[High prevalence of asymptomatic COVID-19 in haemodialysis: learning day by day in the first month of the COVID-19 pandemic]. / Alta prevalencia de COVID-19 asintomático en hemodiálisis. Aprendiendo día a día el primer mes de pandemia de COVID-19.

Dialysis patients are a risk group for SARS-CoV-2 infection and possibly further complications, but we have little information. The aim of this paper is to describe the experience of the first month of the SARS-CoV-2 pandemic in a hospital haemodialysis (HD) unit serving the district of Madrid with the second highest incidence of COVID-19 (almost 1,000 patients in 100,000h). In the form of a diary, we present the actions undertaken, the incidence of COVID-19 in patients and health staff, some clinical characteristics and the results of screening all the patients in the unit. We started with 90 patients on HD: 37 (41.1%) had COVID-19, of whom 17 (45.9%) were diagnosed through symptoms detected in triage or during the session, and 15 (40.5%) through subsequent screening of those who, until that time, had not undergone SARS-CoV-2 PCR testing. Fever was the most frequent symptom, 50% had lymphopenia and 18.4% <95% O2 saturation. Sixteen (43.2%) patients required hospital admission and 6 (16.2%) died. We found a cluster of infection per shift and also among those using public transport. In terms of staff, of the 44 people involved, 15 (34%) had compatible symptoms, 4 (9%) were confirmed as SARS-CoV-2 PCR cases by occupational health, 9 (20%) required some period of sick leave, temporary disability to work (ILT), and 5 were considered likely cases. CONCLUSIONS: We detected a high prevalence of COVID-19 with a high percentage detected by screening; hence the need for proactive diagnosis to stop the pandemic. Most cases are managed as outpatients, however severe symptoms are also appearing and mortality to date is 16.2%. In terms of staff, 20% have required sick leave in relation to COVID-19.

Bundled Payment Reform and Dialysis Facility Closures in ESKD.

BACKGROUND: In 2011, inclusion of injectable medications into an expanded ESKD payment bundle prompted concerns that dialysis facilities facing higher costs might close, disrupting care delivery and access to care. Whether this policy change influenced dialysis facility closures is unknown. METHODS: To examine whether facility closures increased after 2011 and whether factors influencing closures changed, we analyzed US Renal Data System registry data to identify all patients receiving in-center hemodialysis from 2006 through 2015 and to track dialysis facility closures. We used interrupted time series logistic regression models and estimated marginal effects to examine immediate and longer-term changes in the likelihood of being affected by facility closures following payment reform. We also examined whether associations between selected predictors of closures indicating populations at "high risk" of closure (patient characteristics, facility characteristics, and geography-related characteristics) and closures changed after payment reform. RESULTS: Dialysis facility closures were uncommon over the study period. In adjusted models, the relative odds of experiencing a closure declined by 37% (odds ratio [OR], 0.63; 95% confidence interval [95% CI], 0.59 to 0.67) immediately after payment reform and declined by an additional 6% (OR, 0.94; 95% CI, 0.91 to 0.97) annually thereafter, corresponding to a 0.3% lower absolute probability of closure in 2015 in association with payment reform. Patients who were black and who dialyzed at small, hospital-based facilities experienced slight increases in closures following payment reform, whereas Hispanic and Medicare/Medicaid dual-eligible patients experienced slight decreases in closures. CONCLUSIONS: Expansion of the ESKD payment bundle was not associated with increased closure of dialysis facilities, although the likelihood of closures changed slightly for some higher-risk populations.

Arteriovenous Fistula Use in the United States and Dialysis Facility-Level Comorbidity Burden.

