Nightly home hemodialysis: Five and one-half years of experience in Lynchburg, Virginia

Background: Lynchburg Nephrology Dialysis Incorporated initiated a nightly home hemodialysis (NHHD) program in September 1997. As of April 30, 2003, 40 patients had completed training; 28 patients were at home and 2 patients were in training. The average age of the patients at the initiation of the home‐based therapy was 50 years, with a range of 23 to 81 years. There have been 24,239 treatments at home with a total of 84.86 patient‐years on NHHD, the longest patient for 66.7 months and the shortest for 1 month. Methods: Patients dialyzed using the Fresenius 2008H machine, 6 to 10 hr, 5 to 6 nights per week. Treatment parameters included a blood flow rate of 200 to 250 mL/min; a dialysis flow rate of 200 to 300 mL/min; and a standard dialysis solution with 2.0 mEq/L potassium, 3.0 to 3.5 mEq/L calcium concentrations, 35 mEq/L HCO₃, and 140 mEq/L sodium. The longitudinal data of each patient in the program for 1, 2, 3, 4, and 5 years were compared to the same patient's pre‐NHHD data. There were 25 patients in the program for 1 year, 19 patients for 2 years, 14 patients for 3 years, 6 patients for 4 years, and 4 patients for 5 years. Results: Statistically significant improvement occurred in all five groups' need for antihypertensive medications and phosphate binders, SF36 scores, calcium/phosphorus product, blood pressure, number of hospital admissions, and number of days of stay in the hospital. The mortality rate was 2.4% deaths per patient‐year with a 95% confidence interval of 0.9% to 9.4%. Conclusions: In a longitudinal study, NHHD showed significant improvements in patient secondary outcomes. The improvement in these secondary outcomes was associated with an improvement in mortality rate.     

Association between patient psychosocial characteristics and receipt of in‐center nocturnal hemodialysis among prevalent dialysis patients

Introduction: Compared to traditional in‐center hemodialysis (HD), in‐center nocturnal dialysis (INHD) is characterized by longer sessions and nighttime administration, which may lead to better outcomes for some patients. Given the importance of patient choice in the decision to initiate INHD, we explored associations between patients’ psychosocial characteristics and their receipt of INHD. Methods: Among hemodialysis patients at a medium‐sized dialysis organization, we identified INHD patients as those for whom ≥80% of dialysis sessions were INHD sessions—starting at 6:30 pm or later and lasting ≥5 hours—over the 3 months (≥20 sessions total) after their first INHD session. We extracted dialysis session data from electronic medical records and psychosocial data from social worker assessments. We tested associations of patients’ psychosocial characteristics—as well as demographic and clinical characteristics—with INHD receipt among all hemodialysis patients (INHD and HD) in bivariate analyses and multivariable logistic regression models. Findings: Among 759 patients with complete data, we identified 47 (6.2%) as INHD patients. On average, these patients were more likely than HD patients to be employed (full‐time 10.6% vs. 5.2%; part‐time 17.0% vs. 4.2%; P < 0.001), and they were significantly less likely to require ambulatory assistance (14.9% vs. 39.6%, P < 0.001). In multivariable regressions, we found that part‐time employment (versus being unemployed) was associated with a 7.1 percentage‐point higher likelihood of being an INHD patient (P = 0.01), and the negative association with ambulatory assistance needs approached statistical significance (P = 0.056). No other psychosocial factors included in this main regression analysis were statistically significantly associated with INHD patient status. Discussion: Researchers comparing the outcomes of patients undergoing INHD versus other treatment modalities will need to account for differences in employment status—and other factors like requiring ambulatory assistance and age which may predict the ability to work—between INHD users and comparison patients to avoid bias in estimates.     

