Clinical Assessment of Dialysis Quality

One may ask what index of dialysis adequacy should be used instead of Kt Vurea. It is tempting to give a simple formula, easy to implement and easy for bureaucrats to control. If such a formula were really developed, nephrol-ogists would not be needed in dialysis centers - computer programs and dialysis technicians would suffice. I do not believe that such a formula will be developed any time soon as dialysis is a very complex procedure. The use of rigid, quantitative guidelines (e.g., spKt...

Enrichment of the Dialysis Fluid

Although dialysis fluid predominantly contains electrolytes, a buffer and glucose, the potential exists for other compounds to be added for specific applications. The first such approach was the addition of urea to the dialysis fluid to minimise dialysis disequilibrium 25 which was also used more recently by Doorenbos et al. 26 . Other compounds that have been added include amino acids to compensate for the loss during dialysis 27, 28 , ethanol for the treatment of ethylene glycol or methanol...

Materials and Methods

Nine critically ill patients with acute renal failure (ARF) requiring CRRT were included in the prospective observational cohort study. For all subjects a diagnosis of 'severe sepsis' was made according to the criteria of Bone et al. 8 including (1) at least 2 systemic inflammatory response syndrome (SIRS) criteria (2) confirmed or suspected infection, and (3) multiple organ dysfunction syndrome. The study protocol was approved by the hospital ethics committee. All septic patients were treated...

Justification for Short Dialysis

Three factors were necessary for the widespread acceptance of short dialysis economic incentives, technical feasibility, and medical scientific justification 10 . Economic incentives were demonstrated by early proponents of short dialysis. In the meantime, very efficient dialyzers had been designed and their values demonstrated in short-term studies 11, 12 . Nevertheless, short-term studies would not be sufficient for the widespread use of short dialysis. Some scientific support and a...

Clinical and Organizational Monitoring

IMS Working with Guidelines (EBPG) and SOPs Orientation towards quality and continual improvement is a fundamental principle within Fresenius Medical Care and a key element of management policy for all business sectors. Within the Patient Care Business Unit, FME aims to set and achieve higher standards of dialysis care supported by both internal, corporate requirements as well as external standards. FME's overall approach to quality assurance is based on the principles of continuous quality...

Hypertension in Hemodialysis Patients

Hypertension occurs in 90 of patients starting hemodialysis and persists in 70-90 of hemodialysis patients in the US 57 . In the large, multicenter Hemodialysis (HEMO) Study more than 70 of patients were hypertensive by JNC VI guidelines, and almost 75 required antihypertensive medications 58 . This is contrary to the situation in the late 1960s, when strict control of true dry body weight was practiced and the majority of patients did not require antihypertensive agents 59 . There is a...

Managing Complexity

The Importance of Best Practice Transfer across the Borders Setting Core Elements and Driving Local As pointed out, while different country settings impose different combinations of services and require adaptation to local practices, international clinical outcome guidelines determine the same level of quality care to be delivered. The challenge today is to give the right answer to satisfy the expectations of payers and to achieve the same level of good dialysis outcome that all patients...

The Production of Dialysis Fluid

Dialysis Mixing Tank

Historically the production of dialysis fluid was by the manual mixing of concentrated electrolyte solution with water in a large tank, which was then heated and pumped to the dialyser 1 . With the advent of single-patient proportioning systems in the late 1960s, the production of the dialysis fluid moved to the patients bedside and whilst this approach remains the most widely used, alternatives such as a central delivery system or systems that incorporate pre-mixed dialysis fluid continue to...

References

1 US Renal Data System, USRDS 2005 Annual Data Report Atlas of End-Stage Renal Disease in the United States. Bethesda, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2005. 2 Neilson EG, Hull AR, Wish JB, Neylan JF, Sherman D, Suki WN The Ad Hoc Committee report on estimating the future workforce and training requirements for nephrol-ogy. The Ad Hoc Committee on Nephrology Manpower Needs. J Am Soc Nephrol 1997 8 suppl 9 S1-S4. 3 Wolfe RA, Ashby...

The NCDS Dosing Controversy and HEMO

In addition to the step function in outcome shown in figure 4 , continuous linear and exponential functions relating probability of failure to Kt V could also be written with equivalent p values as described in the mechanistic analysis paper 7 , Subsequently others strongly argued that outcome should be an exponential function as shown in figure 5A because of accumulating OS experiences which indicated continuing improvement in outcome up to spKt V 1.40 8 , The HEMO study 2 was subsequently...

Water for the Production of Dialysis Fluid

Generally patients undergoing three times weekly dialysis treatments utilise dialysis fluid flow rates of between 500 and 800 ml min, which corresponds to the use of 120-200 litres of fluid over a 4-hour treatment session. In contrast to the normal population, who not only are exposed to significantly lower volumes of water and in whom the gut offers a high degree of protection from impurities that may be present, dialysis patients are not only exposed to higher volumes of water, but during...

Vitamin C Effects on Erythropoiesis

The management of anemia utilizes much of the resources dedicated to patients on dialysis hemoglobin, ferritin, transferrin saturation, erythropoietin therapy and the intravenous administration of iron complexes IV-iron are reviewed extensively for each patient, with dose adjustments monthly or even at more frequent intervals. Improved vitamin C status may lead to improved anemia management in these patients. The biochemistry of vitamin C and iron are intimately related at the level of the...

An Alternative Hypothesis

The reduced survival in MHD patients with a low BMI has recently been explained by a novel hypothesis 7 . Briefly, both in healthy and MHD subjects, visceral organ mass i.e. high metabolic rate compartment, HMRC relative to whole body mass HMRC BW is inversely related to weight and urea distribution volume V . V, as determined by urea kinetic modeling, is closely related to MM fig. 1 , whereas fat mass contributes only marginally. Viscera are the most likely source of uremic toxins, and their...

Suggested Reading

1 Rettig RA, Levinksy NG eds Kidney Failure and the Federal Government. Washington, National Academy Press, 1991. 2 Wolfe RA Methodology for Developing a Basic Case Mix Adjustment for the Medicare ESRD Prospective Payment System. Available at www.med.umich.edu Kidney. 3 43 CFR Part 405, et al. Medicare Program Revisions to Payment Policies Under the Physician Fee Schedule for Calendar-Year 2006 Proposed Rule CMS-1502-P . August 8, 2005. 4 Implementation Support for the Quality Incentive Payment...