pattern of modality choice according to comorbidities and then evaluated how such choices affected mortality in incident dialysis patients. Methods We analyzed 32,280 incident dialysis patients in Korea. Patterns in initial dialysis choice were assessed by multivariate logistic regression analyses. Multivariate Poisson regression analyses were performed to evaluate the effects of interactions between comorbidities and dialysis modality on mortality and to quantify these interactions using the synergy factor. Results Prior histories of myocardial infarction (p = 0.031), diabetes (p = 0.001), and congestive heart failure (p = 0.003) were independent factors favoring the initiation with peritoneal dialysis (PD), but were associated with increased mortality with PD. In contrast, a history of cerebrovascular disease and 1-year increase in age favored initiation with hemodialysis (HD) and were related to a survival benefit with HD (p < 0.001, both). While favoring initiation with HD, having Medical Aid (p = 0.001) and male gender (p = 0.047) were related to increased mortality with HD. Furthermore, although the severity of comorbidities did not inf luence dialysis modality choice, mortality in incident PD patients was significantly higher compared to that in HD patients as the severity of comorbidities increased (p for trend < 0.001). Conclusions Some comorbidities exerted independent effects on initial choice of dialysis modality, but this choice did not always lead to the best results. Further analyses of the pattern of choosing dialysis modality according to baseline comorbid conditions and related consequent mortality outcomes are needed. PMID:28651309

The Methodist Hospital CCU: a Beacon unit of excellence.

PubMed

Lewis, Tricia; Abanobi, Beatrice; Alleman, Paula; Ballinas, Eva; Botbyl, Brenda; Bries, Girlie; Clark, Liz; Clarkson, Terri; Cooper, Bridgette; Cooper, Jason; Cox, Shelly; Cude, Rebecca; Davis, Juanita; Delosreyes, Arlene; Durst, Kimberly; East, Ana; Edwards, Erving; Ellison, Rose; Eparwa, Perlita; Forjuoh, Harriet; Foster, Donald; Foytik, Lisa; Gordon, Maria; Grace, Jean; Green, Lisa; Harrison, Cassandra; Herrera, Rubin; Horn, Mary; Hunsinger, Cheryce; Issac, Annamma; Jackson, Valerie; Johnson, Athie; Kitayama, Susanna; Karaan, Juliet; Kezmarski, Mary; Kleinrock, Richard; Latson, Maria; Lee, Valerie; Long, Robin; Macapagal, Fred; Magsino, Diana; Manojkumar, Saleena; Martin, Denise; Matura, Lea Ann; McCarthy, Cynthia; McClellan, Emma; McDaniel, Christy; Mengo, Pam; Meurer, Judy; Muttathottil, Liz; Osayande, Esther; Osei-Frimpong, Diana; Phillips, Betty; Pittman, James; Pratt, Craig; Putney, David; Refuerzo, Laarni; Rendon, Lavinia; Richter, Russ; Simms, Sylvia; Sitoy, Diana; Small-Nelson, Judith; Sosa, Tomas; Stuckey, Denise; Tacquard, Natalie; Talbott, Sarah; Talladen, Aleine; Taylor, Shani; Thomas, Lini; Thompson, Pam; Walters, Gordon; West, Rachel

2005-06-01

This article features the Coronary Care Unit of The Methodist Hospital of Houston, Texas. This unit was one of the first Beacon Critical Care Units recognized by the American Association of Critical Care Nurses. This article focuses on how to achieve this award. The Coronary Care Unit nursing infrastructure is described, and specific unit examples are included.

User-driven conversations about dialysis through Facebook: A qualitative thematic analysis.

PubMed

Ahmed, Salim; Haines-Saah, Rebecca J; Afzal, Arfan R; Tam-Tham, Helen; Al Mamun, Mohammad; Hemmelgarn, Brenda R; Turin, Tanvir C

2017-04-01

As one of the most popular social networking sites in the world, Facebook has strong potential to enable peer support and the user-driven sharing of health information. We carried out a qualitative thematic analysis of the wall posts of a public Facebook group focused on dialysis to identify some of the major themes discussed. We searched Facebook using the word 'dialysis'. A Facebook group (Dialysis Discussion Uncensored) with the highest number of members was selected amongst publicly available forums related to dialysis and operated in English (http://www.facebook.com/groups/DialysisUncensored). Two researchers independently extracted information on features of the group including purpose, group members and the user-generated posts on the group wall. Posts were further analysed to develop major themes. Characteristics of a Facebook group based on its participants and activities are presented. Three themes are described with representative quotations. In a period of 2 weeks, we found 1257 wall posts with total of 31 636 likes and 15 972 comments. All messages were in English, and the majority of the participants were dialysis patients. However, we observed the participation of family members and care providers as well. Posts were categorized into three major themes: sharing information, seeking and providing emotional and social support and sharing experience. Findings of this study provide an example of how a social networking platform can enable patients and their families to share information and to encourage peer-based support for managing dialysis-related experiences. © 2016 Asian Pacific Society of Nephrology.

Risk factors for drainage-requiring ascites after refractory peritonitis in peritoneal dialysis patients.

PubMed

Lee, Cheng-Chia; Tu, Kun-Hua; Chen, Hsiao-Hui; Chang, Ming-Yang; Hung, Cheng-Chieh

2016-10-01

Refractory peritonitis remains a thorny issue for patients with chronic peritoneal dialysis (PD). Shortly after catheter removal, some patients develop persistent peritoneal inflammation and ascites formation, which require percutaneous drainage for symptom relief. Our study aimed at finding the risk factors for this kind of event. A total of 47 PD patients complicated with refractory peritonitis who underwent catheter removal between January 2009 and December 2011 were enrolled in this study. Data were compared between patients with and without the development of symptomatic ascites requiring drainage during hospitalization. Among the 47 refractory peritonitis patients, 15 patients developed symptomatic ascites that needed further drainage shortly after catheter removal during hospitalization. The following factors were associated with an increased risk: longer dialysis duration, higher peritoneal Kt/V urea, and a significant rise in serum C-reactive protein (CRP) level after catheter removal. These patients had a prolonged hospital stay (62 vs 21 days, P < 0.001) and a significantly higher risk of recurrent loculated ascites during subsequent 6 months of follow-up (33.3 vs 6.2 %, P = 0.022) compared with patients who did not develop ascites requiring drainage during hospitalization. A significant portion of patients with refractory PD peritonitis experienced ascites requiring drainage shortly after catheter removal, which led to a prolonged hospitalization. Whether routine drain placement at the time of catheter removal for this high-risk group would be of benefit warrants further prospective studies.

Coronary artery disease treatment in dialysis patients at the Hospital das Clínicas da Faculdade de Medicina de Botucatu--UNESP.

PubMed

Vieira, Paula Ferreiro; Garcia, Paula Dalsoglio; Bregagnollo, Edson Antonio; Carvalho, Fábio Cardoso; Kochi, Ana Cláudia; Martins, Antonio Sérgio; Caramori, Jaqueline Costa Teixeira; Franco, Roberto Jorge da Silva; Barretti, Pasqual; Martin, Luis Cuadrado

2007-05-01

Interventional treatment of coronary insufficiency is underemployed among dialysis patients. Studies confirming its efficacy in this set of patients are scarce. To assess the results of interventional treatment of coronary artery disease in patients undergoing dialysis. A total of 34 dialysis patients submitted to coronary angiography between September 1995 and October 2004 were divided according to presence or absence of coronary lesion, type of treatment and presence or absence of diabetes mellitus. The groups were compared according to their clinical and survival characteristics. Survival of patients undergoing interventional treatment was compared to overall survival of 146 dialysis patients at the institution in the same period. Interventional treatment was indicated to the same clinical conditions in the general population. Thirteen patients with no angiography coronary lesions presented a survival rate of 100% in 48 months as compared to 35% of 21 patients with coronary artery disease. Diabetic patients had a lower survival rate compared with non-diabetics. Angioplasty had a worse prognosis compared to surgery; however, 80% of patients undergoing angioplasty were diabetic. Seventeen patients submitted to interventional procedures presented a survival rate similar to that of the others 146 hemodialysis patients without clinical evidence of coronary disease. This small series shows that myocardial revascularization, whenever indicated, can be performed in dialysis patients. This conclusion is corroborated by similar mortality rates in two groups of patients: coronary patients submitted to revascularization and overall dialysis patients.

