Aim: To identify the major difficulties nephrologists in the US face in providing adequate dialysis. Methods:To identify the perceived obstacles to achieving adequate dialysis in the US, 30 clinical support specialists responsible for nursing education and training were polled. Their responses together with those found in the recent literature were summarized and analyzed. Results: The obstacles identified fell into the following major categories: (1) economic; (2) personnel shortage; (3) education, and (4) cultural. The principal specific difficulties identified in providing adequate dialysis were the provision of sufficient time and frequency of dialysis, adequate volume control and vascular and peritoneal access. Conclusions: The obstacles we currently face are serious but can be conquered through better understanding of the problems and education of professionals, patients and payers. The simple improvement in two specific areas, the creation of more native arteriovenous fistulae and growth of home dialysis, are identified as the highest priorities to overcome these obstacles. Copyright © 2007 S. Karger AG, Basel

Before embarking on identifying the major difficulties the American nephrologist faces in providing adequate dialysis, we must examine the issue of provision of ade quacy and clinical outcomes in the US compared to other countries. During the past decade we have observed a heated debate between those justifying the higher mortality rate among US dialysis patients and those explaining the differences in mortality between the US and other industrialized countries based on differences in the practice of dialysis [1, 2]. Table 1 summarizes some of the arguments used in these debates to justify their respective positions. There is no doubt that the statistical analysis is greatly complicated by variables that are difficult to adjust such as race (100% Asians in Japan and a mixture of African-Americans, Hispanics, Native Americans and Caucasians in the US), cultural differences, degree of patient compliance and financial incentives. Nonetheless, the marked differences in survival between the US and other industrialized nations, particularly among older patients, and the obvious differences in dialytic practices deserve our consideration.

Even if there are significant differences in the practice of dialysis between the US and Europe and Japan, are these practices important in determining outcome? In other words, do the significant differences in treatment time and UFRs explain the differences in survival between the US and the rest of the industrialized world? Furthermore, the definition of adequacy remains controversial. Should we measure adequacy with Kt/V, Kt, middle molecule clearances, an index reflecting solute removal and achievement of dry weight, nutritional parameters, inflammation parameters and/or purely clinical observations?


© 2007 S. Karger AG, Basel 0253-5068/07/0251-0048$23.50/0

Jose A. Diaz-Buxo, MD, FACP

1001 Morehead Square Drive, Suite 470

Charlotte, NC 28203 (USA)

Tel. +1 704 370 0625, Fax +1 704 370 0644, E-Mail [email protected]

Table 1. Arguments that justify or criticize the lower US survival for dialysis patients


US has the world's highest treatment rate for incident kidney failure Universal acceptance for uremia therapy in the US Genetic differences better explain the results elsewhere (Japan) Less compliant patients in the US Larger patients in the US Higher transplantation rate, reducing the pool of more viable patients


Inadequate dialysis: faster and short dialysis, high ultrafiltration rate Japan accepts almost as many diabetics as the US and the mean age of incident patients is higher in Japan Older Americans live longer than older Japanese

Better training of physicians in dialysis in Japan and Europe Nursing shortage and limited training in the US

The most recent report from the DOPPS Study shed some light on these issues and especially on the important role of treatment time on patient outcomes [3]. This is pertinent since a significant change in treatment time is to a great extent controlled by the existing infrastructure, reimbursement, personnel availability, patient acceptance and compliance and the general practice culture of the community. Longer treatment time and slower ultrafiltration rate (UFR) have been considered advantageous for hemodialysis (HD) patients for some time. According to the ANZDATA 2004 report, unadjusted patient survival improves for all increments of dialysis time in the range of 12 h/week to more than 18 h/week [4]. Furthermore, the hazard ratio (RR) for death was reduced by 23% when treatment time was increased to 4.54.9 h/session as compared to the reference treatment time 4.0-4.4 h/session. In Japan, treatment time longer than 4.5 h was associated with reduced RR death up to approximately 6 h and short dialysis times increased the risk of death over the reference of 4.5 h [5]. The recent DOPPS report showed that Europe and Japan have significantly longer (p < 0.0001) average treatment times than the US [3]. Kt/V increased concomitantly with treatment time in all three regions. Treatment time made a greater contribution to delivered Kt/V in Japan than in Europe or the US, where blood flow contributed more to K and treatment time accounted for a very small proportion of total Kt/V (2-3%). Treatment time of >240 min was independently associated with a significantly lower RR mortality (RR = 0.81, p = 0.0005). Every 30 min longer dialysis time was associated with a 7% reduction in RR (p < 0.0001). A synergistic interaction occurred between Kt/V and treatment time toward mortality reduction (p = 0.007). Most importantly, UFR >10 ml/h/kg was associated with higher odds of intradialytic hypotension

(OR = 1.30, p = 0.045) and a higher mortality risk (RR = 1.09, p = 0.02). A longer dialysis time and higher Kt/V were independently, as well as synergistically, associated with lower mortality and rapid UFR was associated with higher mortality risk. In view of the marked differences in treatment time, UFR and all-cause mortality between the US and Europe and Japan, it is pertinent to identify the major difficulties the nephrologist may face in providing adequate dialysis in the US.