The integrated management for renal replacement therapy in Portugal

Portugal was the first European country to introduce an integrated management of end‐stage renal disease (IM ESRD). This new program integrates various dialysis services and products, which are reimbursed at a fixed rate/patient/week called “comprehensive price payment.” This initiative restructured the delivery of dialysis services, the monitoring of outcomes, and the funding of renal replacement therapy. This article described the implementation of a new model of comprehensive provision of hemodialysis (HD) services and aimed to assess its impact on dialysis care. Quality assessments and reports of patient satisfaction, produced by the Ministry of Health since 2008, as well as national registries and reports, provided the data for this review. Indicators of HD services in all continental facilities show positive results that have successively improved along the period of 2009–2011, in spite of an average annual growth of 3% of the population under HD treatment. Mortality rates for HD patients were 12.7%, 12%, and 11%, respectively in 2009, 2010, and 2011; annual hospitalization rates were 4.9%, 3.8%, and 4.4% for the same years; key performance indicators showed averages above the reference values such as hemoglobin, serum phosphorus, eKt/V, water quality, number of days of hospitalization per patient per year, and number of weekly dialysis sessions. The financing analysis of IM ESRD demonstrates a sustained control of global costs, without compromising quality. The IM ERSD program is an innovative and quality‐driven approach that benefits both dialysis patients and providers, contributing toward the rationalization of service provision and the efficient use of resources.     

Challenges and limitations of maintenance hemodialysis in urban South India

Maintenance hemodialysis is a treatment modality available to few patients reaching end-stage renal disease in India. However, the morbidity and outcome of such treatment remains largely unknown. A retrospective cohort of patients commencing hemodialysis in a secondary care institution in India between January 1, 2002 and December 31, 2004 was studied. Patient demographics, cardiac status, access, hospitalizations, and emergency room visits were assessed and outcomes determined. During the study period, 95 patients (66 males, 29 females) commenced maintenance hemodialysis. The underlying cause of chronic kidney disease was diabetic nephropathy in 66.3% of patients. Cumulative follow-up was 676+9.1 patient months. The mean serum creatinine (+SD) at initiation of dialysis was 8.39+3.28 mg%. Thirty-six percent of patients had a functioning arteriovenous fistula at commencement of dialysis, while the remaining 64% of patients required temporary access. The mean number of comorbidities was 1.9+1.0/patient; diastolic dysfunction was deemed to be present in 20.4% of the patients. The hospitalization rate was 3.9/patient year; the number of visits to the emergency room was 4.9/patient year. Cardiac pathology was the most common cause leading to hospitalization and emergency room visits. Diabetic patients were older and had higher cardiac morbidity (p<0.01). The outcome was as follows: 39% transferred to other units; 27% died; 9% switched to CAPD; 8% lost to follow-up; 1% transplantation: Kaplan-Meier survival analysis showed a median survival of 410 days. Patients commencing hemodialysis in an urban dialysis center in South India are predominantly male and have significant comorbidity including diabetes and cardiac disease. Outcome is generally poor. Hence, a huge opportunity for improvement exists.     

The role of a nurse case manager in implementing a critical pathway for infrainguinal bypass surgery

BACKGROUND: A previous study showed the effectiveness of a clinical pathway for infrainguinal bypass surgery in reducing postoperative length of stay (LOS) in an acute care setting. Most of the deviations from the pathway were due to patient factors (50%) and/or external disposition problems (30%), but 20% were related to physician or system problems that could potentially be modified. The current study examined those factors influencing LOS following infrainguinal bypass surgery and the impact of daily rounds by a nurse case manager--a vascular nurse specialist--on LOS and pathway deviations. METHODS: Data were collected through detailed chart review and prospective tracking of pathway deviations. LOS was compared in 58 patients on the modified pathway (with the nurse case manager) to 69 patients on the original pathway and 67 prepathway controls. Multivariate analysis was used to identify factors influencing postoperative LOS and to compare LOS among the three groups. RESULTS: Use of a nurse case manager significantly reduced physician-related deviations, from the pathway from 10% to 0% (p = .015), and reduced system-related deviations from 3% to 0%. Median postoperative LOS was 7 days before the pathway was begun, 6 days with the original pathway, and 5 days after the introduction of a vascular nurse specialist (p = .0001). There were no differences in rates of complications, rates of readmission, or mortality. CONCLUSIONS: Intervention by a nurse case manager facilitated implementation of a critical pathway for patients undergoing infrainguinal bypass surgery, especially by preventing patient deviations due to intrainstitutional factors.     