RATIONALE & OBJECTIVE: Patients with multiple comorbid conditions are less likely to use an arteriovenous fistula (AVF) for hemodialysis vascular access. Some dialysis facilities have high rates of AVF placement despite having patients with many comorbid conditions. This study describes variation in facility-level use of AVFs across the facility-level burden of patient comorbid conditions. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Medicare patients receiving hemodialysis for 1 year or more in US dialysis facilities. PREDICTORS: Facility-level burden of patient comorbid conditions; patient characteristics. OUTCOMES: Odds of AVFs versus other access types; facility-level use of AVFs. ANALYTICAL APPROACH: Facility-level comorbidity burden was calculated by summing individual comorbid conditions, determining the average per patient, then defining 11 groups based on facility percentile ranking. Generalized estimating equations with a logit link were used to estimate the odds of AVF placement at the patient level. For the facility-level analysis, a generalized estimating equation model with the identity link was fit to characterize the percentage of AVF use at each facility. RESULTS: Overall, AVF use was 65.8% in 315,919 prevalent hemodialysis patients among 5,813 facilities. After adjustment for patient characteristics, AVF use was 0.27, 0.30, 1.05, and 1.74 percentage points lower than the median among facilities in the 61st to 70th, 71st to 80th, 81st to 90th, and 91st to 99th percentiles of comorbidity, respectively, and 0.42, 0.63, 1.34, and 1.90 percentage points higher than the median among facilities in the 31st to 40th, 21st to 30th, 11th to 20th, and 1st to 10th percentiles of comorbidity, respectively. Facilities in the greater than 99th percentile of comorbidity burden had AVF use that was 3.47 percentage points lower than the median. Facilities in the less than 1st percentile of comorbidity burden had AVF use that was 2.64 percentage points greater than the median. LIMITATIONS: Limited to Medicare dialysis-dependent patients treated for 1 year or more. CONCLUSIONS: After adjustment for patient characteristics, we found small differences in facility rates of AVF use except in the extremes of high or low levels of comorbidity burden. Our study demonstrates that dialysis facilities with a relatively high patient comorbidity burden can achieve similar fistula rates as facilities with healthier patients. Although high comorbidity burden does not explain low facility AVF use, additional study is needed to understand differences in AVF use rates between facilities with similar comorbidity burdens.

Direct costs of integrated procedures of conventional hemodialysis performed by nursing professionals.

OBJECTIVE: to analyze the mean direct cost of the constituent procedures of conventional hemodialysis, performed in three public teaching and research hospitals. METHOD: quantitative, exploratory-descriptive study, of the multiple case study type. The mean direct cost was calculated by multiplying the time (timed) spent by nursing professionals, on the execution of procedures, by the unit cost of direct labor, added to the cost of materials and solutions/medications. RESULTS: the total mean direct cost, in patients with an arteriovenous fistula corresponded to US$25.10 in hospital A, US$37.34 in hospital B and US$25.01 in hospital C, and in patients with a dual lumen catheter, US$32.07 in hospital A, US$40.58 in hospital B and US$30.35 in hospital C. The weighted mean values obtained were US$26.59 for hospital A, US$38.96 for hospital B and US$27.68 for hospital C. It was noted that the "installation and removal of hemodialysis fistula access" caused a significantly lower economic impact compared to "installation and removal of hemodialysis catheter access". CONCLUSION: with the knowledge developed it will be possible to support hospital managers, technical managers and nursing professionals in the decision making process, with a view to the rational allocation of the necessary inputs for the performance of conventional hemodialysis.

Persistent Variation in Medicare Payment Authorization for Home Hemodialysis Treatments.

OBJECTIVE: To analyze variation in medical care use attributable to Medicare's decentralized claims adjudication process as exemplified in home hemodialysis (HHD) therapy. DATA SOURCES/STUDY SETTING: Secondary data analysis using 2009-2012 paid Medicare claims for HHD and in-center hemodialysis (IHD). STUDY DESIGN: We compared variation across Medicare administrative contractors (MACs) in predicted paid treatments per standardized patient-month for HHD and IHD patients. We used ordinary least-squares regression to determine whether higher paid HHD treatment counts expanded HHD programs' presence among dialysis facilities. DATA COLLECTION: We identified HHD and IHD treatments using procedure, revenue center, and claim condition codes on type 72x claims. PRINCIPAL FINDINGS: MACs varied persistently in predicted HHD treatments per patient-month, ranging from 14.3 to 21.9 treatments versus 10.9 to 12.4 IHD treatments. The presence of facilities' HHD programs was uncorrelated with average HHD payment counts. CONCLUSIONS: Medicare's claims adjudication process promotes variation in medical care use, as we observe among HHD patients. MACs' discretionary decision making, while potentially facilitating innovation, may admit inefficiency in care practice as well as inequitable access to health care services. Regulators should weigh the benefits of flexibility in local coverage decisions against those of national standards for medical necessity.

Strategies to increase patient safety in Hemodialysis: Application of the modal analysis system of errors and effects (FEMA system). / Estrategias para aumentar la seguridad del paciente en hemodiálisis: Aplicación del sistema de análisis modal de fallos y efectos (sistema AMFE).