To identify the perceived obstacles to achieve adequate dialysis in the US, we contacted 30 clinical support specialists responsible for the nursing education and training for a large dialysis provider in the US. This group of educators is exposed to a medical team caring for more than 125,000 patients. Their responses are summarized in table 2.

Increasing time and frequency of HD should improve adequacy. However, three principal obstacles have been identified that impede its implementation: (1) the complex logistics with the present infrastructure required to increase the frequency and/or time of dialysis sessions; (2) the higher cost mostly associated with the additional personnel time, and (3) resistance from nurses and patients. The obvious solution to this problem would be treatment of a higher proportion of patients at home. The under-utilization of center stations is often quoted as an obstacle to home dialysis referral since there is an economic incentive to fill up in-center vacancies. Furthermore, home therapy requires a minimal number of patients before it becomes financially profitable since there are fixed operational expenses (dedicated training nurses and physical plant) that are independent of revenue [6]. Finally, the present reimbursement methodology provides no direct outcome-based financial incentives. This process may very well change in the future with the in-

Table 2. Obstacles to achieving adequate dialysis in the US Inability to increase time and frequency of HD

Logistics/infrastructure Economics

Resistance from nurses and patients Underutilization of center stations: tendency to fill up in-center before sending patients home

Home therapies require a minimal number of patients to break even: difficulty obtaining support during the growing period No direct outcomes-based financial incentives

Culture of short dialysis or 'dialysis in the fast lane' despite high cardiovascular comorbid-

ity and inadequate volume control Noncompliant patients

Signing off treatment early or arriving late Skipping treatments Reluctance to use larger and more frequent PD exchanges or longer time on HD Nursing shortage and high staff turnover

Poor supervision of patient data by nursing supervisors or nephrologists Lack of adequate education in dialysis Physicians Nurses Patients

Inadequate vascular or peritoneal access

Patient's reluctance to accept venipunctures after experiencing central lines Frequent hospitalizations due to comorbid conditions independent of end-stage renal disease

Suboptimal treatments during hospitalizations troduction of global capitation and disease management programs. Disease management is likely to improve endstage renal disease outcomes and should reward those who offer optimal dialysis by reducing the cost of treating complications [7].

We have evolved into a culture of short and efficient dialysis, perhaps a reflection of the fast-paced, high technology American way and personnel shortage. In an attempt to avoid inadequate dialysis, formal guidelines such as K/DOQI have been formulated and goals of adequacy established. Technological advances have made it possible to attain the goals in an ever shorter time by increasing the surface area and improving the configuration of hemodialyzers, increasing blood and dialysate flows and providing better monitoring devices to prevent intradialytic complications (blood volume monitors and blood temperature monitors). The application of these tools and practices have made it possible to satisfy the adequacy goals in an ever-increasing proportion of patients, but with minimal impact on patient survival [8]. This brings into question the validity of the adequacy goals and has generated interest in other clinical parameters that may be as or more important than solute removal indices. Short, efficient, thrice weekly HD does not leave much room for error. It is also very taxing on large individuals and those with high ultrafiltration requirements. Short and highly efficient dialysis makes non-compliant patients particularly vulnerable. There are a considerable number of patients who sign off treatment early, arrive late for dialysis, entirely skip treatments or try to negotiate shorter dialysis times with the nephrolo-gist. The mere sight of the person responsible for patient transportation often generates a request for stopping treatment. Such practices are rare or entirely unacceptable in most other cultures. Non-adherence with dialysis has been reported to be associated with increasing mortality and hospitalization risk [9]. Other studies have suggested that American dialysis patients are less compliant with therapy than those in other countries [10]. In addition to noncompliance, patients are often reluctant to increase time on HD or use larger and more frequent peritoneal dialysis (PD) exchanges.

There is a serious nursing shortage in the US and a definitely slowing rate of growth in the number of registered nurses. Their current average age exceeds 45 years, with only 9.1% under the age of 30 as compared to 25.1% in 1980 [11]. A random sample of 1,000 members of the American Nephrology Nurses Association confirmed a similar average age for nephrological nurses and identified that 19% of the nurses were planning to leave their job within the next year [12]. This national nursing shortage compounded by a high staff turnover in dialysis units is a significant obstacle to the implementation of any practices that require additional personnel time. Furthermore, it compromises the quality of nurse training and the supervision of patient data. The high turnover significantly increases the cost of provision of therapy by reducing the productivity of personnel during training, compromises continuity of care and has the potential to increase errors.

