scispace - formally typeset
Search or ask a question

Showing papers in "Dialysis & Transplantation in 2006"


Journal ArticleDOI
TL;DR: Intervention to increase Hemodialysis patients’ perceived social support and decreased anxiety may contribute to enhanced self-care ability and positive health outcome, and may subsequently improve self- care and the psychosocialadjustment to hemodialysis.
Abstract: Mukadder Mollaoglu, PhDThe author is with Cumhuriyet University School of Nursing, Department of Medical Nursing, Sivas, Turkey.Background.Hemodialysistherapyrequirespatientstoundergomajorlifestylechanges.Patientswithincreasedperceivedsocialsupport and decreased anxiety are more likely to enhance self-care.PatientsandMethods.Adescriptive-correlationalstudydesignwasusedtoanalyzethebaselinedataofagroupofhemodialysispatients (n¼140). Three instruments were used: the Exercise of Self-Care Agency Scale (ESCA), the Hamilton Anxiety RatingScale (HAM-A), and the Multidimensional Scale of Perceived Social Support (MSPSS). Descriptive, bivariate, and multivariateanalyses were completed.Results.Socialsupportandanxietyaresignificantpredictorsofself-careaftercontrollingfortheeffectoftimeondialysis.Resultsindicatedthatpatientswhoperceivedhigherlevelsofsocialsupportandlowerlevelsofanxietyweremorelikelytohaveahigherlevel of self-care.Conclusions.Interventionstoincreasehemodialysispatients’perceivedsocialsupportanddecreasedanxietymaycontributetoan enhanced self-care ability and positive health outcome, and may subsequently improve self-care and the psychosocialadjustment to hemodialysis.

35 citations


Journal ArticleDOI
TL;DR: The chitosan-based bandage from HemCon is a safe and effective hemostatic agent to reduce prolonged posthemodialysis puncture site bleeding and may reduce the use of occlusive compression straps.
Abstract: Drs.Bachtell,Grunkemeier,andJinarewithProvidenceHealthSystem;T.GoodelliswithOregonHealthS and Dr. Gregory is with Oregon Medical Laser Center, Portland, Oregon. Background.Bleedingfromcoagulopathichemodialysispuncturesitescancontributetoanemiaindialysispatients,andcurrent compressive dressings may contribute to graft thrombosis. We studied the safety and efficacy of a new chitosan-based bandage with an active clotting surface and compared its time to hemostasis and compression strap usage in dialysis access puncture wounds with that of conventional gauze dressings. Methods. Fifty patients received both the chitosan-based and conventional gauze dressings in random order on 2 successive visits. Time to hemostasis and compression strap usage were compared between the visits. Time to hemostasis was analyzed using the binary response variable at 2 and 4 minutes. A compression strap wasused if dressing application was unsuccessful at 4 minutes. Covariates included coagulation state as measured by laboratory analysis and anticoagulation therapy. Results.Hemostasiswasachievedby2minutesin30%ofthechitosan-basedand38%oftheconventionaldressings(p ¼0.608) andby4minutesin86%ofthechitosan-basedand72%oftheconventionaldressings(p ¼0.040).Compressionstrapusagewas reducedby50%inthechitosan-basedgroupcomparedtotheconventionalgroup(7vs.14patients;p ¼0.052).Noadverseevents were reported with either dressing. Conclusions. The chitosan-based bandage from HemCon is a safe and effective hemostatic agent to reduce prolonged posthemodialysis puncture site bleeding and may reduce the use of occlusive compression straps.

23 citations


Journal ArticleDOI
TL;DR: This article, the final installment in a series focused on dialysis clinic design, will guide you through special design, color choices, and material selection—the final steps in making your clinic design safe and effective.
Abstract: The needs of building occupants should be the most important component of project programming. If neglected, the success of a clinic could be in jeopardy. Architectural considerations, both for the patients, who spend a significant part of their day receiving treatment, and for the medical staff, which spends all day working within the space, must be foremost among issues evaluated in the design process. When you address healthcare needs through design, you need to think about comfort as well as safety for patients and medical staff. This article, the final installment in a series focused on dialysis clinic design, will guide you through special design, color choices, and material selection—the final steps in making your clinic design safe and effective.

9 citations


Journal ArticleDOI
TL;DR: The authors have worked together to develop anautomated wearable wearable artificial kidney since 1986 and Dr. Roberts is also a member of D&T’s Editorial Advisory Board.
Abstract: Martin Roberts, PhD; David B.N. Lee, MDThe authors are with the David Geffen School of Medicine at the University of California, Los Angeles and the Veterans AffairsGreater Los Angeles Healthcare System, North Hills, California. Since 1986, the authors have worked together to develop anautomated wearable artificial kidney. Dr. Roberts is also a member of D&T’s Editorial Advisory Board.