Revisiting the association between altitude and mortality in dialysis patients

It was recently reported that residential altitude is inversely associated with all‐cause mortality among incident dialysis patients; however, no adjustment was made for key case‐mix and laboratory variables. We re‐examined this question in a contemporary patient database with comprehensive clinical and laboratory data. In a contemporary 8‐year cohort of 144,892 maintenance dialysis patients from a large dialysis organization, we examined the relationship between residential altitude and all‐cause mortality. Using data from the US Geological Survey, the average residential altitudes per approximately 43,000 US zip codes were compiled and linked to the residential zip codes of each patient. Mortality risks for these patients were estimated by Cox proportional hazard ratios. The study population's mean ± standard deviation age was 61 ± 15 years. Forty‐five percent of patients were women, and 57% of patients had diabetes. In fully adjusted analysis, those residing in the highest altitude strata (≥6000 ft) had a lower all‐cause mortality risk in fully adjusted analyses: death hazard ratio: 0.92 (95% confidence interval, 0.86–0.99), as compared with patients in the reference group (<250 ft). Residential altitude is inversely associated in all‐cause mortality risk in maintenance dialysis patients notwithstanding the unknown and unmeasured confounders.     

Survival Advantage of Tailored Dialysis

Survival has been defined as an index of adequacy of dialysis. These hard data are the basis for comparing results obtained by different schedules or policies. The aim of the study was to assess mortality rate recorded within a system of tailored dialysis (1–6 dialysis per week in out‐of‐hospital settings: home hemodialysis, self‐ and limited care dialysis). Data recorded in a single center (1998–2003) were compared with data gathered in the Registry of Dialysis and Transplantation in the whole Region (1998–2000). Methods: Out‐of‐hospital dialysis unit is active since 1971, in which a new program integrating self‐ and limited care and home dialysis started since 1998. Patients: Incident dialysis patients starting renal replacement therapy within the program and all further patients starting dialysis in the Region in the same period were compared in an historical prospective cohort study. Results: 55 patients in the Unit and further 1443 patients in the whole Region started RRT since 1998. Main features of 55 patients were 32 males 23 females; median age 51 years, range 20–76; 72.7% displaying at least 1 comorbid factor. Throughout the period gross mortality rate was 4/125 patient‐years in the Center. Kaplan–Meier curves showed a 1‐year survival of 100% vs. 91%, respectively, in the Center and in the whole Region, and a 2‐year survival of 95.5% vs. 76.6%, respectively, in the Center and in the whole Region (p = 0.001). The main demographic features were remarkably different in both settings (for the whole Region median age 66 years, range 2.2–101, at least 1 comorbidity in 56.9% of patients). In an attempt to correct for the different baseline characteristics, a multivariate Cox regression analysis was performed. The whole model resulted in statistically significant value (p = 0.000) and an increasing mortality risk resulted for age at starting dialysis, diabetes, and collagenopathy. In conclusion, tailored, high‐efficiency dialysis policy may allow superior survival results. A longer follow up is needed to confirm our approach; in larger cohorts, the finding of a low mortality rate in a relatively young population with high comorbidity may underline the need to review our current concepts on dialysis adequacy.     