BACKGROUND: Haemodialysis (HD) patients are a high-risk population group. For these patients, an error could have catastrophic consequences. Therefore, systems that ensure the safety of these patients in an environment with high technology and great interaction of the human factor is a requirement. OBJECTIVES: To show a systematic working approach, reproducible in any HD unit, which consists of recording the complications and errors that occurred during the HD session; defining which of those complications could be considered adverse event (AE), and therefore preventable; and carrying out a systematic analysis of them, as well as of underlying real or potential errors, evaluating their severity, frequency and detection; as well as establishing priorities for action (Failure Mode and Effects Analysis system [FMEA systems]). METHODS: Retrospective analysis of the graphs of all HD sessions performed during one month (October 2015) on 97 patients, analysing all recorded complications. The consideration of these complications as AEs was based on a consensus among 13 health professionals and 2 patients. The severity, frequency and detection of each AE was evaluated by the FMEA system. RESULTS: We analysed 1303 HD treatments in 97 patients. A total of 383 complications (1 every 3.4 HD treatments) were recorded. Approximately 87.9% of them was deemed AEs and 23.7% complications related with patients' underlying pathology. There was one AE every 3.8 HD treatments. Hypertension and hypotension were the most frequent AEs (42.7 and 27.5% of all AEs recorded, respectively). Vascular-access related AEs were one every 68.5 HD treatments. A total of 21 errors (1 every 62 HD treatments), mainly related to the HD technique and to the administration of prescribed medication, were registered. The highest risk priority number, according to the FMEA, corresponded to errors related to patient body weight; dysfunction/rupture of the catheter; and needle extravasation. CONCLUSIONS: HD complications are frequent. Consideration of some of them as AEs could improve safety by facilitating the implementation of preventive measures. The application of the FMEA system allows stratifying real and potential errors in dialysis units and acting with the appropriate degree of urgency, developing and implementing the necessary preventive and improvement measures.

Inequalities in transplant waiting list activation across Italian dialysis centers.

BACKGROUND: The demand for kidney transplant exceeds organ supply; therefore, understanding patient-related and contextual factors associated with waiting list activation is key in ensuring that organ allocation is efficient and equitable. We sought to assess whether inequalities in wait-listing probability exist across centers and evaluate correlates of wait-listing in Italy. METHODS: We linked the MigliorDialisi dataset (1,238 patients enrolled in 54 Italian hemodialysis centers) to administrative data concerning the activity of each participating center and contextual information abstracted from the Italian Institute of Statistics. We modeled the odds of waiting list activation for patients on dialysis by the subjects' sociodemographic, biomedical and psychosocial factors along with center-related and contextual factors. RESULTS: The crude enlistment rate was 26% (95% CI 9-54) distributed as follows: 21, 34 and 33% in northern, central, and southern Italy, respectively (p < 0.01). Older patients with poorer health conditions and lower expectations toward transplantation outcomes were less likely to be wait-listed in multilevel multivariable logistic regression. In the fully adjusted model there was not a statistically significant variation in wait-listing across northern, central, and southern regions. However, the variance explained by center-related factors accounted for 12% (p < 0.01) of total variability in enlistment likelihood (20% in patients >65 years, p < 0.01). CONCLUSIONS: Our results showed that inter-center variation exists after adjusting for case mix. Additionally, we identified individual modifiable factors associated with wait-listing inequalities.

Chapter 1 UK RRT incidence in 2010: national and centre-specific analyses.

INTRODUCTION: This chapter describes the characteristics of adult patients starting renal replacement therapy (RRT) in the UK in 2010 and the incidence rates for RRT in Primary Care Trusts and Health Boards (PCT/HBs) in the UK. METHODS: The basic demographics and clinical characteristics are reported on patients starting RRT from all UK renal centres. Presentation time, defined as time between first being seen by a nephrologist and start of RRT, was also studied. Age and gender standardised ratios for incidence rates in PCT/HBs were also calculated. RESULTS: In 2010, the incidence rates in the UK and England were similar to 2009 at 107 per million population (pmp). The incidence rate fell in Scotland (from 104 pmp to 95 pmp), increased in Northern Ireland (from 88 pmp to 101 pmp) and Wales (from 120 pmp to 128 pmp). There were wide variations between PCT/HBs in standardised incidence ratios. The median age of all incident patients was 64.9 years (IQR 51.0, 75.2). For transplant centres this was 63.1 years (IQR 49.7, 74.2) and for non-transplanting centres 66.5 years (IQR 52.9, 76.0). The median age for non-Whites was 57.1 years. Diabetic renal disease remained the single most common cause of renal failure (24%). By 90 days, 68.3% of patients were on haemodialysis, 18.1% on peritoneal dialysis, 7.7% had had a transplant and 5.9% had died or stopped treatment. The mean eGFR at the start of RRT was 8.7 ml/ min/1.73 m(2) which was similar to the previous three years. Late presentation (<90 days) fell from 28.2% in 2005 to 20.6% in 2010. There was no relationship between social deprivation and presentation pattern. CONCLUSIONS: Incidence rates have plateaued in England over the last five years. They have fallen in Scotland and fallen and then risen again in Northern Ireland and Wales. Wales continued to have the highest incidence rate of the countries making up the UK.