8 citations


Journal ArticleDOI
TL;DR: There is a constant need for structured education of medical students in the practical, legal, and ethical aspects of organ and tissue donation.
Abstract: Objective. The aim of this study was to assess and explore medical students' attitudes toward tissue and organ donation and their willingness to donate their own organs or those of a deceased relative in a setting without well-organized organ donation programs and education. Methods. Medical students from all 6 years of medical studies were surveyed using a questionnaire that included attitude and willingness measures. We also asked the medical students about the feelings they would expect to experience if they had the responsibility of asking family members of a recently deceased patient about donating the patient's organs. Results. Participants had highly positive attitudes toward tissue and organ donation and a great willingness to donate tissues and organs. Students in this study were more willing to donate if the purpose was helping others than if the purpose was to help the development of science, and they were more willing to donate their own organs than those of a deceased family member. Although students were willing to donate all organs, the organ they were most willingness to donate after death was the kidney. Participants who had signed donor cards held more positive attitudes about organ donation and were more willing to donate organs than were participants who had not signed donor cards. More than half the medical students said they would feel uncomfortable if in a situation of asking others for organ donation. Conclusion. These findings suggest there is a constant need for structured education of medical students in the practical, legal, and ethical aspects of organ and tissue donation.

8 citations



Journal ArticleDOI
TL;DR: DairyDelicious low-phosphorus milk is an important adjunct to the diet of most CKD stage 5 patients who use or drink milk and permits expansion of food choices and promotes patient diet satisfaction without increasing serum phosphorus.
Abstract: Background Control of serum phosphorus has become one of the most critical issues in the management and welfare of the population of those with stage 5 chronic kidney disease (CKD). Milk is a food staple desired by many in this population, yet it is a food especially high in phosphorus. This study was designed to test the acceptance of DairyDelicious low-phosphorus milk by CKD stage 5 patients and to evaluate its effect on their serum phosphorus levels. Methods Twenty CKD stage 5 patients who liked milk but avoided it because of its high phosphorus content were given a 1-month supply of DairyDelicious low-phosphorus (116 mg/8 fl oz), low-potassium (197 mg/8 fl oz) milk. The serum phosphorus, calcium, and albumin levels of the patients were measured at the beginning and end of the study. Baseline and poststudy questionnaires were used to survey patient satisfaction. Results The serum phosphorus levels of the participants were not significantly changed at the end of the study. All study participants reported that they enjoyed the low-phosphorus milk; most stated that they were generally happier with their diet and that they used fewer high-phosphorus foods during the month. Conclusions DairyDelicious low-phosphorus milk is an important adjunct to the diet of most CKD stage 5 patients who use or drink milk. Use of this product permits expansion of food choices and promotes patient diet satisfaction without increasing serum phosphorus.

7 citations


Journal ArticleDOI
TL;DR: Comparing actual use of EPO and intravenous iron with that recommended in KDOQI guidelines provides incentive for payers and dialysis centers to examine their current practices and improve the quality and efficiency of anemia treatment in this population.
Abstract: Background Treatment of patients receiving hemodialysis who have anemia varies considerably despite the availability of established practice guidelines from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) Objective To compare actual use of erythropoietin (EPO) and intravenous (IV) iron with that recommended in KDOQI guidelines Methods A budget impact model was used to calculate costs per member per month (PMPM) for actual practice versus recommended practice were calculated using Medicare reimbursement rates for EPO and IV iron A sensitivity analysis tested the impact of varying the recommended dosages by ± 50% Results For EPO, a net savings PMPM of $257 (if administered by IV ) or $252 (if administered subcutaneously) could be achieved with adherence to KDOQI guidelines Adherence to KDOQI recommendations for IV iron would increase Medicare reimbursements for this drug by an estimated $6 PMPM Sensitivity analysis revealed a significant potential savings even if the dose of EPO used in practice was increased by 50% Conclusions In the face of limited resources and changing reimbursement policies, dialysis providers will need to find ways of reducing costs without compromising the quality of care Clinical practice guidelines such as KDOQI can be used to assist providers in meeting this challenge Among Medicare patients who have anemia of chronic kidney disease, adherence to KDOQI treatment recommendations could translate into a significant savings for Medicare Our findings provide incentive for payers and dialysis centers to examine their current practices and improve the quality and efficiency of anemia treatment in this population