The advanced practice nurse–nephrologist care model: Effect on patient outcomes and hemodialysis unit team satisfaction

The tertiary care nurse practitioner/clinical nurse specialist (NP/CNS) is an advanced practice nurse with a relatively new role within the health‐care system. It is stated that care provided by the NP/CNS is cost‐effective and of high quality but little research exists to document these outcomes in an acute‐care setting. The clinical coverage pattern by nephrologists and NP/CNS of a hemodialysis unit in a large academic center allowed such a study. Two NP/CNS plus a nephrologist followed two of three hemodialysis treatment shifts per day; only a nephrologist followed the third shift. The influence of this care pattern of patients was examined using a cross‐sectional review of outcomes such as adequacy of delivered dialysis, anemia management, phosphate control, hospitalizations, etc. In addition, the level of satisfaction of the dialysis team and perceptions of care delivered with the care models was assessed. The care model staff‐to‐patient‐number ratio was similar in both groups (1:27 for NP/CNS plus nephrologist; 1:29 for nephrologist alone). Patient demographics were similar in both groups but the NP/CNS–nephrologist group had patients with more comorbidities. No statistically significant (p < 0.05) differences existed between the groups in patient laboratory data, adherence to standards, medications, inter‐ and intradialytic blood pressure, achievement of target postdialysis weights, and hospitalizations or emergency room visits. Significantly more adjustments were made to target weights and medications and more investigations were ordered by the NP/CNS–nephrologist team. Team satisfaction and perceptions of care delivery were higher with the NP/CNS–nephrologist model. It is concluded that the NP/CNS–nephrologist care model may increase the efficiency of the care provided by nephrologists to chronic hemodialysis patients. The model may also be a solution to the problem of providing nephrologic care to an ever‐growing hemodialysis population.     

A comparison of center-based vs. home-based daily hemodialysis for patients with end-stage renal disease

Home hemodialysis has been a therapeutic option for almost 4 decades. The complexity of dialysis equipment has been a factor-limiting adoption of this modality. We performed a feasibility study to demonstrate the safety of center-based vs. home-based daily hemodialysis with the NxStage System One portable hemodialysis device. We also performed a retrospective analysis to determine if clinical effects previously associated with short-daily dialysis were also seen using this novel device. We conducted a prospective, 2-treatment, 2-period, open-label, crossover study of in-center hemodialysis vs. home hemodialysis in 32 patients treated at 6 U.S. centers. The 8-week In-Center Phase (6 days/week) was followed by a 2-week transition period and then followed by the 8-week Home Phase (6 days/week). We retrospectively collected data on hemodialysis treatment parameters immediately preceding the study in a subset of patients. Twenty-six out of 32 patients (81%) successfully completed the study. Successful delivery of at least 90% of prescribed fluid volume (primary endpoint) was achieved in 98.5% of treatments in-center and 97.3% at home. Total effluent volume as a percentage of prescribed volume was between 94% and 100% for all study weeks. The composite rate of intradialytic and interdialytic adverse events per 100 treatments was significantly higher for the In-Center Phase (5.30) compared with the Home Phase (2.10; p=0.007). Compared with the period immediately preceding the study, there were reductions in blood pressure, antihypertensive medications, and interdialytic weight gain. Daily home hemodialysis with a small, easy-to-use hemodialysis device is a viable dialysis option for end-stage renal disease patients capable of self/partner-administered dialysis.     

Provision and quality of dialysis services in Libya

Dialysis is entirely funded by the public health care sector in Libya. Access to treatment is unrestricted for citizens but there is a lack of local information and no renal registry to gather national data. This cross-sectional study aimed to investigate dialysis provision and practice in Libyan dialysis facilities in 2009. A structured interview regarding dialysis capacity, staffing and methods of assessment of dialysis patients, and infection control measures was conducted with the medical directors of all 40 dialysis centers and 28 centers were visited. A total of 2417 adult patients were receiving maintenance dialysis in 40 centers, giving a population prevalence of approximately 624 per million. Most dialysis units were located in the northern part of the country and only 12.5% were free-standing units. Only three centers offered peritoneal dialysis. One hundred ninety-two hemodialysis rooms hosted 713 functioning hemodialysis stations, giving a ratio of one machine to 3.4 patients. Around half of centers operated only two dialysis shifts per day. Nephrologist/internist to patient ratio was 1:40 and nurse to patient ratio was 1:3.7. We found a wide variation in monitoring of dialysis patients, with dialysis adequacy assessed only in a minority. Separate rooms were allocated for chronic viral infection seropositive patients in 92.5% of the units. In general, the provision of dialysis is adequate but several areas for improvement have been identified, including a need for implementation of guidelines, recruitment of more nephrologists, and the development of more cost-effective alternatives such as peritoneal dialysis and transplantation.     