Healthcare costs of the progression of chronic kidney disease and different dialysis techniques estimated through administrative database analysis.

PubMed

Roggeri, Alessandro; Roggeri, Daniela Paola; Zocchetti, Carlo; Bersani, Maurizio; Conte, Ferruccio

2017-04-01

Chronic kidney disease (CKD) progression is associated with significant comorbidities and costs. In Italy, limited evidence of healthcare resource consumption and costs is available. We therefore aimed to investigate the direct healthcare costs in charge to the Lombardy Regional Health Service (RHS) for the treatment of CKD patients in the first year after starting hemodialysis and in the 2 years prior to dialysis. Citizens resident in the Lombardy Region (Italy) who initiated dialysis in the year 2011 (Jan 1 to Dec 31) were selected and data were extracted from Lombardy Regional databases on their direct healthcare costs in the first year after starting dialysis and in the 2 years prior to it was analyzed. Drugs, hospitalizations, diagnostic procedures and outpatient costs covered by RHS were estimated. Patients treated for acute kidney injury, or who died or stopped dialysis during the observational period were excluded. From the regional population (>9,700,000 inhabitants), 1067 patients (34.3 % females) initiating dialysis were identified, of whom 82 % underwent only hemodialysis (HD), 13 % only peritoneal dialysis (PD) and the remaining 5 % both treatments. Direct healthcare costs/patient were € 5239, € 12,303 and € 38,821 (€ 40,132 for HD vs. € 30,444 for PD patients) for the periods 24-12 months pre-dialysis, 12-0 months pre-dialysis, and in the first year of dialysis, respectively. This study highlights a significant economic burden related to CKD and an increase in direct healthcare costs associated with the start of dialysis, pointing to the importance of prevention programs and early diagnosis.

Potential Role of Vegetarianism on Nutritional and Cardiovascular Status in Taiwanese Dialysis Patients: A Case-Control Study.

PubMed

Ou, Shih-Hsiang; Chen, Mei-Yin; Huang, Chien-Wei; Chen, Nai-Ching; Wu, Chien-Hsing; Hsu, Chih-Yang; Chou, Kang-Ju; Lee, Po-Tsang; Fang, Hua-Chang; Chen, Chien-Liang

2016-01-01

Cardiovascular disease remains the most common cause of death for patients on chronic dialysis. End stage renal disease patients undergoing dialysis imposed to reduce phosphorus intake, which likely contributes to development of vegetarian diet behaviors. Vegetarian diets are often lower in protein content, in contradiction to the recommendation that a high protein diet is followed by patients undergoing dialysis. The purpose of the study was to investigate the effects of a vegetarian diet on the nutritional and cardiovascular status of dialysis patients. A study of 21 vegetarian dialysis patients and 42 age- and sex-matched non-vegetarian dialysis patients selected as controls was conducted in the Kaohsiung Veterans General Hospital. Brachial-ankle pulse wave velocity and biochemistry data including total homocysteine levels, serum lipid profiles, high-sensitivity C-reactive protein, vitamin D levels, albumin, and normalized protein catabolic rate were measured. Compared with the non-vegetarian control group, vegetarian subjects had lower body weight, body mass index, serum phosphate, blood urea nitrogen, serum creatinine, vitamin D, uric acid, albumin, and normalized protein catabolic rate (p < 0.05). The vegetarian group showed higher brachial-ankle pulse wave velocity than the non-vegetarian group (1926.95 ± 456.45 and 1684.82 ± 309.55 cm/sec, respectively, p < 0.05). After adjustment for age, albumin, pre-dialysis systolic blood pressure, and duration of dialysis, vegetarian diet remained an independent risk factor for brachial-ankle pulse wave velocity. The present study revealed that patients on dialysis who follow vegetarian diets may experience subclinical protein malnutrition and vitamin D deficiency that could offset the beneficial cardiovascular effects of vegetarianism.

Potential Role of Vegetarianism on Nutritional and Cardiovascular Status in Taiwanese Dialysis Patients: A Case-Control Study

PubMed Central

Chen, Mei-Yin; Huang, Chien-Wei; Chen, Nai-Ching; Wu, Chien-Hsing; Hsu, Chih-Yang; Chou, Kang-Ju; Lee, Po-Tsang; Fang, Hua-Chang; Chen, Chien-Liang

2016-01-01

Background & Objectives Cardiovascular disease remains the most common cause of death for patients on chronic dialysis. End stage renal disease patients undergoing dialysis imposed to reduce phosphorus intake, which likely contributes to development of vegetarian diet behaviors. Vegetarian diets are often lower in protein content, in contradiction to the recommendation that a high protein diet is followed by patients undergoing dialysis. The purpose of the study was to investigate the effects of a vegetarian diet on the nutritional and cardiovascular status of dialysis patients. Design, Setting, Participants, Measurements A study of 21 vegetarian dialysis patients and 42 age- and sex-matched non-vegetarian dialysis patients selected as controls was conducted in the Kaohsiung Veterans General Hospital. Brachial-ankle pulse wave velocity and biochemistry data including total homocysteine levels, serum lipid profiles, high-sensitivity C-reactive protein, vitamin D levels, albumin, and normalized protein catabolic rate were measured. Results Compared with the non-vegetarian control group, vegetarian subjects had lower body weight, body mass index, serum phosphate, blood urea nitrogen, serum creatinine, vitamin D, uric acid, albumin, and normalized protein catabolic rate (p < 0.05). The vegetarian group showed higher brachial-ankle pulse wave velocity than the non-vegetarian group (1926.95 ± 456.45 and 1684.82 ± 309.55 cm/sec, respectively, p < 0.05). After adjustment for age, albumin, pre-dialysis systolic blood pressure, and duration of dialysis, vegetarian diet remained an independent risk factor for brachial-ankle pulse wave velocity. Conclusions The present study revealed that patients on dialysis who follow vegetarian diets may experience subclinical protein malnutrition and vitamin D deficiency that could offset the beneficial cardiovascular effects of vegetarianism. PMID:27295214

Home visit program improves technique survival in peritoneal dialysis.

PubMed

Martino, Francesca; Adıbelli, Z; Mason, G; Nayak, A; Ariyanon, W; Rettore, E; Crepaldi, Carlo; Rodighiero, Mariapia; Ronco, Claudio

2014-01-01

Peritoneal dialysis (PD) is a home therapy, and technique survival is related to the adherence to PD prescription at home. The presence of a home visit program could improve PD outcomes. We evaluated its effects on clinical outcome during 1 year of follow-up. This was a case-control study. The case group included all 96 patients who performed PD in our center on January 1, 2013, and who attended a home visit program; the control group included all 92 patients who performed PD on January 1, 2008. The home visit program consisted of several additional visits to reinforce patients' confidence in PD management in their own environment. Outcomes were defined as technique failure, peritonitis episode, and hospitalization. Clinical and dialysis features were evaluated for each patient. The case group was significantly older (p = 0.048), with a lower grade of autonomy (p = 0.033), but a better hemoglobin level (p = 0.02) than the control group. During the observational period, we had 11 episodes of technique failure. We found a significant reduction in the rate of technique failure in the case group (p = 0.004). Furthermore, survival analysis showed a significant extension of PD treatment in the patients supported by the home visit program (52 vs. 48.8 weeks, p = 0.018). We did not find any difference between the two groups in terms of peritonitis and hospitalization rate; however, trends toward a reduction of Gram-positive peritonitis rates as well as prevalence and duration of hospitalization related to PD problems were identified in the case group. The retrospective nature of the analysis was a limitation of this study. The home visit program improves the survival of PD patients and could reduce the rate of Gram-positive peritonitis and hospitalization. Video Journal Club "Cappuccino with Claudio Ronco" at http://www.karger.com/?doi=365168.