7 citations


Journal ArticleDOI
TL;DR: Calcium acetate more readily permits optimal phosphorus binding within NKF/K-DOQI guidelines, and is an alternative phosphorus binder that is a more soluble and efficient phosphate binder.
Abstract: Hyperphosphatemia in patients with end-stage renal disease (ESRD) is associated with secondary hyperparathyroidism and renal osteodystrophy, and is independently associated with an increased risk of mortality. Therefore, tight control of serum phosphorus is considered essential in these patients. Ideally, the best phosphorus binder would be inexpensive, nontoxic, well tolerated, and potent. Currently, calcium-based binders are generally considered first-line agents for the treatment of hyperphosphatemia in ESRD. However, excessive calcium absorption may produce hypercalcemia and possibly soft-tissue and vascular deposition. Calcium carbonate is a widely used effective, inexpensive, over-the-counter phosphate binder. Calcium acetate is an alternative phosphorus binder that is a more soluble and efficient phosphate binder. Equimolar doses of calcium acetate bind twice as much phosphorus as calcium carbonate. As a result, phosphorus binding can be achieved with a lower dose of calcium. The NKF/K-DOQI guidelines state that the total dose of elemental calcium provided by calcium-based phosphate binders should not exceed 1,500 mg/day. Calcium acetate more readily permits optimal phosphorus binding within these guidelines. This review focuses on calcium binders.

6 citations


Journal ArticleDOI
TL;DR: A number of improvements to DFC have been implemented by the Centers for Medicare & Medicaid Services, and these can provide guidance for future efforts to evaluate other patient-oriented renal care websites.
Abstract: Background Medicare launched its Dialysis Facility Compare (DFC) website tool on Medicare.gov in 2001. This article reports on the methods and results of our recent evaluation of that website tool. Methods We conducted qualitative research with 270 dialysis and pre-dialysis patients, family members, and dialysis professionals to obtain feedback, to study respondents' information needs, and to identify ways to improve DFC. Results Participants viewed DFC as providing useful information, but also as needing improvement in both content and usability. Conclusions We recommended a number of improvements to DFC, many of which have been implemented by the Centers for Medicare & Medicaid Services. Our methods and results can provide guidance for future efforts to evaluate other patient-oriented renal care websites.

6 citations



Journal ArticleDOI
TL;DR: The CD-1000 performed its intended function of maintaining a dry and clean environment for the catheter and exit site with a high level of satisfaction from the patients along with a low rate of infection during the study interval.
Abstract: Background Central venous catheters (CVCs) are responsible for an estimated 250,000–400,000 bloodstream infections per year, with an associated mortality of 10%–35%. Colonization of the external surface of the catheter, distal spread of organisms down the catheters' intraluminal surfaces, and tap water have all been implicated in CVC infections. Methods In February, 2005, twenty-nine patients were prescribed and used the CD-1000, a new surgical dressing, to protect their catheter and exit site wound while performing high risk activities such as showering. This retrospective review was performed to evaluate the effectiveness of the CD-1000 at protecting the catheter and exit site from water and debris. In addition, patient satisfaction with the dressing and catheter infection rates were evaluated. Results The patient group used the CD-1000 for an average of 76.13 days (range, 26–147 days), and 96.4% reported that it was effective at keeping the catheter and exit site dry and clean while showering, and would recommend use of this dressing to anyone living with a catheter. Eleven of the 29 patients (37.9%) reported having had a catheter infection prior to using the CD-1000. During the study period there was 1 catheter infection (3.5%) resulting in a catheter infection rate for the study interval of 0.45/1,000 catheter days. Conclusion The CD-1000 allowed patients living with CVCs to return to showering and to engage in other high-risk activities previously not allowed. The dressing performed its intended function of maintaining a dry and clean environment for the catheter and exit site with a high level of satisfaction from the patients along with a low rate of infection during the study interval.