Superior patient and technique survival with very high standard Kt/V in quotidian home hemodialysis

We studied the association of patient and dialysis factors with patient and technique survival in a cohort of all of our 191 of patients surviving >3 months on quotidian home hemodialysis (QHHD). Eighty‐one patients were on nocturnal QHHD and 110 on short ‐daily QHHD. Weekly dialysis time was 7.5–48 hours, single pool Kt/V was 0.38–4.5 per treatment, and weekly standardKt/V was 2.1–7.5. The association of 18 patient and dialysis variables with patient and technique survival was analyzed by Kaplan‐Meier and Cox analyses. Ninety‐nine patients (52%) remained on QHHD, 34 (18%) were transplanted, 31 (16%) returned to 3/week HD, and 27 (14%) died. The 5‐year patient survival was 71% ± 6% (night: 79% ± 7%, day: 69% ± 9%, P = 0.002). The 5‐year technique survival was 80% ± 4% (night: 93% ± 3%, day: 46% ± 17%, P = 0.001). In Cox analyses, patient survival was independently associated with standard Kt/V (hazard ratio [HR] = 0.29, P < 0.0001), graduating from high school (HS) (HR = 0.11, P = 0.0002), and use of graft/fistula (HR = 0.22, P = 0.007). Technique survival was independently associated with standard Kt/V (HR = 0.50, P = 0.0003) and start of QHHD after 2003 (HR = 0.18, P = 0.007). Every increase in standard Kt/V was associated with improved survival. The highest survival occurred when standard Kt/V exceeded 5.1, only possible when weekly dialysis hours exceed 35 hours. In QHHD, higher standard Kt/V, education, and subcutaneous access are associated with better patient survival and higher standard Kt/V and longer experience of center with better technique survival. There was no upper limit of standard Kt/V, where survival plateaus. The amount of minimally “adequate” dialysis should be much increased.     

CathAway fistula vascular access program achieves improved outcomes and sets a new standard of treatment for end‐stage renal disease

Hemodialysis patients using central venous catheters (CVCs) for vascular access are at greater risk of infection and death vs. arterial venous fistula (AVF). In 2008, DaVita initiated the CathAway quality improvement initiative, a multidisciplinary program to reduce CVC use in favor of AVF. Our retrospective analysis examined CVC use for incident (≤90 days) and prevalent (>90 days) patients receiving hemodialysis in the years 2006 to 2010. Outcomes included annual mean percentage of patients with CVCs, new CVC placements per 100 patient years, CVC survival, and percentage patient days with CVC. Over 152,000 patient records were reviewed. Between 76.2% and 79.7% of incident patients used a CVC annually, but for prevalent patients, the proportion decreased from 41.1% in 2006 to 33.5% in 2010. The number of new CVC placements per 100 patient years increased slightly for incident patients but fell annually from 64.8 in 2006 to 55.2 in 2010 for prevalent patients. The percentage of treatment days with CVCs was stable among incident patients (70.4%–74.3%) but fell among prevalent patients from 26.1% in 2006 to 16.5% in 2010. The mean duration of CVC use in incident patients was between 53.0 days (SD, 27.8) in 2006 and 54.1 days (SD, 28.1) in 2009, and for prevalent patients between 158.9 days (SD, 123.0) in 2006 and 128.1 days (SD, 112.0) in 2010. CathAway significantly decreased CVC use in prevalent hemodialysis patients. Decreasing incident patient use will require improvements in predialysis care.     