Pregnancy in chronic dialysis, late diagnosis, and other problems

NASA Astrophysics Data System (ADS)

Ramadani, S.; Nasution, A. T.; Nasution, S.; Lubis, H. R.

2018-03-01

The incidence of pregnancy in patients with chronic kidney disease (CKD) undergoing hemodialysis is rare. Forpregnant patients with CKD undergoing regular hemodialysis, the effects of renal disease on the fetus should be noted and require specific strategies. A 30-year-old woman had no menstruation for 4 months. Abdominal ultrasound showed single fetus within 16 weeks of pregnancy. She had previously been in regular hemodialysis twice a week since 2015, then the frequency of hemodialysis was increased to thrice a week for 4 hours/dialysis. During pregnancy, she was given erythropoiesis stimulating agent, controlled protein nutrition (0.6-1.5g/kg/day) and routine pregnancy controls to an obstetrician. After 31-32 weeks gestation, thebaby was born alive with low birth weight (1800g). Maintaining pregnancy in women with regular hemodialysis is still challenging and difficult. Prolonged/intensive dialysis during pregnancy results in longer gestational periods, higher fetal weights, and a higher likelihood of survival. Based on a dialysis guideline for pregnancy in CKD, hemodialysis is performed at least 20 hours/week to maintain pre-dialysis of BUN≤50mg/dl hemoglobin should be at least 10-11g/dL. We reported a case of pregnancy in dialysis CKD patient undergoing hemodialysis thricea week (4 hours/dialysis). The baby was born alive with low birth weight (1800 g).

[Height and weight growth delay and protein-energy malnutrition in children with chronic dialysis].

PubMed

Perţea, L; Diaconeasa, Lavinia; Burlea, M; Munteanu, Mihaela; Brumariu, O

2010-01-01

Growth retardation is an important problem in children with chronic renal disease, and malnutrition is a determinative factor. The study intends to assess the relationship between protein-energy malnutrition and stature-weight retardation in children enrolled in chronic dialysis program. The study group was composed of 16 children (5 boys and 11 girls--sex ratio of 2.2) hospitalized in the IVth Nephrology Clinic at Clinical Emergency Hospital "St. Maria" Iaşi, 13 rural and 3 urban, aged between 9 and 17 years, with chronic dialysis program. This was a follow-up study during a period of 4 years (2006-2009), resulting in correlations between anthropometric paremeters, biochemical, BIA and DEXA data. The stature-weight deficiency of the 16 patients was as follows: after an average period of 61.7 months of HD and 32.7 months of PD, in children older than 12 years (mean age 15.27 years), 7 of 10 had stature-weight deficits higher than (-3DS) or (-4DS). The group with less than (-2DS) stature-weight deficits showed the same mean age of 15.2 years, the protein energy-malnutrition was present in 2 cases (33%) and was attributed to a dialysis period shorter than 13.8 months. The late diagnosis of the disease (at an average age of 13 years), the long period of chronic dialysis program (over 39.5 months on average) and the early debut of malnutrition are favoring or worsening factors of stature-weight retardation. After correlating ESG with biochemical, BIA and DEXA data, in our group were identified 4 cases of moderate malnutrition and 9 cases of severe malnutrition.

Sevelamer is cost-saving vs. calcium carbonate in non-dialysis-dependent CKD patients in italy: a patient-level cost-effectiveness analysis of the INDEPENDENT study.

PubMed

Ruggeri, Matteo; Cipriani, Filippo; Bellasi, Antonio; Russo, Domenico; Di Iorio, Biagio

2014-01-01

To conduct a cost-effectiveness analysis of sevelamer versus calcium carbonate in patients with non-dialysis-dependent CKD (NDD-CKD) from the Italian NHS perspective using patient-level data from the INDEPENDENT-CKD study. Patient-level data on all-cause mortality, dialysis inception and phosphate binder dose were obtained for all 107 sevelamer and 105 calcium carbonate patients from the INDEPENDENT-CKD study. Hospitalization and frequency of dialysis data were collected post hoc for all patients via a retrospective chart review. Phosphate binder, hospitalization, and dialysis costs were expressed in 2012 euros using hospital pharmacy, Italian diagnosis-related group and ambulatory tariffs, respectively. Total life years (LYs) and costs per treatment group were calculated for the 3-year period of the study. Bootstrapping was used to estimate confidence intervals around outcomes, costs, and cost-effectiveness and to calculate the cost-effectiveness acceptability curve. A subgroup analysis of patients who did not initiate dialysis during the INDEPENDENT-CKD study was also conducted. Sevelamer was associated with 0.06 additional LYs (95% CI -0.04 to 0.16) and cost savings of EUR -5,615 (95% CI -10,066 to -1,164) per patient compared with calcium carbonate. On the basis of the bootstrap analysis, sevelamer was dominant compared to calcium carbonate in 87.1% of 10,000 bootstrap replicates. Similar results were observed in the subgroup analysis. RESULTS were driven by a significant reduction in all-cause mortality and significantly fewer hospitalizations in the sevelamer group, which offset the higher acquisition cost for sevelamer. Sevelamer provides more LYs and is less costly than calcium carbonate in patients with NDD-CKD in Italy.

Association of Dialysate Bicarbonate Concentration With Mortality in the Dialysis Outcomes and Practice Patterns Study (DOPPS)

PubMed Central

Tentori, Francesca; Karaboyas, Angelo; Robinson, Bruce M.; Morgenstern, Hal; Zhang, Jinyao; Sen, Ananda; İkizler, T. Alp; Rayner, Hugh; Fissell, Rachel B.; Vanholder, Raymond; Tomo, Tadashi; Port, Friedrich K.

2013-01-01

Background Most hemodialysis patients worldwide are treated with bicarbonate dialysis using sodium bicarbonate as the base. Few studies have assessed outcomes of patients treated with different dialysate bicarbonate levels, and the optimal concentration remains uncertain. Study Design The Dialysis Outcomes and Practice Patterns Study (DOPPS) is an international prospective cohort study. Setting & Participants This study included 17,031 patients receiving thrice-weekly in-center hemodialysis from 11 DOPPS countries (2002–2011). Predictor Dialysate bicarbonate. Outcomes All-cause and cause-specific mortality and first hospitalization, using Cox regression to estimate the effects of dialysate bicarbonate concentration, adjusting for potential confounders. Measurements Demographics, comorbid conditions, laboratory values, and prescriptions were abstracted from medical records. Results Mean dialysate bicarbonate was 35.5 ± 2.7 (SD) mEq/L, ranging from 32.2 ± 2.3 mEq/L in Germany to 37.0 ± 2.6 mEq/L in the US. Prescription of high dialysate bicarbonate (≥38 mEq/L) was most common in the US (45% of patients). Approximately 50% of DOPPS facilities used a single dialysate bicarbonate concentration. 3,913 patients (23%) died during follow-up. Dialysate bicarbonate concentration was positively associated with mortality (adjusted HR, 1.08 per 4 mEq/L higher [95% CI, 1.01–1.15]; HR for dialysate bicarbonate ≥38 vs. 33–37 mEq/L, 1.07 [95% CI, 0.97–1.19]). Results were consistent across levels of pre-dialysis session serum bicarbonate and between facilities that used a single dialysate bicarbonate concentration and those that prescribed different concentrations to individual patients. The association of dialysis bicarbonate with mortality was stronger in patients with longer dialysis vintage. Limitations Due to the observational nature of the current study, we cannot rule out that the reported associations may be biased by unmeasured confounders. Conclusions High