Journal ArticleDOI
TL;DR: It was found that new ESRD patients initiated treatment using PD had a higher survival rate than did those patients who chose to initate with HD, and non-diabetic patients had a high survival rate more than did diabetic patients.
Abstract: Background In many parts of the world, diabetic nephropathy is the principal cause of patients requiring renal replacement therapy. The survival rate of diabetic patients on maintenance dialysis, either hemodialysis (HD) or peritoneal dialysis (PD), is lower than that of non-diabetic patients on either modality. However, studies analyzing the rates of survival between the methods have reported conflicting results. Methods We used a retrospective analysis of data obtained from the China Medical University Hospital in Taiwan. All new end-stage renal disease (ESRD) patients who were undergoing initial dialysis, either HD or PD, for more than 3 months at our hospital from January 2000 through December 2003, and were followed-up through June 2004, were included. We compared survival rates between diabetic and non-diabetic patients, and between the 2 modalities. Results Of the 445 patients studied, 219 patients (49.2%) received HD and 226 patients (50.8%) received PD as their initial therapy. One hundred two HD patients (46.6%) and 96 PD patients (42.5%) were diabetic. The average age was 60 ± 13 years for the HD patient group and 57 ± 16 years for the PD patient group. The hemoglobin level for the HD group was 9.5 ± 1.4 g/dL and 9.4 ± 1.3 g/dL for the PD group. The serum albumin level was 3.0 ± 0.6 g/dL for the HD group and 2.9 ± 0.6 g/dL for the PD group. There was no significant difference in the number of co-morbidities between the HD and PD patients. Kaplan-Meier survival curve and Cox-regression analysis were used to compare the relative ratio (RR) of mortality between the HD and PD patient groups. Among these 445 patients, PD patients were associated with a significantly lower risk of death (RR: 0.382) compared with the HD patients. Older age (≥65 years), diabetes mellitus as the cause of ESRD, co-morbidity of ischemic heart disease, congestive heart failure, cerebral vascular accident, peripheral artery occlusive disease, or liver cirrhosis, and Hb levels <8.0 g/dL) and serum albumin levels <2.8 g/dL were associated with a significantly high risk of mortality. Conclusion We found that new ESRD patients initiated treatment using PD had a higher survival rate than did those patients who chose to initate with HD. Additionally, non-diabetic patients had a higher survival rate than did diabetic patients. More than 2 co-morbidities, Hb level <8.0 g/dL), and serum albumin level <2.8 g/dL had a significantly high mortality rate in dialysis patients.

Journal ArticleDOI
TL;DR: The first installment in a series of four articles that will outline a plan of action for the development and design needs of a dialysis clinic focused on determining staffing and space needs and financial options, and navigating contract options for assembling a team.
Abstract: Developing a dialysis clinic is a multistep process that must be approached methodically and with focused attention to project needs and requirements. This article is the first installment in a series of four articles that will outline a plan of action for the development and design needs of a dialysis clinic—whether you're developing a clinic from the ground up or outfitting and upgrading an existing unit. This installment focuses on the first steps involved in developing a plan of action for new facility construction, including determining staffing and space needs and financial options, and navigating contract options for assembling a team.

Journal ArticleDOI
TL;DR: Assessment of intradialytic change in plasma volume is not useful for evaluating the hydration status of HD patients in clinical practice, as it clearly indicates that intradialsytic changes in plasmaVolume does not influence either pre-dialysis or post- dialysis blood pressure.
Abstract: Background. Hypervolemia is considered a major pathogenic factor for hypertension in patients receiving hemodialysis (HD). We examined the effect of intradialytic changes in body weight and plasma volume on blood pressure (BP) in a cohort of chronic HD patients. Patients and Methods. One hundred chronic, stable HD patients were the subjects of the present study. They were divided into 2 groups according to their pre-dialysis BP. Each group was examined for potential significant correlations of intradialytic changes in body weight and plasma volume with pre- and post-dialysis blood pressure values. The intradialytic decrease in plasma volume was calculated from pre-dialysis and post-dialysis total plasma protein concentrations and was expressed as a percentage of the plasma volume at the beginning of the hemodialysis session. Results. In group A (hypertensive group, n=43), post-dialysis systolic and diastolic blood pressure (SBP and DBP) were significantly lower than pre-dialysis values (p < 0.05). The mean intradialytic reduction in body weight was 2.97±1.33 kg, and the mean intradialytic decrease in plasma volume was 13.6%±8.23%. There was no significant correlation between intradialytic change in either SBP or DBP and intradialytic change in body weight or plasma volume. In group B (normotensive group, n=57), post-dialysis SBP and DBP were significantly lower than pre-dialysis levels (p < 0.05). The mean intradialytic reduction in body weight was 2.64±1.07 kg, and the mean intradialytic decrease in plasma volume was 13.4%±7.73%. A positive significant correlation was recorded between intradialytic change in SBP and change in body weight in normotensive group. Multiple regression analysis revealed that for the study patients as a whole, pre-dialysis SBP, intradialytic change in SBP, pre-dialysis DBP, and post-dialysis SBP were not significantly correlated with intradialytic changes in plasma volume and body weight. Conclusions. Our findings clearly indicate that intradialytic change in plasma volume does not influence either pre-dialysis or post-dialysis blood pressure. From our results, we conclude that assessment of intradialytic change in plasma volume is not useful for evaluating the hydration status of HD patients in clinical practice.

