Hemodiafiltration with endogenous reinfusion with and without acetate-free dialysis solutions: effect on ESA requirement.

BACKGROUND: Hemofiltrate reinfusion (HFR) is a form of hemodiafiltration (HDF) in which replacement fluid is constituted by ultrafiltrate from the patient 'regenerated' through a cartridge containing hydrophobic styrene resin. Bicarbonate-based dialysis solutions (DS) used in routine hemodialysis and HDF contain small quantities of acetate (3-5 mM) as a stabilizing agent, one of the major causes of intradialytic hypotension. Acetate-free (AF) DS have recently been made available, substituting acetate with hydrochloric acid. The impact of AF DS during HFR on Hb levels and erythropoietic-stimulating agent (ESA) requirement in chronic dialysis patients was assessed. PATIENTS AND METHODS: After obtaining informed consent, 30 uremic patients treated by standard bicarbonate dialysis (BHD, DS with acetate) were randomized to treatment in 3-month cycles: first AF HFR, followed by HFR with acetate, and again AF HFR. At the beginning and end of each period, Hb and ESA requirements were evaluated. RESULTS: A significant increase in the Hb level was observed throughout all periods of HFR versus BHD (from 11.1 to 11.86 g/dl; p = 0.04), with a significant decrease of ESA requirements from 29,500 to 25,033 IU/month (p = 0.04). CONCLUSION: Regardless of the presence or absence of acetate in DS, HFR per se allows a significant lowering of ESA dosage versus BHD, while at the same time increasing Hb levels. Taking for granted the clinical impact produced, HFR seems to provide a relevant decrease in end-stage renal disease patient costs.

More of the same: improving outcomes through intensive hemodialysis.

The typical dialysis patient faces both a poor quality of life and a significantly shortened survival. This is often blamed on "uremia." However, defining the clinical entity of uremia is surprisingly difficult. It represents the clinical sequelae of the effects of retention products, other effects of renal disease, and the effects of other comorbid conditions. The list of retention products that could act as uremic toxins is lengthy, but it would appear that urea itself does not contribute significantly to the uremic state. Larger molecular weight substances are likely the major contributors to the uremic milieu. Regardless of the causes, the uremic state persists in many patients who are reaching their dialysis adequacy targets as defined by urea clearance. This raises the possibility that more intensive hemodialysis could improve patient outcomes. Hemodialysis can be intensified by increasing dialysis efficiency without changing duration or frequency. Alternatively, hemodialysis duration, frequency, or both can be increased. All intensification methods increase small solute removal, but the removal of larger molecular weight retention products depends more upon treatment time. Modalities such as short daily hemodialysis, long intermittent hemodialysis, and quotidian nocturnal hemodialysis have been associated with a variety of clinical improvements, as well as improvements in quality of life and a lower standardized mortality ratio. However, the HEMO study approach of intensifying small solute clearance without significant modifications of the dialysis schedule does not appear to be effective. Future research will help to define the optimal treatment duration and frequency in hemodialysis patients.

The extent of uremic malnutrition at the time of initiation of maintenance hemodialysis is associated with subsequent hospitalization.

OBJECTIVE: End-stage renal disease (ESRD) patients with signs of uremic malnutrition at the time of initiation of maintenance hemodialysis (MHD) are likely to remain malnourished over the subsequent year. Because poor nutritional status is associated with worse clinical outcomes in MHD patients, we hypothesized that ESRD patients with evidence of uremic malnutrition at the time of initiation of MHD would have more hospitalization events compared with patients initiating MHD without signs of malnutrition during the first year of therapy. DESIGN/INTERVENTION: This was an observational cohort of incident MHD patients, with no specific nutritional intervention. SETTING: Vanderbilt University Outpatient Dialysis Unit. PATIENTS: All newly initiated MHD patients at Vanderbilt University Outpatient Dialysis Unit were recruited for study purposes. A total of 149 patients were included in the study. MAIN OUTCOME MEASURE: The following parameters were recorded at the time of initiation of MHD: age; race; gender; serum concentrations of albumin, creatinine, cholesterol, and transferrin; and whether the patient had insulin-dependent diabetes mellitus. The number of hospital admissions and length of stay in the hospital were recorded for all study patients during the first year of MHD. Associated hospital charges were obtained for a subgroup of 52 patients. RESULTS: Study variables were associated with hospitalization in the subsequent year, the number of hospital admissions, and the length of stay in the hospital. Patients who initiated MHD in the lowest quartile of serum albumin had a significantly greater average of admissions compared with patients who initiated in the highest quartile (1.77 +/- 1.82 versus 0.72 +/- 0.96 admissions, P =.002). The length of stay in the hospital was also higher in the lowest quartile of serum albumin (8.96 +/- 9.96 versus 3.83 +/- 5.68 days, P =.006). Serum creatinine was also inversely associated with greater average number of admissions (2.27 +/- 2.41 versus 0.83 +/- 1.68 admissions, P =.004) and longer length of stay (12.43 +/- 15.15 versus 4.72 +/- 11.57 days, P =.017) in lowest compared with the highest quartile. In addition, the costs associated with hospitalizations were higher in the group of patients initiating MHD with lower concentrations of serum albumin and serum creatinine. CONCLUSIONS: In this study of incident MHD patients, the concentrations of 2 nutritional parameters, serum albumin and serum creatinine at the time of initiation of MHD, were significantly and negatively associated with hospitalization events. There was also a trend for greater hospital charges in patients with lower concentrations of serum albumin and creatinine.