Chapter 2 UK RRT prevalence in 2010: national and centre-specific analyses.

INTRODUCTION: This chapter describes the characteristics of adult patients on renal replacement therapy (RRT) in the UK in 2010. METHODS: Data were electronically collected from all 72 renal centres within the UK. Cross-sectional and longitudinal analyses were performed to describe the demographics of prevalent RRT patients in 2010 at centre and national level. Age and gender standardised ratios for prevalence rates per million population per year were calculated. RESULTS: There were 50,965 adult patients receiving RRT in the UK on 31st December 2010. The UK prevalence of RRT (including paediatric patients) was 832 pmp. This represented an annual increase in prevalent numbers of approximately 4% although there was significant variation between centres and regions. From 2009 to 2010 there was a 1.5% increase in the number of patients on haemodialysis (HD), a 3.2% fall in peritoneal dialysis (PD) patients and a 5.4% increase in patients with a functioning transplant. The number of patients receiving home HD has increased 23% since 2009. Median RRT vintage was 5.6 years. The median age was 57.9 years (HD 66.3 years, PD 61.7 years and transplant 51.2 years) compared to 55 years in 2000. Prevalence rates in males exceeded those in females. The most common identifiable renal diagnosis was biopsyproven glomerulonephritis (16.0%), followed by diabetes (14.9%). Transplantation was the most common treatment modality (48%), HD in 44% and PD 8%. CONCLUSIONS: The HD and transplant population continued to expand whilst the PD population contracted. There were national, regional and dialysis centre level variations in prevalence rates. Prevalent patients were on average 4 years older than 10 years ago. This has implications for service planning and ensuring equity of care for RRT patients.

The costs in provision of haemodialysis in a developing country: a multi-centered study.

BACKGROUND: Chronic Kidney Disease is a major public health problem worldwide with enormous cost burdens on health care systems in developing countries. We aimed to provide a detailed analysis of the processes and costs of haemodialysis in Sri Lanka and provide a framework for modeling similar financial audits. METHODS: This prospective study was conducted at haemodialysis units of three public and two private hospitals in Sri Lanka for two months in June and July 2010. Cost of drugs and consumables for the three public hospitals were obtained from the price list issued by the Medical Supplies Division of the Department of Health Services, while for the two private hospitals they were obtained from financial departments of the respective hospitals. Staff wages were obtained from the hospital chief accountant/chief financial officers. The cost of electricity and water per month was calculated directly with the assistance of expert engineers. An apportion was done from the total hospital costs of administration, cleaning services, security, waste disposal and, laundry and sterilization for each unit. RESULTS: The total number of dialysis sessions (hours) at the five hospitals for June and July were 3341 (12959) and 3386 (13301) respectively. Drug and consumables costs accounted for 70.4-84.9% of the total costs, followed by the wages of the nursing staff at each unit (7.8-19.7%). The mean cost of a dialysis session in Sri Lanka was LKR 6,377 (US$ 56). The annual cost of haemodialysis for a patient with chronic renal failure undergoing 2-3 dialysis session of four hours duration per week was LKR 663,208-994,812 (US$ 5,869-8,804). At one hospital where facilities are available for the re-use of dialyzers (although not done during study period) the cost of consumables would have come down from LKR 5,940,705 to LKR 3,368,785 (43% reduction) if the method was adopted, reducing costs of haemodialysis per hour from LKR 1,327 at present to LKR 892 (33% reduction). CONCLUSIONS: This multi-centered study demonstrated that the costs of haemodialysis in a developing country remained significantly lower compared to developed countries. However, it still places a significant burden on the health care sector, whilst possibility of further cost reduction exists.

Impact of non-traditional phosphate binders and cinacalcet on haemodialysis patient biochemistry, pill burden and cost.