Journal ArticleDOI
TL;DR: Pre-transplant psychological evaluation of patients who have lost their previous graft is paramount because it can enable detection of psychological morbidity, which, along with risk factors for postoperative noncompliance, should be addressed prior to re-trans transplantation.
Abstract: Approximately 30% of kidney transplant recipients experience a transplant failure during the first 5 years following transplantation. Although transplant failure is experienced as an adverse event, more than two thirds of patients who lose their graft desire another transplantation because it is less intrusive than dialysis and is associated with a better quality of life. We present a review of the scientific literature on the psychological impact of graft loss, and follow with a series of criteria specific to the assessment of re-transplant candidates. The psychological reactions to organ loss that have been identified, ranging from denial to grief, need to be assessed in re-transplant candidates. Moreover, the significance of graft loss for patients, their attitude about re-transplantation, and their motivation to go through surgery once more should be evaluated. Issues of compliance also warrant particular attention. Pre-transplant psychological evaluation of patients who have lost their previous graft is paramount because it can enable detection of psychological morbidity, which, along with risk factors for postoperative noncompliance, should be addressed prior to re-transplantation.

Journal ArticleDOI
TL;DR: It was observed that serum albumin level and Ca×P product negatively affected low blood flow rate when dialysis was performed at a BFR of less than 350 mL/min.
Abstract: Background Arteriovenous fistulas are the most frequently used blood vessel entrances in chronic hemodialysis patients. In this study, we evaluated the appropriateness of arteriovenous fistulas and the association between having a problematic fistula (a fistula unable to reach the required blood flow rate of 350 mL/min) and patient clinical and laboratory values. Patients and Methods Thirty-eight hemodialysis patients (26 men and 12 women), were included in the study. Their mean age was 58 years, with a range of 35–79 years. Patients were classified according to blood flow rate. Group 1 patients had BFR 350 mL/min (n = 17). Demographic, clinical, and biochemical data, and fistula location of the 2 groups were compared, and parameters that influence low blood flow were evaluated. Results No statistically significant differences were found between the groups in age, sex, duration of dialysis, and body mass index (p > 0.05). Serum albumin and hemoglobin levels of the dialysis patients with low BFR were highly significantly lower than in the patients whose BFR was more than 350 mL/min (p 0.05). Evaluation of the effects of hemoglobin, serum albumin, serum Ca×P, and parathormone levels on low blood flow rate during hemodialysis using backward stepwise logistic regression showed the model was highly significant (p < 0.01), with a Negelkerke R2 of 0.790 and an explanatory coefficient of the model of 94.7%. Conclusions When dialysis was performed at a BFR of less than 350 mL/min, serum albumin, hemoglobin, parathormone levels, and Ca×P product—which all have proven prognostic value—were adversely affected. We observed that serum albumin level and Ca×P product negatively affected low blood flow rate.

Journal ArticleDOI
TL;DR: The importance of multidisciplinary care is illustrated by this case study of a woman with stage 4 chronic kidney disease who became pregnant and the complex interaction between disciplines and the patient's psychosocial needs is highlighted.
Abstract: The importance of multidisciplinary care is illustrated by this case study of a woman with stage 4 chronic kidney disease who became pregnant. Her case highlights the complex interaction between disciplines and the patient's psychosocial needs. Developing trust, compromise, and collaboration was equally as important as having adequate urea reduction rates and extracellular volume stability for the successful outcome of this pregnancy and birth.

Journal ArticleDOI
TL;DR: It is expected that combined measurements of ferritin and sTFR concentrations with sTfR/logF index calculation could improve diagnostic reliability for accurate evaluation of the iron status of patients with ACKD, particularly those with concomitant inflammatory or infective conditions.
Abstract: Objective. The aim of this study was to assess the value of the soluble serum transferrin receptor (sTfR) and the transferrin receptor-ferritin index (sTfR/logF) as new markers of iron status in patients with anemia of chronic kidney disease (ACKD) both treated and not treated with recombinant human erythropoietin (rHuEPO) therapy. Materials and Methods. The study included 53 patients and 61 controls. The concentration of sTfR was determined by an immunoturbidimetric assay. Values for the sTfR/logF index were calculated as the ratio of sTfR to logarithm ferritin level. Results. The results showed iron-depleted patients had significantly higher median sTfR and sTfR/logF values (sTfR: 1.75 and 1.40 mg/L; sTfR/logF: 0.99 and 0.77) relative to those of iron-repleted patients (sTfR: 1.07 and 0.73 mg/L; sTfR/logF: 0.39 and 0.26) in ACKD patients—both those treated and those not treated with rHuEPO. Receiver operating characteristic analysis showed a higher diagnostic accuracy of the sTfR/logF index (area under curve [AUC] ¼ 0.970) versus sTfR concentration (AUC ¼ 0.890) in the assessment of the iron status of ACKD patients. The tested parameters showed no significant differences according to C-reactive protein concentration (p ¼ 0.108 and 0.147), in contrast to serum ferritin concentration (p ¼ 0.045). Conclusions: The study results showed the tested parameters to be reliable in the assessment of the iron status of patients with ACKD, with a higher discriminating power of the sTfR/logF index versus the sTfR. It is expected that combined measurements of ferritin and sTfR concentrations with sTfR/logF index calculation could improve diagnostic reliability for accurate evaluation of the iron status of patients with ACKD, particularly those with concomitant inflammatory or infective conditions.