[Uremic patients--late referral, early death]. / Urämische Patienten--späte Uberweisung, früher Tod.

BACKGROUND AND OBJECTIVE: A number of reports from various countries document that patients with renal failure who are referred late to renal units, have more complications e. g. lack of vascular access when dialysis has to be started as well as longer hospitalisation and have also a higher risk of early death. No data on these points are available from Germany. PATIENTS AND METHODS: In a retrospective analysis the timing of referral to the nephrologists was studied in two Departments of Medicine, e. g. Heidelberg and Vienna, for all patients who started renal replacement therapy. For patients in Heidelberg the relation between timing of referral and survival on dialysis was analysed using the Kaplan-Maier-technique. RESULTS: In Heidelberg 280 patients were analysed, 174 men, 106 women, age 61.8 +/- 14.5 years; 136 diabetic patients (9 type 1). They had been referred from GPs (n = 131), specialists (diabetologists, cardiologists; n = 20), emergency departments (n = 33), other hospitals (n = 90) or other institutions (n = 16). The measured median creatinine clearance at the time of referral was 14 ml/min (5-34). The median interval between referral and start of dialysis was 17 weeks. 137 patients had been referred < 17 weeks and 143 patients > or = 17 weeks prior to the start of dialysis. 97 of the 111 patients referred < or = 4 weeks prior to dialysis and 59 of the 169 patients referred > 4 weeks had to be dialysed with a central catheter. There were clear differences in patient survival. In patients referred < 17 weeks before the start of dialysis, the actuarial risk of death during the first 12 month was 34.2 % compared to 5.5 % (p < 0.0001) in patients referred > or = 17 weeks. Even the mortality in the interval between 12 and 24 months after the start of dialysis was clearly higher (15.3 %) in patients with late compared to early referral (11.4 %). CONCLUSION: Late referral of patients with impaired renal function to renal units causes more frequent problems of vascular access, longer hospitalisation, more medical complications, higher costs and higher mortality. Early referral of patients with renal failure is indispensable to improve dialysis outcomes.

Impact of a high-dependency care area on the nutritional management of patients with acute uremia.

At this institution, all non-intensive care unit (ICU)-based patients with acute uremia were previously managed on the general nephrology ward, and there were concerns that these patients may not have been benefiting from optimal management, particularly with regard to nutrition. In 1998, a renal high-dependency care (RHDC) unit was established within the ward, providing opportunity to compare the clinical management and outcomes of acutely uremic patients in 2 annual cohorts that were admitted both before and after implementation of the RHDC unit. Retrospective case reviews complemented data collected prospectively on the unit since 1995. There were 108 patients included from 1995 to 1996 and 86 patients included from 1998 to 1999; no patients were excluded, but a few case records were unobtainable. Both patient groups were demographically similar (median age, 68 years pre-RHDC, 62.5 years with the RHDC unit), and initial illness severity/comorbidity showed no significant differences. Nutritional support increased significantly (P <.05) from 22.4% in 1995 to 1996 to 38.4% of patients in 1998 to 1999, reflecting increased oral supplementation. Dialysis requirements were similar (60.2% v 63.5%). The proportion of patients requiring admission to the ICU (17.6% v 8.1%) and the total number of ICU bed days used (195 v 86) was reduced in 1998 to 1999. Cost analysis showed little overall difference between the 2 cohorts; the actual cost of improved nutritional management was negligible. The RHDC area and its nurse-based protocols have increased nutritional support for acutely uremic patients, allowing a reduction in ICU usage without any worsening in outcomes.

Resource limitations and strategies for the treatment of uremia. A dialysis unit in the Himalayan foothills.