News and Traditional Indications from Short Daily Dialysis: Different Schemes to Optimized ESF Response

Dialysis adequacy indexed by Kt/V in hemodialysis (HD) patients is recommended as a single-pool Kt/V of at least 1.2 per session thrice weekly. But many patients cannot achieve this adequacy target. Although dialysis time is the most important as a factor influencing Kt/V, it is difficult to prolong dialysis time in practice because of its economic impact and poor patient compliance.
Objective:  The aim of this study is to investigate the effect of increasing blood flow rate on dialysis adequacy in HD patients with low Kt/V.
Methods:  This study enrolled 36 HD patients with single-pool Kt/V <1.2 per session thrice weekly, which was measured in dialyzer blood flow rate of 230 mL/min. We increased 15% of blood flow rate in patients <65 kg of body weight and 20% in patients >65 kg. And then we compared Kt/V and urea reduction ratio (URR) between before and after increasing blood flow rate.
Results:  The mean age was 48 ± 11 years (23–73 years), and the number of males was 25. Of the total patients, 24 patients had dry weight <65 kg. Mean dialysis duration was 52 ± 50 months (3–216 months). Mean Kt/V before increasing blood flow rate was 1.02 ± 0.09. It increased to 1.14 ± 0.12 after increasing blood flow rate (p < 0.001). Of the total 36 patients, 13 patients (36.1%) achieved adequacy target (Kt/V ≤ 1.2). Mean URR before increasing blood flow rate was 56.9 ± 4.0%. It also increased to 60.8 ± 4.1% (p < 0.001).
Conclusion:  Our data suggest that increasing blood flow rate by 15–20% of previous flow rate is effective in achieving dialysis adequacy in HD patients with low Kt/V.     

Blood Access Outcomes Associated with Short Daily Hemodialysis

With the growing number of reports that daily hemodialysis (DHD) improves clinical outcomes and quality of life, there has been increased interest in the effects of more frequent venipunctures on blood accesses. Since 1996, we have converted 30 patients (27 in‐center, 3 home) from conventional 3/week dialysis to short, daily, 6/week dialysis (sDHD). Twenty‐five patients started for medical indications. End‐stage renal disease (ESRD) causes were diabetes mellitus (in 7), hypertension (6), glomerulonephritis (8), hereditary nephritis (2), and other (7). Mean (±SD) age was 57 ± 16 years. Patients had an average of 3.8 major comorbidities in addition to ESRD. Thirty patients were followed on sDHD for 388 patient‐months: 9 patients died after 4.2 ± 6.7 months, 3 were transplanted at 5.4 ± 2.2 months, and 3 were disenrolled at 9.3 ± 10.5 months. Fifteen patients remain on sDHD at 20.4 ± 14.1 months. Access problems for the 12 months prior to sDHD were compared to those that occurred while the patient was on sDHD. Problems were tracked by access type. There were 40 different accesses in 30 patients with a cumulative 28.07 access‐years pre‐DHD; 24 of these accesses were artificial bridge grafts (ABG) of either polytetrafluoroethylene or bovine material. There were 27 access problems pre‐DHD, or 0.962 problems per access‐year. On sDHD these same 30 patients had 41 accesses for 34.44 access‐years; 23 of these were ABGs. There were 31 access problems or 0.900 problems per access‐year. There were no significant differences in access problems comparing pre‐DHD with on‐sDHD, either in aggregate or when analyzed by access type. After 39 months of observation, there does not appear to be an increase in blood access problems when patients are converted from conventional dialysis to sDHD.     