Likelihood of Starting Dialysis after Incident Fistula Creation

PubMed Central

Quinn, Robert R.; Garg, Amit X.; Kim, S. Joseph; Wald, Ron; Paterson, J. Michael

2012-01-01

Summary Background and objectives Guidelines promote early fistula creation to avoid central venous catheter use. This practice may lead to fistula creations in patients who never receive dialysis. The objective of this study was to estimate the risk of fistula nonuse with long-term follow-up. Design, setting, participants, & measurements Administrative health data identified 1929 predialysis adults who had their first fistula creation between April of 2002 and March of 2006. Patients were followed for a minimum of 2 years or until they began dialysis, received a kidney transplant, or died. Results The median follow-up times in patients who started dialysis, died without receiving dialysis, and remained in predialysis were 6.1, 11.5, and 38.7 months, respectively. Eighty-one percent of patients initiated dialysis; 9% of patients died without receiving dialysis, and 10% of patients remained predialysis. Forty percent of patients had their first fistula creation 3–12 months before initiating dialysis (the recommended window). Thirty percent were created within 90 days of starting dialysis; 30% were created more than 1 year before starting dialysis, and 10% were created more than 2 years before starting dialysis. Older patients, females, and patients with less comorbidity were not as likely to initiate dialysis after incident fistula creation. Conclusions Most patients who underwent fistula creation before starting dialysis eventually received dialysis with extended follow-up, but the risk was significantly modified by age, sex, and comorbidity. Many patients had fistula creations earlier or later than recommended. PMID:22344512

[Medico-economic assessment of the Pontoise Hospital stroke unit].

PubMed

Yekhlef, F; Decup, D; Niclot, P; Servan, J; Descombes, S; Richecoeur, J; Ollivier, A

2010-11-01

Annually, approximately 120,000 people in France have a stroke. Various controlled studies have pointed out the benefits of treatment in a stroke unit (SU). The objective of this study was to evaluate, from a medical point of view, the economic impact of the Pontoise Hospital SU. Based on the national cost study (NCS [étude nationale des coûts: ENC]) we analyzed data of five diagnosis related groups (DRG) which have a principle diagnosis in relation with stroke. This work was limited to strokes and transient ischemic events in adults and excluded sub-arachnoid hemorrhage. Medical and economic parameters were collected over the period from January to October 2006 and compared with those of the same period in 2005, that is to say before the opening of the SU. Three hundred and twenty-three hospital stays occurred between January 1st and October 31st, 2006 and 216 during the same time period before the opening of the SU, an increase of approximately 50% of all stroke-related admissions in our hospital. The number of stays carried out in the neurology unit increased by 29%. There was no significant difference between the two periods regarding age (median 69 versus 70 years) and sex- ratio. Average length of stay (ALS) was the same (9 days). There were no significant differences concerning the death rate (5.6% versus 6.2%) and that of discharge to home (44.6% versus 44.4%). The cost by stay in 2006 was 3534 euros [median; min 664-max 57,542] versus 3541 euros in 2005 [681-35,149] (p=0.57). Analysis by DRG highlighted an increase in the cost for serious strokes, cerebral infarctions and hemorrhages. For transitory ischemic events, the cost and the ALS decreased. After the opening of the SU, there was an increase in the activity without an increase in the total cost. This could be related in part to the limited means allocated to the stroke unit at its opening (in particular medical staff). The NCS can be used to evaluate the activity of a stroke unit. This work could

Determination of dextrose in peritoneal dialysis solution by localized surface plasmon resonance technique based on silver nanoparticles formation

NASA Astrophysics Data System (ADS)

Masrournia, Mahboube; Montazarolmahdi, Maliheh; Sani, Faramarz Aliasghari

2017-07-01

Determination of dextrose in peritoneal dialysis with a method based on silver nanoparticles (AgNPs) formation was investigated. In a green chemistry method, silver nanoparticles (AgNPs) were synthesized in the natural polymeric matrix of gelatin. The nanoparticles were characterized with UV-Vis spectroscopy and transmission electron microscopy (TEM). Absorbance signal of AgNPs could be applied to determine the various concentrations of dextrose solutions. Drop wise and ultrasonic methods were used and compared with each other. The dynamic range of methods with limit of detection and relative standard deviations were obtained. Results for real sample (peritoneal dialysis) were satisfied.

Australian consumer perspectives on dialysis: first national census.

PubMed

Ludlow, Marie J; Lauder, Lydia A; Mathew, Timothy H; Hawley, Carmel M; Fortnum, Debbie

2012-11-01

The percentage of people in Australia who undertake home dialysis has steadily decreased over the past 40 years and varies within Australia. Consumer factors related to this decline have not previously been determined. A 78-question survey was developed and piloted in 2008 and 2009. Survey forms were distributed to all adult routine dialysis patients in all Australian states and territories (except Northern Territory) between 2009 and 2010. Of 9223 distributed surveys, 3250 were completed and returned. 49% of respondents indicated they had no choice in the type of dialysis and 48% had no choice in dialysis location. Respondents were twice as likely to receive information about haemodialysis (85%) than APD (39%) or CAPD (41%). The provision of education regarding home modalities differed significantly between states, and decreased with increasing patient age. Additional nursing support and reimbursement of expenses increased the proportion of those willing to commence dialysis at home, from 13% to 34%. State differences in the willingness to consider home dialysis, the degree of choice in dialysis location, the desire to change current dialysis type and/or location, and the provision of information about dialysis were identified. The delivery of pre-dialysis education is variable, and does not support all options of dialysis for all individuals. State variances indicate that local policy and health professional teams significantly influence the operation of dialysis programs. © 2012 The Authors. Nephrology © 2012 Asian Pacific Society of Nephrology.

Phosphate Removal by Peritoneal Dialysis: The Effect of Transporter Status and Peritoneal Dialysis Prescription

PubMed Central

Courivaud, Cecile; Davenport, Andrew

2016-01-01

♦ Background: Interventional trials failed to demonstrate that increasing urea clearance improved peritoneal dialysis (PD) patient survival. Hyperphosphatemia is a well-recognized predictor of cardiovascular and all-cause mortality in PD patients. Simplification of PD small solute clearance targets focuses away from larger solutes, including phosphate. In the US and UK, increasing use of automated peritoneal dialysis (APD) cyclers with shorter dwell times could also potentially reduce peritoneal phosphate removal compared to continuous ambulatory peritoneal dialysis (CAPD). ♦ Methods: Total phosphate and peritoneal phosphate clearances were measured in a prospective observational cohort of 380 adult PD patients attending a tertiary university hospital between 1996 and 2013 for routine assessment of PD adequacy. ♦ Results: Eighty-seven patients (22.9%) were hyperphosphatemic. Taking the mean 4-hour dialysate to plasma (D/P) ratio for phosphate, 193 (50.8%) were fast and fast-average transporters and 187 (49.2%) were slow and slow-average transporters (compared to 276 [72.6%] and 104 [27.4%], respectively, for peritoneal creatinine transporter status). Faster peritoneal phosphate transporter status was associated with over-hydration (odds ratio [OR] = 2.45 [1.43 – 4.20], p = 0.001). Whereas the 4-hour D/P creatinine and peritoneal weekly creatinine clearance did not differ between those who were hyperphosphatemic or not, the hyperphosphatemic patients had lower 4-hour D/P phosphate and lower peritoneal weekly phosphate clearance (p = 0.019, and p = 0.06 respectively). We found greater peritoneal phosphate clearance for patients choosing CAPD compared to APD, irrespective of the peritoneal phosphate transporter status. ♦ Conclusion: Peritoneal creatinine transporter status and creatinine clearance cannot be used as surrogate markers of peritoneal phosphate transport and clearance. Hyperphosphatemia was more common in PD patients with slower peritoneal