India has made great strides in health care since gaining independence in 1947. Much still needs to be done. Scarce health care resources are directed at priorities that include infant and maternal mortality, immunizations, malnutrition, communicable disease prevention, and access to protected water and sanitation. There is, therefore, no government reimbursement for treatment of patients with ESRD (estimated incidence of 100 per million population). Transplantation, the modality of choice in India, benefits only 2-3% of ESRD patients. Hemodialysis is primarily used short-term for pretransplant stabilization. A very small minority of patients is placed on maintenance hemodialysis or CAPD. The annual cost of renal replacement therapies is more than 10 times the per capita gross national product. Financial constraints pose ethical problems for the nephrologist related to adequate prescriptions and compliance. Preventing the progression of kidney disease and reducing the cost of disposables through indigenous manufacture are initiatives that need to be explored.

The economic cost of dialysis: a comparison between peritoneal dialysis and in-center hemodialysis in a Spanish unit.

We have studied the economic cost of dialysis therapy in our area (public setting) during 1994, comparing the cost of different modalities of in-center hemodialysis (HD) and home peritoneal dialysis (PD). Analyzed costs included: personnel, drug expenditure, disposable (dialysis- and non-dialysis-related), laboratory, other services, indirect costs, maintenance and redemption, hospital admissions, transport, and home supplies. The final cost per patient and year (in 1994 US$) was: hemodiafiltration (AN69 filter, bicarbonate buffer) $58,890; HD polymethylmethacrylate filter and bicarbonate buffer $55,076; HD cuprophane and acetate buffer $49,767; CAPD $31,201; and cost of automated PD $42,519. The main expenditure sections were: home supply and hospital admissions for PD patients, and personnel, drug expenditures, disposable dialysis material, indirect costs, hospital admissions, and transport for HD patients. Home peritoneal dialysis therapy has a significantly lower economic cost than any in-center HD modality.

Clinical epidemiology in chronic uremia.

The burden of disease in end-stage renal disease (ESRD) is high. The cost of end-stage renal disease therapy is also high. The age and co-morbidity of patients is increasing, and many patients are started on therapy with little hope of rehabilitation, and with a high likelihood of death within a short period of time. Data from large prospective studies are necessary to help patients and doctors to make decisions concerning the initiation and cessation of dialysis. Inadequate dialysis and malnutrition may adversely influence clinical outcome, and cardiovascular disease exerts a large influence on morbidity and mortality. Clinical trials are necessary concerning the effect on clinical outcome of dialysis prescription, interventions to improve malnutrition, hypertension, anemia, hyperparathyroidism, hyperlipoproteinemia, and diabetes mellitus.

[Costs of care in uremia. How much does kidney transplantation cost?]. / Kostnader ved uremikeromsorg. Hva koster nyretransplantasjon?

The cost of kidney transplantation and hemodialysis have been recorded (in 1986). Tissue typing, operation and initial stay in hospital cost NOK 103,000 per patient, and further treatment for the first year after operation NOK 114,000. Subsequent annual costs were NOK 70,000, mainly for drugs. Hemodialysis costs NOK 287,000 per year. Transplantation was cost-effective by almost NOK one million per patient over a five-year period. If the current high national rate of transplantation (42 patients per million), which keeps both the national waiting list (23 patients per million) and the dialysis population at a low level, is sustained over the next five years, then total national expenditures for dialysis and transplantation are predicted to be approx. NOK 400 millions. If no transplants were performed during this period the waiting list would increase to 175 patients per million, and expenditures (for dialysis) to approx. NOK 750 millions. Additional huge investments would be needed in order to expand the facilities for dialysis. Because of high transplant rate, only 18 per cent of all treated uremics in Norway are now on dialysis, versus 73 per cent in Western Europe. Since transplantation is much cheaper than dialysis, national expenditures per treated patient are lower in Norway than in any other country.

Cost-effective care of end-stage renal disease: a billion dollar question.

We examined the survival time and costs of therapy for patients with end-stage renal disease. A computer simulation model of the current system was constructed to estimate the cost-effectiveness of home and center hemodialysis and live related as well as cadaver donor renal transplantation. Analysis of the simulation showed that live related donor transplantation was the least costly and had the greatest survival time, while center hemodialysis had the poorest cost-effectiveness. By simulating changes to the present system of care, we found that shifts from center dialysis to either home dialysis or cadaver donor transplantation would save $7000 to $8000 per life year, or $284 million per year for the existing end-stage renal disease population. However, if legislative changes fail to produce real shifts from center hemodialysis, costs will increase. We conclude that the substantial costs for end-stage renal disease can be contained by shifting from the widespread use of center hemodialysis.