A randomized trial of three diabetes registry implementation strategies in a community internal medicine practice

BACKGROUND: Disease registries are powerful tools with the potential to transform the way chronic diseases are managed. To date, however, little work has been done to determine how to optimize the implementation of a chronic disease registry in practice. METHODS: Twenty-nine physicians and their nurse teams in a large community internal medicine practice participated in this 6-month prospective randomized trial in 2000. Teams were assigned to one of three implementation strategies using information from a diabetes registry. Process and outcome measures for diabetes management were analyzed. Process measures included the percentage of patients completing glycosylated hemoglobin (Hgb) testing within 6 months and low-density lipoprotein (LDL) testing within 12 months. Outcome measures included the percentage of patients with a glycosylated Hgb > 9.3% (equivalent to a HgbA1c > 8.0%), the percentage of patients with an LDL cholesterol > 130 mg/dl, and the percentage of patients with controlled blood pressure, defined as < 130/85 millimeters of mercury. Mean change in LDL and glycosylated Hgb values was also measured. RESULTS: Teams randomized to an intervention strategy that included direct letters to patients showed significant improvement across a number of measures. The improvement was most apparent among patients without recent testing or with poorly controlled disease. The two interventions that did not include direct patient letters resulted in limited improvement. DISCUSSION: Disease registries can be used to improve outcomes in the management of diabetes and other chronic diseases. Better outcomes were seen in patients who received letters based on registry-generated data. This strategy should be included as part of a comprehensive chronic disease management plan. Further refinements in the use of registries should result in further incremental improvement.     

Determinants of survival in patients receiving dialysis in Libya

Maintenance dialysis is associated with reduced survival when compared with the general population. In Libya, information about outcomes on dialysis is scarce. This study, therefore, aimed to provide the first comprehensive analysis of survival in Libyan dialysis patients. This prospective multicenter study included all patients in Libya who had been receiving dialysis for >90 days in June 2009. Sociodemographic and clinical data were collected upon enrolment and survival status after 1 year was determined. Two thousand two hundred seventy‐three patients in 38 dialysis centers were followed up for 1 year. The majority were receiving hemodialysis (98.8%). Sixty‐seven patients were censored due to renal transplantation, and 46 patients were lost to follow‐up. Thus, 2159 patients were followed up for 1 year. Four hundred fifty‐eight deaths occurred, (crude annual mortality rate of 21.2%). Of these, 31% were due to ischemic heart disease, 16% cerebrovascular accidents, and 16% due to infection. Annual mortality rate was 0% to 70% in different dialysis centers. Best survival was in age group 25 to 34 years. Binary logistic regression analysis identified age at onset of dialysis, physical dependency, diabetes, and predialysis urea as independent determinants of increased mortality. Patients receiving dialysis in Libya have a crude 1‐year mortality rate similar to most developed countries, but the mean age of the dialysis population is much lower, and this outcome is thus relatively poor. As in most countries, cardiovascular disease and infection were the most common causes of death. Variation in mortality rates between different centers suggests that survival could be improved by promoting standardization of best practice.     

Peritoneal Dialysis and Hemodialysis in Pregnancy

Management of women who require dialysis during pregnancy is an unusual and challenging clinical problem for both the nephrologist and the obstetrician. More than 200 pregnancies have been reported in women requiring hemodialysis, and more than 50 pregnancies in women on peritoneal dialysis. Surveys from several countries of pregnancy in dialysis patients provide data regarding management and outcomes. Conception rates are significantly lower in women on dialysis, and when these women do become pregnant, the spontaneous abortion rate usually exceeds 40%. However, in the pregnancies that continue, as many as 71% result in surviving infants. Pregnant women require longer, more intense hemodialysis, and enough experience has been reported to support the use of peritoneal dialysis as well as hemodialysis during pregnancy. The patients typically experience anemia, hypertension, and premature delivery. Most infants are small for gestational age, and the stillbirth rate is as high as 12%. While the potential problems are many, sufficient data has been accumulated to provide clinicians with guidelines to help them manage pregnant women on dialysis and to achieve successful outcomes.     