Evaluation of passive diffusion bag and dialysis samplers in selected wells at Hickam Air Force Base, Hawaii, July 2001

USGS Publications Warehouse

Vroblesky, Don A.; Pravecek, Tasha

2002-01-01

Field comparisons of chemical concentrations obtained from dialysis samplers, passive diffusion bag samplers, and low-flow samplers showed generally close agreement in most of the 13 wells tested during July 2001 at Hickam Air Force Base, Hawaii. The data for chloride, sulfate, iron, alkalinity, arsenic, and methane appear to show that the dialysis samplers are capable of accurately collecting a passive sample for these constituents. In general, the comparisons of volatile organic compound concentrations showed a relatively close correspondence between the two different types of diffusion samples and between the diffusion samples and the low-flow samples collected in most wells. Divergence appears to have resulted primarily from the pumping method, either producing a mixed sample or water not characteristic of aquifer water moving through the borehole under ambient conditions. The fact that alkalinity was not detected in the passive diffusion bag samplers, highly alkaline waters without volatilization loss from effervescence, which can occur when a sample is acidified for preservation. Both dialysis and passive diffusion bag samplers are relatively inexpensive and can be deployed rapidly and easily. Passive diffusion bag samplers are intended for sampling volatile organic compounds only, but dialysis samplers can be used to sample both volatile organic compounds and inorganic solutes. Regenerated cellulose dialysis samplers, however, are subject to biodegradation and probably should be deployed no sooner than 2 weeks prior to recovery. 1 U.S. Geological Survey, Columbia, South Carolina. 2 Air Florce Center for Environmental Excellence, San Antionio, Texas.

Challenges in Hospital-Associated Infection Management: A Unit Perspective.

PubMed

Stacy, Kathleen M

2015-01-01

Maintaining a successful unit-based continuous quality improvement program for managing hospital-associated infections is a huge challenge and an overwhelming task. It requires strong organizational support and unit leadership, human and fiscal resources, time, and a dedicated and motivated nursing staff. A great deal of effort goes into implementing, monitoring, reporting, and evaluating quality improvement initiatives and can lead to significant frustration on the part of the leadership team and nursing staff when quality improvement efforts fail to produce the desired results. Each initiative presents its own unique set of challenges; however, common issues influence all initiatives. These common issues include organization and unit culture, current clinical practice guidelines being used to drive the initiatives, performance discrepancies on the part of nursing staff, availability of resources including equipment and supplies, monitoring of the data, and conflicting quality improvement priorities.

Hospital-level changes in adult ICU bed supply in the United States

PubMed Central

Wallace, David J.; Seymour, Christopher W.; Kahn, Jeremy M.

2017-01-01

Objective Although the number of intensive care beds in the United States is increasing, little is known about the hospitals responsible for this growth. We sought to better characterize national growth in intensive care beds by identifying hospital-level factors associated with increasing numbers of intensive care beds over time. Design We performed a repeated-measures time series analysis of hospital-level intensive care bed supply using data from Centers for Medicare and Medicaid Services. Setting All United States acute care hospitals with adult intensive care beds over the years 1996 to 2011. Measurements & Main Results We described the number of beds, teaching status, ownership, intensive care occupancy and urbanicity for each hospital in each year of the study. We then examined the relationship between increasing intensive care beds and these characteristics, controlling for other factors. The study included 4,457 hospitals and 55,865 hospital-years. Overall, the majority of intensive care bed growth occurred in teaching hospitals (net +13,471 beds, 72.1% of total growth), hospitals with 250 or more beds (net +18,327 beds, 91.8% of total growth) and hospitals in the highest quartile of occupancy (net +10,157 beds, 54.0% of total growth). In a longitudinal multivariable model, larger hospital size, teaching status, and high intensive care occupancy were associated with subsequent-year growth. Furthermore, the effects of hospital size and teaching status were modified by occupancy: the greatest odds of increasing intensive care unit beds were in hospitals with 500 or more beds in the highest quartile of occupancy (adjusted OR: 18.9; 95% CI: 14.0 – 25.5; p<0.01) and large teaching hospitals in the highest quartile of occupancy (adjusted OR: 7.3; 95% CI: 5.3 – 9.9; p<0.01). Conclusions Increasingly, intensive care bed expansion in the United States is occurring in larger hospitals and teaching centers, particularly following a year with high intensive care

Hospital-based glaucoma clinics: what are the costs to patients?

PubMed

Sharma, A; Jofre-Bonet, M; Panca, M; Lawrenson, J G; Murdoch, I

2010-06-01

To investigate the costs to patients attending hospital-based glaucoma clinics. A patient-based costs questionnaire was developed and completed for patients attending six ophthalmology units across London (Ealing General Hospital, St Georges Hospital, Mile End Hospital, Upney Centre Barking, St Ann's Hospital and the Royal London Hospital). The questionnaire considered age, sex, ethnicity as well as patient-based costs, opportunity costs, and companion costs. All patients visiting for review or appointments were approached non-selectively. A total of 100 patients were sampled from each unit. The mean age of the full sample was 69.6 years (SD 12.6), with little variation between sites (68.5-71.8 years). There was an almost equal sex distribution (male (298 (50.6%)). There was no major difference in occupational distribution between sites. The majority of people came to hospital by bus (40%) or car (26%). Female patients went slightly more by cab or car, whereas male patients went slightly more by foot or train. There was some variability in transport method by site. The data showed that the Royal London hospital had the highest mean cost per visit (pound16.20), whereas St Georges had the lowest (pound12.90). Upney had the second highest mean cost per visit (pound15.20), whereas Ealing and St Ann's had similar mean costs of (pound13.25) and (pound13), respectively. Travel costs accounted for about one-fifth of the total patient's costs. For all glaucoma clinics, total societal costs were higher than the sum of patients' costs because of the high frequency of companions. A surprising finding was that two-thirds of the population (392 or 66.6%) reported no qualification-considerably higher than the national census statistics for the same population. To our knowledge this paper presents direct and indirect patient costs in attending hospital glaucoma units for the first time. It highlights the significance of opportunity costs when considering health-care interventions

Peritoneal Dialysis to Treat Patients with Acute Kidney Injury-The Saving Young Lives Experience in West Africa: Proceedings of the Saving Young Lives Session at the First International Conference of Dialysis in West Africa, Dakar, Senegal, December 2015.

PubMed

Abdou, Niang; Antwi, Sampson; Koffi, Laurence Adonis; Lalya, Francis; Adabayeri, Victoria May; Nyah, Norah; Palmer, Dennis; Brusselmans, Ariane; Cullis, Brett; Feehally, John; McCulloch, Mignon; Smoyer, William; Finkelstein, Fredric O

2017-01-01

In December 2015, as part of the First African Dialysis Conference organized in Dakar, Senegal, 5 physicians from West African countries who have participated in the Saving Young Lives Program reviewed their experiences establishing peritoneal dialysis (PD) programs to treat patients with acute kidney injury (AKI). Thus far, nearly 200 patients have received PD treatment in these countries. The interaction and discussion amongst the participants at the meeting was meaningful and informative. The presentations highlighted the creativity, conviction, and determination of the physicians in overcoming the various barriers and challenges they encountered to establish PD/AKI programs. Hopefully, these successes and the increased awareness of the importance of early diagnosis and treatment of AKI will inspire much needed support from government, hospital, and international organizations. Copyright © 2017 International Society for Peritoneal Dialysis.

Insulin Resistance in Nondiabetic Peritoneal Dialysis Patients: Associations with Body Composition, Peritoneal Transport, and Peritoneal Glucose Absorption.