Journal ArticleDOI
TL;DR: The three key changes made in the current K/DOQI guidelines are outlined in Table I, which include the definition of anemia, the target Hgb level, and the target iron status as measured by transferrin saturation and ferritin level.
Abstract: T he National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/ DOQI) guidelines for the management of anemia in chronic kidney disease (CKD) were updated this past spring for the second time since their initial publication in 1997. The charter guidelines focused on the treatment of anemia in dialysisdependent end-stage renal disease (ESRD) patients. In 2001, these guidelines were broadened to include the subpopulation of CKD patients who were not on dialysis. These most recent update pertains to non-dialysis–dependent CKD patients stages 1 through 5, dialysisdependent (either hemodialysis or peritoneal dialysis) ESRD patients, and renal transplant patients. This update was prompted by evidence from various clinical and observational studies that primarily addressed the target hemoglobin (Hgb) level for patients with CKD. These new guidelines differ from previous ones in the significance accorded this evidence. They can be regarded as either guidelines or recommendations for clinical practice. The evidence comes not only from studies conducted in the United States but also from those conducted in Canada, Europe, the United Kingdom, Mexico, and the Middle East. The European Best Practice guidelines from 2004 were also evaluated. The three key changes made in the current K/DOQI guidelines are outlined in Table I. These changes include the definition of anemia, the target Hgb level, and the target iron status as measured by transferrin saturation and ferritin level.

Journal ArticleDOI
TL;DR: Graft and patient survival was similar in patients previously treated with PD or HD and excellent in pre-dialysis patients, whereas rejection and GT rates were similar with all pre-transplant treatment modalities.
Abstract: Background The effect of pre-transplant treatment modality on renal transplant outcomes is still controversial. A negative patient selection for treatment with peritoneal dialysis (PD) some years ago gave the impression of poorer transplant survival than with hemodialysis (HD). Objectives To evaluate the influence of pre-transplant treatment (PD, HD, or patients who were pre-dialysis) on initial delayed graft function (DGF), graft thrombosis (GT), global rejection rate, and survival among patients at a single university hospital with a strong tradition of performing renal transplants. Patients The study analyzed 563 renal transplants (HD: 80%, PD: 16.5%, pre-dialysis: 3.5%) performed at a single center between January 1996 and May 2002. Results There were no differences in immunosuppressive protocol during the study. The HD patients were older (p=0.004). The proportion of diabetics was higher among patients who received PD (20%) than in those who underwent HD (8%) and in those who were pre-dialysis (10%) (p=0.002). There were no differences between PD and HD patients in donor type (brain death: 55.6% PD vs. 55.6% HD; non-heart-beating [NHB]: 39% PD vs. 35% HD; dual pediatric: 6% PD vs. 7% HD; dual elderly: 0% PD vs. 2% HD). Despite the higher proportion of diabetics among PD patients, graft and patient survival did not differ between patients coming from PD, HD, and those who were pre-dialysis. Patient/graft survival after 1 year was 100%/100% with Pre-D, 96.5%/95% with PD, and 95.6%/92.5% with HD. Patient/graft survival after 3 years was 100%/100% with pre-dialysis, 94.1%/94.1% with PD, and 91.7%/89% with HD. DGF incidence was higher in HD patients than in PD and pre-dialysis patients (p<0.001) even when brain-dead (p<0.01) and NHB (p<0.001) donors were analyzed separately. The global rejection rate was the same for all patients regardless of pre-transplant treatment. There was a very low rate of graft thrombosis, with no statistical differences between the groups (0.9% PD and 1.3% HD). Conclusion Graft and patient survival was similar in patients previously treated with PD or HD and excellent in pre-dialysis patients. A significantly higher rate of initial DGF was confirmed in HD patients, whereas rejection and GT rates were similar with all pre-transplant treatment modalities.

Journal ArticleDOI
TL;DR: The new conditions to participation are divided into three sets of requirements, relating to patient safety, patient care, and administrative matters, which address the patient safety requirements.
Abstract: The new conditions to participation are divided into three sets of requirements, relating to (1) patient safety, (2) patient care, and (3) administrative matters. This installment, which is the first of a three-part series on these proposed requirements, addresses the patient safety requirements. The second and third installments will discuss the patient care and administrative provisions of the proposed regulations.