Tandem dialyzers with dual monitors to meet Kt/V targets

Purpose:  This study evaluated improvements in dialyzer reuse parameters and clinical outcomes associated with a CQI project in a hospital‐based dialysis center in which high flux polysulfone dialyzers were replaced with high flux Polyflux® dialyzers (GAMBRO® Renal Products). Methods:  Dialyzers were reprocessed using a Renatron® II Dialyzer Reprocessing System in conjunction with Renalin® sterilant (Minntech Corp.). Renalog® RM software was used to track dialyzer reprocessing rates and failures. Reasons for dialyzer failure included inadequate dialyzer volume; excess pressure; appearance; clotting during use; and maximum number of uses reached. The average number of dialyzer reuses with polysulfone dialyzers between January and June 2002 were compared to that achieved with Polyflux® dialyzers for the same periods in 2003 and 2004. Analysis periods were separated to avoid the impact of dialyzer transition on clinical parameters. Achievement of URR goals during these same periods was likewise compared. Results:  Transition from polysulfone to Polyflux® dialyzers was associated with a >40% increase in average number of reuses between 2002 and 2003 and a >63% increase comparing the 2002 and 2004 periods. During the 2002 analysis period with polysulfone dialyzers the target URR of 65% was achieved in approximately 75% of hemodialysis patients; this increased to nearly 95% with Polyflux® dialyzers in both the 2003 and 2004 periods, despite more reprocessing of these dialyzers. Conclusions:  These results demonstrate an improvement in both reuse efficiency and clinical outcomes associated with Polyflux dialyzers. Identifying clinical products through CQI studies that provide an economic and clinical advantage plays an important role in the success of hospital‐based hemodialysis.     

The Clinical Impact of Increasing the Hemodialysis Dose

Good evidence suggests that improvements in dialysis efficiency reduce morbidity and mortality of hemodialysis (HD) patients. Dialysis efficiency has also been related to better control of arterial blood pressure (BP), anemia, and serum phosphorus levels, and to improvement in patients' nutritional status. Over a 2‐year period, the present self‐controlled study of 34 HD patients (23 men, 11 women; age, 52.6 ± 14.5 years; HD duration, 55.9 ± 61.2 months) looked at the effect on clinical and laboratory parameters of increasing the delivered dialysis dose under a strict dry‐weight policy. Dialysis dose was increased without increasing dialysis time and frequency. A statistically significant increase was seen in delivered HD dose: the urea reduction ratio (URR) increased to 60% ± 10% from 52% ± 8%, and then to 71% ± 7% (p < 0.001); Kt/V_urea increased to 1.22 ± 0.28 from 0.93 ± 0.19, and then to 1.55 ± 0.29 (p < 0.001). A statistically significant increase in hemoglobin concentration also occurred—to 10.8 ± 1.9 g/dL from 10.4 ± 1.7 g/dL, and then to 11.0 ± 1.3 g/dL (p < 0.05 as compared to baseline)—with no significant difference in weekly erythropoietin dose. Statistically significant decreases occurred in the systolic and diastolic blood pressures during the first year; they then remained unchanged. Systolic blood pressure decreased to 131 ± 23 mmHg from 147 ± 24 mmHg (p < 0.001); diastolic blood pressure decreased to 65 ± 11 mmHg from 73 ± 12 mmHg (p < 0.001). Serum albumin increased insignificantly to 4.4 ± 0.4 g/dL from 4.3 ± 0.4 g/dL, and then significantly to 4.6 ± 0.3 g/dL (p = 0.002 as compared to both previous values). Normalized protein catabolic rate increased significantly to 1.16 ± 0.15 g/kg/day from 0.93 ± 0.16 g/kg/ day (p < 0.001), and then to 1.20 ± 0.17 g/kg/day (p < 0.001 as compared to baseline). We conclude that the increases achieved in average Kt/V_urea per hemodialysis session by increasing dialyzer membrane area, and blood and dialysate flows, without increasing dialysis time above 4 hours, in patients hemodialyzed thrice weekly, coupled with strict dry‐weight policy, resulted in improvements in hypertension, nutritional status, and anemia.