PubMed

Bernardo, Ana Paula; Oliveira, Jose C; Santos, Olivia; Carvalho, Maria J; Cabrita, Antonio; Rodrigues, Anabela

2015-12-07

Insulin resistance has been associated with cardiovascular disease in peritoneal dialysis patients. Few studies have addressed the impact of fast transport status or dialysis prescription on insulin resistance. The aim of this study was to test whether insulin resistance is associated with obesity parameters, peritoneal transport rate, and glucose absorption. Insulin resistance was evaluated with homeostasis model assessment method (HOMA-IR), additionally corrected by adiponectin (HOMA-AD). Enrolled patients were prevalent nondiabetics attending at Santo António Hospital Peritoneal Dialysis Unit, who were free of hospitalization or infectious events in the previous 3 months (51 patients aged 50.4 ± 15.9 years, 59% women). Leptin, adiponectin, insulin-like growth factor-binding protein 1 (IGFBP-1), and daily glucose absorption were also measured. Lean tissue index, fat tissue index (FTI), and relative fat mass (rel.FM) were assessed using multifrequency bioimpedance. Patients were categorized according to dialysate to plasma creatinine ratio at 4 hours, 3.86% peritoneal equilibration test, and obesity parameters. Obesity was present in 49% of patients according to rel.FM. HOMA-IR correlated better with FTI than with body mass index. Significant correlations were found in obese, but not in nonobese patients, between HOMA-IR and leptin, leptin/adiponectin ratio (LAR), and IGFBP-1. HOMA-IR correlated with HOMA-AD, but did not correlate with glucose absorption or transport rate. There were no significant differences in insulin resistance indices, glucose absorption, and body composition parameters between fast and nonfast transporters. A total of 18 patients (35.3%) who had insulin resistance presented with higher LAR and rel.FM (7.3 [12.3, interquartile range] versus 0.7 [1.4, interquartile range], P<0.001, and 39.4 ± 10.1% versus 27.2 ± 11.5%, P=0.002, respectively), lower IGFBP-1 (8.2 ± 7.2 versus 21.0 ± 16.3 ng/ml, P=0.002), but similar glucose absorption and

Peritoneal Dialysis Dose and Adequacy

MedlinePlus

... and other minerals dissolved in water, called dialysis solution, is placed in a person's abdominal cavity through ... to pass from the blood into the dialysis solution. These wastes then leave the body when the ...

Dialysis modality and survival: Done to death.

PubMed

Trinh, Emilie; Chan, Christopher T; Perl, Jeffrey

2018-03-14

The debate surrounding whether peritoneal dialysis or hemodialysis is associated with differential survival continues as the numerous comparative studies over the past 3 decades have yielded conflicting results. Findings have also evolved over time in the setting of changing patient characteristics, advances in dialytic technologies, and the use of more robust statistical and epidemiologic approaches. Here, we will critically review the body of evidence, both historical and contemporary, comparing survival across dialysis modalities. Significant limitations of the observational nature of the current literature will be highlighted given that no adequately powered randomized controlled trials exist. Given the lack of consistency and limitations of current studies, coupled with the poor survival across both modalities, we can likely conclude that survival comparisons between both modalities do not appreciably differ. Hence, the choice of dialysis modality should not be dictated by survival comparisons, but rather be based on an individualized and informed decision making that places patient preference and lifestyle considerations at the forefront, while integrating medical factors and availability of resources and support. The emphasis of future research should move beyond survival outcomes when comparing dialysis modalities, and instead be redirected to patient-endorsed and patient-reported outcomes. © 2018 Wiley Periodicals, Inc.

Understanding the Recent Increase in Ferritin Levels in United States Dialysis Patients: Potential Impact of Changes in Intravenous Iron and Erythropoiesis-Stimulating Agent Dosing.

PubMed

Karaboyas, Angelo; Zee, Jarcy; Morgenstern, Hal; Nolen, Jacqueline G; Hakim, Raymond; Kalantar-Zadeh, Kamyar; Zager, Philip; Pisoni, Ronald L; Port, Friedrich K; Robinson, Bruce M

2015-10-07

Anemia management changed substantially among dialysis patients in the United States around the time of implementation of the new Centers for Medicare & Medicaid Services bundled payment system and erythropoiesis-stimulating agent (ESA) label change in 2011. Among these, average ferritin levels increased dramatically and have remained high since; this study sought to gain understanding of this sustained rise in ferritin levels. Trends in mean ferritin, hemoglobin, IV iron dose, and ESA dose from 2009 to 2013 were examined in 9735 patients from 91 United States Dialysis Outcomes and Practice Patterns Study facilities. Linear mixed models were used to assess the extent to which intravenous (IV) iron and ESA dose accounted for patients' changes in ferritin over time. Mean ESA dose and hemoglobin levels declined throughout the study. Mean IV iron dose increased from 210 mg/mo in 2009-2010 to a peak of 280 mg/mo in 2011, then declined back to 200 mg/mo and remained stable from 2012 to 2013. Mean ferritin increased from 601 ng/ml in the third quarter of 2009 to 887 ng/ml in the first quarter of 2012; models suggest that higher IV iron dosing was a primary determinant during 2011, but lower ESA doses contributed to the sustained high ferritin levels thereafter. In a subset of 17 facilities that decreased IV iron dose in 2011, mean ferritin rose by 120 ng/ml to 764 ng/ml, which appeared to be primarily due to ESA reduction. Together, changes in IV iron and ESA doses accounted for 46% of the increase in ferritin over the study period. In contrast to expectations, the rise in average IV iron dose did not persist beyond 2011. The sustained rise in ferritin levels in United States dialysis patients after policy changes in 2011, to average levels well in excess of 800 ng/ml, appeared to be partly due to reductions in ESA dosing and not solely IV iron dosing practices. The effect of these changes in ferritin on health outcomes requires further investigation. Copyright © 2015 by

Understanding the Recent Increase in Ferritin Levels in United States Dialysis Patients: Potential Impact of Changes in Intravenous Iron and Erythropoiesis-Stimulating Agent Dosing

PubMed Central

Zee, Jarcy; Morgenstern, Hal; Nolen, Jacqueline G.; Hakim, Raymond; Kalantar-Zadeh, Kamyar; Zager, Philip; Pisoni, Ronald L.; Port, Friedrich K.; Robinson, Bruce M.

2015-01-01

Background and objectives Anemia management changed substantially among dialysis patients in the United States around the time of implementation of the new Centers for Medicare & Medicaid Services bundled payment system and erythropoiesis-stimulating agent (ESA) label change in 2011. Among these, average ferritin levels increased dramatically and have remained high since; this study sought to gain understanding of this sustained rise in ferritin levels. Design, setting, participants, & measurements Trends in mean ferritin, hemoglobin, IV iron dose, and ESA dose from 2009 to 2013 were examined in 9735 patients from 91 United States Dialysis Outcomes and Practice Patterns Study facilities. Linear mixed models were used to assess the extent to which intravenous (IV) iron and ESA dose accounted for patients’ changes in ferritin over time. Results Mean ESA dose and hemoglobin levels declined throughout the study. Mean IV iron dose increased from 210 mg/mo in 2009–2010 to a peak of 280 mg/mo in 2011, then declined back to 200 mg/mo and remained stable from 2012 to 2013. Mean ferritin increased from 601 ng/ml in the third quarter of 2009 to 887 ng/ml in the first quarter of 2012; models suggest that higher IV iron dosing was a primary determinant during 2011, but lower ESA doses contributed to the sustained high ferritin levels thereafter. In a subset of 17 facilities that decreased IV iron dose in 2011, mean ferritin rose by 120 ng/ml to 764 ng/ml, which appeared to be primarily due to ESA reduction. Together, changes in IV iron and ESA doses accounted for 46% of the increase in ferritin over the study period. Conclusions In contrast to expectations, the rise in average IV iron dose did not persist beyond 2011. The sustained rise in ferritin levels in United States dialysis patients after policy changes in 2011, to average levels well in excess of 800 ng/ml, appeared to be partly due to reductions in ESA dosing and not solely IV iron dosing practices. The effect of

[Effects of distance between residence and hemodialysis unit on cardiovascular complications and treatments of maintenance hemodialysis patients].