Journal Article
TL;DR: The patients on PD had a different clinical picture of ED presentation than did the patients on hemodialysis, and Aggressive patient education and monitoring are recommended to reduce the number of ED visits by these patients.
Abstract: Background. The patterns of emergency department (ED) presentation of chronic peritoneal dialysis (PD) patients have not been well documented. This study was designed to analyze the ED presentation, evaluation, and disposition of these patients. Materials and Methods. We retrospectively reviewed the charts of all chronic PD patients who had been treated for more than 1 month at our dialysis center between January 1995 and December 2003. We included patients who visited the ED during this period. Data were collected on demographics, etiology of renal failure, chief complaint, diagnosis, length of stay, and disposition. Results. A total of 68 chronic PD patients (26 male, 42 female) were treated at our center during this period. Eight patients were not studied because of incomplete medical records. In addition, 18 patients never visited the ED. The remaining 42 patients made 96 ED visits. The most common presenting complaints were abdominal pain, dyspnea, and nausea/vomiting. The major diagnoses were peritonitis, respiratory tract infection, hypovolemia associated with excessive ultrafiltration, and acute gastroenteritis. Symptomatic hypokalemia was also seen in 5% of patients visiting the ED. Among the patients, 58.3% were admitted. The average duration of admission was 17.2 ± 41.2 days. Conclusion. The patients on PD had a different clinical picture of ED presentation than did the patients on hemodialysis. PD-associated complications-especially peritonitis-constitute major reasons for ED visits. Aggressive patient education and monitoring are recommended to reduce the number of ED visits by these patients.

Journal ArticleDOI
TL;DR: This article, the second of four installments focusing on dialysis clinic design, will review many of the issues that arise in successful project initiation and development from concept through construction, and will address several types of challenges that traditionally occur during the process.
Abstract: During the development and construction of a dialysis clinic, there are decisions that influence the cost, building quality, and completion date of the project. Change orders—changes to the project after bidding and a contractor has been awarded—are often unavoidable. The owner, architect, and contractor, as well as outside agencies, will at times desire to make changes due to whim or necessity. Often, how you approach these changes has a larger impact on cost and schedule than the change itself. This article, the second of four installments focusing on dialysis clinic design, will review many of the issues that arise in successful project initiation and development from concept through construction, and will address several types of challenges that traditionally occur during the process.

Journal ArticleDOI
TL;DR: Iron sucrose administered at a dosage of 100 mg on a maintenance regimen either every other week or every fourth week exceeded most patients' requirements.
Abstract: Objective. Chronic hemodialysis patients often require maintenance intravenous iron, as iron is an essential component of effective erythropoiesis. The Anemia Work Group (NKF-K/DOQI) anemia guidelines suggest a maintenance intravenous iron dose of 25–125 mg, but the optimal maintenance dose regimen remains difficult to determine. K/DOQI recommends these iron parameters: TSAT ≥ 20% and < 50%, ferritin ≥ 100 and < 800 ng/mL. An assessment of the maintenance dose regimen used in the present study is presented in this article. Patients and Methods. Data were collected retrospectively to evaluate clinical response in 40 adult chronic hemodialysis patients who received regular maintenance intravenous iron sucrose of 100 mg either every other week or every fourth week based on their ferritin and transferrin saturation (TSAT) levels. If ferritin level was between 100 and 500 ng/mL and TSAT level was 20% and 30%, then iron sucrose was administered every other week; if ferritin was 500–700 ng/mL or TSAT was 30%–45%, then iron sucrose was administered every fourth week. Ferritin and TSAT levels were monitored quarterly. Results. After the first quarter, 15 (38%) of the patients (n=15) remained on their original dosing regimen; 21 (53%) patients required adjustment to their regimen, either by discontinuing the regimen (n = 18) or decreasing the dosing interval (n = 3), 45% and 7.5% respectively; and 4 (10%) patients required additional intravenous iron supplementation. Conclusion. Iron sucrose administered at a dosage of 100 mg on a maintenance regimen either every other week or every fourth week exceeded most patients' requirements. Maximum intravenous iron maintenance doses for adult chronic hemodialysis patients remain difficult to determine, and the maintenance iron requirement varies from patient to patient.

Journal ArticleDOI
TL;DR: This article summarizes the implications that these proposed regulations have for providers of dialysis services and addresses the administrative provisions of the proposed regulations, including those related to facility governance, medical directorship, and personnel.
Abstract: In February 2005, the Centers for Medicare and Medicaid Services (CMS) released proposed regulations that contain a set of revised conditions to participation in the End-Stage Renal Disease (ESRD) program. If adopted, these regulations will have a dramatic impact on all dialysis providers. Parts I and II of this series of articles, which appeared in the March and April issues of this publication, addressed the patient safety and (more controversial) patient care provisions of the proposed requirements. This, the third and final installment, addresses the administrative provisions of the proposed regulations, including those related to facility governance, medical directorship, and personnel. This article also summarizes the implications that these proposed regulations have for providers of dialysis services. Owners and operators of dialysis facilities should assume that sometime in 2007, new regulations will become final that will include, at a minimum, a significant number of the provisions contained in the proposed regulations.