The lack of adequate education in dialysis and related disciplines for physicians, nurses and patients is considered to have adverse consequences on achieving adequate dialysis in the US. Nephrology training programs and nursing school curricula generally do not offer sufficient exposure to care for dialysis patients. Mehrotra et al. [13] showed that 29% of US training programs had less than 5 PD patients per fellow and there were wide variations in the amount of time trainees spent caring for HD and PD patients. Most programs offer 3 or fewer months of exposure to outpatient HD and many offered no exposure to PD [14], The obvious way to correct this educational deficiency is formal restructuring of the training curriculum to include dialysis theory and practice. In the interim, comprehensive core curricula on PD and home HD are available and should be utilized , 6], Similarly, patient education and better understanding of the various therapeutic options is likely to improve compliance with therapy and increase the proportion of patients achieving adequacy goals.

Inadequate vascular or peritoneal access is a frequent and important impediment to achieving adequacy. Adequate blood flow is essential to obtain our small solute clearance goals. High blood flows become more important when dialysis time is short or frequency is low. Similarly, poor peritoneal flow results in higher dialysate transit time or non-dialytic time and could significantly compromise solute clearance. Furthermore, there is overwhelming evidence of an increased risk of death associated with inadequate HD access [15-18], There is also a clear association between PD catheter placement and the development of exit site and tunnel infections that often lead to peritonitis, catheter loss and technique failure. However, there is no evidence that catheter selection or type of implantation technique affects clinical outcomes.

Dhingra et al. [15] analyzed data from the USRDS and clearly showed that the type of vascular access correlates with mortality risk in the US. The associated RR of death was higher for patients with arteriovenous (AV) grafts and central venous catheters as compared to those with AV fistulae in diabetic and non-diabetic patients. Cause-specific analyses found higher infection-related deaths for catheters and AV grafts compared with AV fistulae among diabetics and to a lesser extent also among non-diabetic patients.

Pastan et al. [16] reported their analysis of a large retrospective cohort to assess the association between risk of death and type of vascular access. The crude mortality from all causes or attributed to infection was significantly higher among patients with grafts and central venous catheters as compared to AV fistulae. The adjusted odds ratios for all-cause and infection-related death among patients dialyzed with a catheter were significantly higher compared to those with AV fistulae. Similarly, Lorenzo et al. [17] showed that unplanned dialysis initiation and temporary catheter use were independently associated with greater mortality rates in incident patients. The combined influence of both variables was associated with greater morbidity and mortality than either variable alone.

Despite the strong evidence supporting the use of a native AF fistula for vascular access and the efforts to promote this practice, the utilization of native AV fistulae remains below the 65% goal of K/DOQI and significantly lower than that of other countries [18-21]. The goal of a prevalent functional AV fistula placement rate of >65% (Guideline is consistent with the Centers for Medicare and Medicaid goal of 65% by 2009. Furthermore, a 70% AV fistula access rate can be achieved even among diabetics and women [22-25].

The Centers for Medicare and Medicaid, in close collaboration with key stakeholders in the renal community, introduced an initiative called Fistula First with the goal of increasing the use of AV fistulae as the primary vascular access in all suitable HD patients [26]. While the present prevalence rate is significantly lower than the K/ DOQI Guidelines, Fistula First reported a gratifying increase to 41% average prevalence rate as of January 2006. It is also being recognized that treatment with PD as the initial mode of renal replacement therapy provides an excellent opportunity to create an AV fistula and the time for its maturation.

A related obstacle to achieving adequate dialysis in the US is the patient's reluctance to accept venipunctures after experiencing a central line. Unfortunately, despite the significant recent increase in AV fistula utilization in the US, the number of central venous catheters has also increased significantly [18, 27].

Frequent hospitalizations due to comorbid conditions independent of end-stage renal disease also interfere with the achievement of adequate dialysis. The transfer of a patient from their center or home environment to the hospital often results in delays of transfer of medical records and change in dialysis prescription, downgrading of the dose or frequency of dialysis or even missing the treatment altogether. Compounding this issue, many of these patients are hospitalized for conditions associated with hypercatabolic states that require additional dialysis, but appropriate adjustments are not made, rendering dialysis suboptimal.

In conclusion, the obstacles faced by American ne-phrologists in providing adequate dialysis are many and serious, but can definitely be overcome. Many of these obstacles are related to the reimbursement system and other economic factors, while others can be easily conquered with better education and the nephrologists taking control of important decisions and practices. Foremost among these are the creation of a native AV fistula with avoidance of central venous catheters and the pursuit of home dialysis. The home alternative is the answer to many of these obstacles and can fit better with the current reimbursement structure.

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