PubMed

Yuan, Jing; Zha, Yan; Yang, Xia; He, Shan; Xie, Ying; Huang, Rong-sai; Xiong, Hong-yan; Sun, Zhao-lin

2013-06-11

To explore the effects of etiological classification and the distance between residence and hemodialysis unit on cardiovascular complications and treatments in maintenance hemodialysis (MHD) patients. A total of 756 MHD patients were collected from 12 hemodialysis centers of Guiyang, China between January 2011 and May 2012. Their distribution characteristics and correlations were based on medical records. And statistical analyses were performed. The ratio of males and females was 1.45: 1. And their mean age was (49.1 ± 14.7) years old. And 496 (65.6%) cases suffered from cardiovascular complications. The analysis of multi-factor Logistic regression revealed that distance between residence and dialysis unit was an independent risk factor of cardiovascular complications. The group of the farthest distance ( > 30 km) had the worst influence on dialysis adequacy Kt/V score, urea clearance rate, dialysis frequency and time per week. And the levels of blood phosphorus, triglyceride and cholesterol in the fourth group had marked elevations. It had a significant positive correlation with distance (P < 0.05). The distance between residence and dialysis unit is an independent risk factor of cardiovascular complications in MHD patients. The farthest distance ( > 30 km) has the greatest influence on dialysis adequacy.

Pharmacotherapy of Hypertension in Chronic Dialysis Patients

PubMed Central

Georgianos, Panagiotis I.

2016-01-01

Among patients on dialysis, hypertension is highly prevalent and contributes to the high burden of cardiovascular morbidity and mortality. Strict volume control via sodium restriction and probing of dry weight are first-line approaches for the treatment of hypertension in this population; however, antihypertensive drug therapy is often needed to control BP. Few trials compare head-to-head the superiority of one antihypertensive drug class over another with respect to improving BP control or altering cardiovascular outcomes; accordingly, selection of the appropriate antihypertensive regimen should be individualized. To individualize therapy, consideration should be given to intra- and interdialytic pharmacokinetics, effect on cardiovascular reflexes, ability to treat comorbid illnesses, and adverse effect profile. β-Blockers followed by dihydropyridine calcium-channel blockers are our first- and second-line choices for antihypertensive drug use. Angiotensin–converting enzyme inhibitors and angiotensin receptor blockers seem to be reasonable third–line choices, because the evidence base to support their use in patients on dialysis is sparse. Add-on therapy with mineralocorticoid receptor antagonists in specific subgroups of patients on dialysis (i.e., those with severe congestive heart failure) seems to be another promising option in anticipation of the ongoing trials evaluating their efficacy and safety. Adequately powered, multicenter, randomized trials evaluating hard cardiovascular end points are urgently warranted to elucidate the comparative effectiveness of antihypertensive drug classes in patients on dialysis. In this review, we provide an overview of the randomized evidence on pharmacotherapy of hypertension in patients on dialysis, and we conclude with suggestions for future research to address critical gaps in this important area. PMID:27797886

Exploring the association between macroeconomic indicators and dialysis mortality.

PubMed

Kramer, Anneke; Stel, Vianda S; Caskey, Fergus J; Stengel, Benedicte; Elliott, Robert F; Covic, Adrian; Geue, Claudia; Cusumano, Ana; Macleod, Alison M; Jager, Kitty J

2012-10-01

Mortality on dialysis varies greatly worldwide, with patient-level factors explaining only a small part of this variation. The aim of this study was to examine the association of national-level macroeconomic indicators with the mortality of incident dialysis populations and explore potential explanations through renal service indicators, incidence of dialysis, and characteristics of the dialysis population. Aggregated unadjusted survival probabilities were obtained from 22 renal registries worldwide for patients starting dialysis in 2003-2005. General population age and health, macroeconomic indices, and renal service organization data were collected from secondary sources and questionnaires. Linear modeling with log-log transformation of the outcome variable was applied to establish factors associated with survival on dialysis. Two-year survival on dialysis ranged from 62.3% in Iceland to 89.8% in Romania. A higher gross domestic product per capita (hazard ratio=1.02 per 1000 US dollar increase), a higher percentage of gross domestic product spent on healthcare (1.10 per percent increase), and a higher intrinsic mortality of the dialysis population (i.e., general population-derived mortality risk of the dialysis population in that country standardized for age and sex; hazard ratio=1.04 per death per 10,000 person years) were associated with a higher mortality of the dialysis population. The incidence of dialysis and renal service indicators were not associated with mortality on dialysis. Macroeconomic factors and the intrinsic mortality of the dialysis population are associated with international differences in the mortality on dialysis. Renal service organizational factors and incidence of dialysis seem less important.

Association of segmental wall motion abnormalities occurring during hemodialysis with post-dialysis fatigue.

PubMed

Dubin, Ruth F; Teerlink, John R; Schiller, Nelson B; Alokozai, Dean; Peralta, Carmen A; Johansen, Kirsten L

2013-10-01

Post-dialysis fatigue (PDF) is a common, debilitating symptom that remains poorly understood. Cardiac wall motion abnormalities (WMAs) may worsen during dialysis, but it is unknown whether WMA are associated with PDF. Forty patients were recruited from University of California San Francisco-affiliated dialysis units between January 2010 and February 2011. Participants underwent echocardiograms before and during the last hour of 79 dialysis sessions. Myocardial segments were graded 1-4 by a blinded reviewer, with four representing the worst WMA, and the segmental scores were summed for each echocardiogram. Patients completed questionnaires about their symptoms. Severe PDF (defined as lasting >2 h after dialysis) was analysed using a generalized linear model with candidate predictors including anemia, intradialytic hemodynamics and cardiac function. Forty-four percent of patients with worsened WMA (n=9) had severe PDF, compared with 13% of patients with improved or unchanged WMA (P = 0.04). A one-point increase in the WMA score during dialysis was associated with a 10% higher RR of severe PDF [RR: 1.1, 95% CI (1.1, 1.2), P < 0.001]. After multivariable adjustment, every point increase in the WMA score was associated with a 2-fold higher risk of severe PDF [RR: 1.9, 95% CI (1.4, 2.6), P < 0.001]. History of depression was associated with severe PDF after adjustment for demographics and comorbidities [RR: 3.4, 95% CI (1.3, 9), P = 0.01], but anemia, hemodynamics and other parameters of cardiac function were not. Although cross-sectional, these results suggest that some patients may experience severe PDF as a symptom of cardiac ischemia occurring during dialysis.

Hypertension and cardiovascular risk assessment in dialysis patients.