Journal ArticleDOI
TL;DR: Elevated PTH seems to affect lymphocyte function and is associated with changes in cellular immunity in a peritoneal dialysis population.
Abstract: Objective The clinical relevance of altered lymphocyte function and its possible relation with uremic toxins such as parathyroid hormone (PTH) is not well understood. We studied the changes in cellular immunity in patients on continuous ambulatory peritoneal dialysis therapy and examined the relationship between T-lymphocyte function and plasma levels of PTH. Patients and Methods Thirty-seven patients (16 male, 21 female) were enrolled in the study. The patients were divided into 2 groups: 22 patients with increased levels of PTH and 15 patients with normal levels of PTH. Lymphocyte subsets (CD2+, CD3+, CD3+/4+, CD3+/8+, CD19+, CD3−/16+56+, CD4/CD8 ratio) were quantitated in both groups using monoclonal antibodies and flow cytometric analysis. Analysis of variance testing was performed to analyze differences between the groups. Results A significant increase in CD3 was observed in patients with increased levels of PTH (71.6±7.9 vs. 57.5±28.1, p<.05). CD3/8 population was also increased in patients with elevated PTH (26.96±8.01 vs. 20.8±13.78, p=NS). CD4/CD8 ratios were lower in patients with elevated PTH than in those who had normal PTH (1.67±0.78 vs. 3.03±2.54, p<.05). No specific differences were observed between these 2 patient groups in CD19 and natural killer cells. Conclusions Elevated PTH seems to affect lymphocyte function and is associated with changes in cellular immunity in a peritoneal dialysis population. Our study is continuing in order to enlarge the study population and collect more data, which will lead to more solid conclusions.

Journal Article
TL;DR: The impact of the recently announced changes to the anemia standards of reimbursement for renal facilities, as introduced by the Centers for Medicare and Medicaid Services is summarized and addressed.
Abstract: This article summarizes and addresses the impact of the recently announced changes to the anemia standards of reimbursement for renal facilities, as introduced by the Centers for Medicare and Medicaid Services. Next month, we will begin a three-part series addressing the potential impact of Medicare's proposed revisions to the Conditions for Coverage to Participaion for the operation of dialysis clinics. We will detail the requirements that must be met by facilities in order to receive reimbursement from Medicare for the treatment of dialysis patients. The March installment will cover patient safety, the April issue will address patient care, and May will look at the administrative provisions of the proposed regulations.

Journal ArticleDOI
TL;DR: This case is presented to highlight all components of extraosseous calcification in a single patient including soft-tissue, visceral, and vascular calcification, and calciphylaxis.
Abstract: Background The most frequent cause of death in patients with chronic kidney disease (CKD) is a cardiovascular event. Disturbances of mineral and bone metabolism result in vascular calcification, which partly accounts for the increased cardiovascular morbidity and mortality. Extraosseous calcification in CKD can produce a range of pathologies including calcific uremic arteriolopathy, extraosseous soft-tissue calcification, calcification involving solid organs, and corneal, conjunctival, peritoneal, vascular, and valvular calcification. In rare instances, calcification can involve all of these structures. Patient We report a CKD patient with extensive extraosseous calcification and calciphylaxis. A 45-year-old woman, known to have CKD since 2001, presented to us with painful ulcers in both great toes and exertional dyspnea. Results Investigations revealed severe renal failure, anemia, hypoalbuminemia, hyperphosphatemia, and normal corrected calcium. Her imaging studies showed diffuse uniform calcification of femoral, posterior tibial, radial, ulnar, and digital arteries. Ophthalmological consultation obtained for red eye suggested this condition was a result of conjunctival and corneal calcification. In a plain abdominal x-ray she had visceral calcification, subcutaneous calcification, and calcification of her abdominal arteries. A Doppler study of both upper- and lower-limb arteries was normal. Biopsy from the skin adjacent to the ulcer was suggestive of calciphylaxis. A superficial temporal artery biopsy showed medial calcification and subintimal fibrosis. Her iPTH was 5,560 pg/mL, and ultrasound of the neck revealed diffusely enlarged parathyroid glands. Alcohol ablation was attempted but failed. The patient was treated with daily dialysis, aluminum-based phosphate binder, and aggressive wound care, and a parathyroidectomy was planned. The patient had sudden cardiac death on dialysis. Conclusions This case is presented to highlight all components of extraosseous calcification in a single patient including soft-tissue, visceral, and vascular calcification, and calciphylaxis.