PubMed

Locatelli, Francesco; Covic, Adrian; Chazot, Charles; Leunissen, Karel; Luño, José; Yaqoob, Mohammed

2004-05-01

Cardiovascular (CV) disease is the main cause of morbidity and mortality in dialysis patients. Hypertension in patients affected by chronic renal insufficiency (CRI) has been recognized as one of the major classical CV risk factors in CRI from the very beginning of the dialysis era. However, its treatment is still unsatisfactory. A discussion is employed to achieve a consensus on key points relating to the epidemiological, pathophysiological and clinical characteristics of hypertension in renal patients, in the light of global CV risk assessment. CV disease is accelerated by CRI, in particular by uraemia-specific risk factors. This is reflected by the fact that general population-based equations for calculating CV risk underestimate the real CV risk in CRI and dialysis patients. Hypertension in dialysis patients is clearly a major CV risk factor. Isolated systolic hypertension with increased pulse pressure is the most prevalent blood pressure (BP) anomaly in dialysis patients, due to stiffening of the arterial tree. BP should be assessed by clinical measurements on a routine basis, leaving 24 h monitoring for selected cases. The targets of BP control should be those recommended by the present guidelines, i.e. <140/90 mmHg, or the lowest possible values that are well tolerated. The pathophysiological cornerstone of hypertension in dialysis patients is extra-cellular volume expansion, which is typically sodium-sensitive, given the loss of renal function. Therefore, the principles of hypertension treatment in dialysis are an achievement of dry body weight, proper dialysis prescription with respect to dialysis time and intra-dialytic sodium balance, and dietary sodium and water restriction. Pharmacological treatment should only be the second option, after the adequate and complete application of all other means. No comparative pharmacological trials have specifically addressed the issue of hypertension control in dialysis patients. Therefore, this workshop group had to

Peritoneal dialysis-related peritonitis: challenges and solutions

PubMed Central

Salzer, William L

2018-01-01

Peritoneal dialysis is an effective treatment modality for patients with end-stage renal disease. The relative use of peritoneal dialysis versus hemodialysis varies widely by country. Data from a 2004 survey reports the percentage of patients with end-stage renal disease treated with peritoneal dialysis to be 5%–10% in economically developed regions like the US and Western Europe to as much as 75% in Mexico. This disparity is probably related to the availability and access to hemodialysis, or in some cases patient preference for peritoneal over hemodialysis. Peritoneal dialysis-related peritonitis remains the major complication and primary challenge to the long-term success of peritoneal dialysis. Fifty years ago, with the advent of the Tenckhoff catheter, patients averaged six episodes of peritonitis per year on peritoneal dialysis. In 2016, the International Society for Peritoneal Dialysis proposed a benchmark of 0.5 episodes of peritonitis per year or one episode every 2 years. Despite the marked reduction in peritonitis over time, peritonitis for the individual patient is problematic. The mortality for an episode of peritonitis is 5% and is a cofactor for mortality in another 16% of affected patients. Prevention of peritonitis and prompt and appropriate management of peritonitis is essential for the long-term success of peritoneal dialysis in all patients. In this review, challenges and solutions are addressed regarding the pathogenesis, clinical features, diagnosis, treatment, and prevention of peritoneal dialysis-related peritonitis from the viewpoint of an infectious disease physician.

A Rare Reason of Ileus in Renal Transplant Patients With Peritoneal Dialysis History: Encapsulated Peritoneal Sclerosis.

PubMed

Gökçe, Ali Murat; Özel, Leyla; İbişoğlu, Sevinç; Ata, Pınar; Şahin, Gülizar; Gücün, Murat; Kara, V Melih; Özdemir, Ebru; Titiz, M İzzet

2015-12-01

Encapsulating peritoneal sclerosis is a rare complication of long-term peritoneal dialysis ranging from moderate inflammation of peritoneal structures to severe sclerosing peritonitis and encapsulating peritoneal sclerosis. Complicated it, ileus may occur during or after peritoneal dialysis treatment or after kidney transplant. We sought to evaluate 3 posttransplant encapsulating peritoneal sclerosis through clinical presentation, radiologic findings, and outcomes. We analyzed 3 renal transplant patients with symptoms of encapsulating peritoneal sclerosis admitted posttransplant to our hospital with ileus between 2012 and 2013. Conservative treatment was applied to the patients whenever necessary to avoid surgery. One patient improved with medical therapy. Surgical treatment was delayed and we decided it as a last resort, in 2 cases with no response to conservative treatment for a long time. Finally, patients with peritoneal dialysis history should be searched carefully before renal transplant for intermittent bowel obstruction story.

Bioimpedance and Fluid Status in Children and Adolescents Treated With Dialysis.

PubMed

Milani, Gregorio P; Groothoff, Jaap W; Vianello, Federica A; Fossali, Emilio F; Paglialonga, Fabio; Edefonti, Alberto; Agostoni, Carlo; Consonni, Dario; van Harskamp, Dewi; van Goudoever, Johannes B; Schierbeek, Henk; Oosterveld, Michiel J S

2017-03-01

Assessment of hydration status in patients with chronic kidney failure treated by dialysis is crucial for clinical management decisions. Dilution techniques are considered the gold standard for measurement of body fluid volumes, but they are unfit for day-to-day care. Multifrequency bioimpedance has been shown to be of help in clinical practice in adults and its use in children and adolescents has been advocated. We investigated whether application of multifrequency bioimpedance is appropriate for total-body water (TBW) and extracellular water (ECW) measurement in children and adolescents on dialysis therapy. A study of diagnostic test accuracy. 16 young dialysis patients (before a hemodialysis session or after peritoneal dialysis treatment) from the Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy, and the Emma Children's Hospital-Academic Medical Center, Amsterdam, the Netherlands. TBW and ECW volumes assessed by multifrequency bioimpedance. TBW and ECW volumes measured by deuterium and bromide dilution, respectively. Mean TBW volumes determined by multifrequency bioimpedance and deuterium dilution were 19.2±8.7 (SD) and 19.3±8.3L, respectively; Bland-Altman analysis showed a mean bias between the 2 methods of -0.09 (95% limits of agreement, -2.1 to 1.9) L. Mean ECW volumes were 8.9±4.0 and 8.3±3.3L measured by multifrequency bioimpedance and bromide dilution, respectively; mean bias between the 2 ECW measurements was +0.6 (95% limits of agreement, -2.3 to 3.5). Participants ingested the deuterated water at home without direct supervision by investigators, small number of patients, repeated measurements in individual patients were not performed. Multifrequency bioimpedance measurements were unbiased but imprecise in comparison to dilution techniques. We conclude that multifrequency bioimpedance measurements cannot precisely estimate TBW and ECW in children receiving dialysis. Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier

[Approach to quality objectives in incidents of patients in peritoneal dialysis].

PubMed

Portolés, J; Ocaña, J; López-Sánchez, P; Gómez, M; Rivera, M T; Del Peso, G; Corchete, E; Bajo, M A; Rodríguez-Palomares, J R; Fernández-Perpen, A; López-Gómez, J M

2010-01-01

In 2007 the Scientific Quality-technical and Improvement of Quality in Peritoneal Dialysis was edited. It includes several quality indicators. As far as we know, only some groups of work had evaluated these indicators, with inconclusive results. To study the evolution and impact of guidelines in Peritoneal Dialysis. Prospective cohort study of each incident of patients in Peritoneal Dialysis, in a regional public health care system (2003-2006). We prospectively collected baseline clinical and analytical data, technical efficacy, cardiovascular risk, events and deaths, hospital admissions and also prescription data was collected every 6 months. Over a period of 3 years, 490 patients (53.58 years of age; 61.6% males.) Causes of ERC: glomerular 25.5%, diabetes 16%, vascular 12.4%, and interstitial 13.3%. 26.48% were on the list for transplant. Dialysis efficacy: Of the first available results, the residual renal function was 6.37 ml/min, achieving 67.6% of all the objectives K/DOQI. 38.6% remained within the range during the entire first year. Anaemia: 79.3% received erythropoietic stimulating agents and maintained an average Hb of 12.1 g/dl. The percentage of patients in the range (Hb: 11-13 g/dl) improved after a year (58.4% vs 56.3% keeping in the range during this time of 25.6%). Evolution: it has been estimated that per patient-year the risk of: 1) mortality is 0.06 IC 95% [0.04-0.08]; 2) admissions 0.65 [0.58-0.72]; 3) peritoneal infections 0.5 [0.44-0.56]. Diabetes Mellitus patients had a higher cardiovascular risk and prevalence of events. The degrees of control during the follow-up in many topics of peritoneal dialysis improve each year; however they are far from the recommended guidelines, especially if they are evaluated throughout the whole study.

The activities of hospital nursing unit managers and quality of patient care in South African hospitals: a paradox?