AIM: The Australian Pharmaceutical Benefits Scheme (PBS) commenced cost subsidization for haemodialysis patients of sevelamer in December 2007, cinacalcet in July 2008 and lanthanum in May 2009. To determine the impact of PBS listing of these medications, we performed a single centre cross-sectional, longitudinal study. METHODS: Dialysis parameters and biochemistry were prospectively collected at 6 monthly intervals for all prevalent haemodialysis patients from October 2007 to April 2010. Medications prescribed to manage chronic kidney disease mineral and bone disorder were recorded. Univariate regression analysis was undertaken for each variable against time. RESULTS: Patient numbers ranged from 87 to 114 in each period. At baseline, mean age was 68.8 ± 14.3 years, 71% male, 15.1 ± 3.5 haemodialysis hours/week and urea reduction ratio 71.9 ± 9.8%. These variables were unchanged over time. The use of sevelamer, cinacalcet and lanthanum increased (P < 0.001). There was a decrease in the use of aluminium- and calcium-based phosphate binders (P < 0.001) but no change in the use of magnesium based phosphate binders (P = 0.09) or calcitriol (P = 0.11). Serum phosphate (P = 0.13) and parathyroid hormone (PTH) (P = 0.87) were unchanged. Mean 'bone pill' burden fell from 60.3/week to 51.9/week (P = 0.02). Mean pill cost increased from Australian dollars (AUD) 12.85/patient per week to AUD 59.85/patient per week (P < 0.001). CONCLUSION: The PBS subsidization of sevelamer, cinacalcet and lanthanum has changed prescribing patterns, although serum phosphate and PTH remain unchanged. These changes have been at an additional cost of AUD 2444/patient per year. Data to address clinical end-points of mortality and hospitalization is needed to determine if the cost of these newer agents is warranted.

Work climate in Mexican hemodialysis units: a cross-sectional study.

BACKGROUND: The work climate (WC) affects the performance of service providers and has an impact on the care provided to users. This is important in the case of conditions that affect the quality of life, as is the case of chronic kidney disease (CKD) treated with haemodialysis. In Mexico, the demand for the care of CKD cases is increasing and the haemodialysis offer is limited. The purpose of this study was to describe and compare the WC in public, private and social security haemodialysis units in Mexico and to validate a tool to measure WC in haemodialysis units (HU). METHOD: 372 professionals from 84 HU in 27 states were interviewed using a questionnaire. This included questions about the WC, quality of care and structure and organisation of the HU. Variables were compared by type of institution and profession. RESULTS: Significant correlations were observed between the WC and indicators of the quality of care. Nine out of fourteen variables presented important differences by type of unit, with a better perception of WC in private units and a poorer perception in social security ones. CONCLUSIONS: The perception of WC relies on the organisation and planning of the institutions, as well as on their infrastructure. In the case of Social Security HU in Mexico, these appear to be the areas that require improvement in order to encourage a better work climate.

Economic consequences of an increased number of patients on outgoing dialysis.

OBJECTIVE: During the past 10 years the number of prevalent patients on dialysis treatment has doubled in Denmark and the number is expected to increase further. The majority of Danish patients on dialysis receive haemodialysis at a hospital-based centre, and increasing patient numbers will put pressure on these dialysis centres. In order to reduce this pressure, more patients will need to be offered dialysis as outgoing treatment. The aim of this study was to analyse the economic consequences of an increased number of patients on outgoing dialysis in a Danish setting. MATERIAL AND METHODS: A Markov model using Danish cost estimates and clinical parameters from the Danish National Registry was developed and used to simulate changes of dialysis modalities, exits to transplantation or death as well as entry of new incident patients over a period of 10 years. RESULTS: The development in total annual costs over a 10-year period showed that an increased number of patients on outgoing dialysis will lead to total savings of approximately €9.6 million. CONCLUSIONS: The estimated savings of approximately €9.6 million only constitute 0.6% of the total cost of dialysis. In terms of cost over time, therefore, an increased number of patients on outgoing treatment will not lead to an increase in costs; the total cost of treatment will probably be unchanged or slightly reduced. The results were sensitive to inclusion of capital costs and exclusion of costs associated with complications or comorbidity.

Acute hepatitis C virus infection assessment among chronic hemodialysis patients in the Southwest Parana State, Brazil.

BACKGROUND: Chronic hemodialysis patients are at higher risk for acquiring hepatitis C virus (HCV). The prevalence varies among different countries and hemodialysis centers. Although guidelines for a comprehensive infection control program exist, the nosocomial transmission still accounts for the new cases of infection. The aim of this study was analyze the follow up of newly acquired acute hepatitis C cases, during the period from January 2002 to May 2005, in the Hemodialysis Center, located in the Southwest region of Parana State, Brazil and to analyze the effectiveness of the measures to restrain the appearance of new cases of acute hepatitis C. METHODS: Patients were analyzed monthly with anti-HCV tests and ALT measurements. Patients with ALT elevations were monitored for possible acute hepatitis C. RESULTS: During this period, 32 new cases were identified with acute hepatitis C virus infection. Blood screening showed variable ALT levels preceding the anti-HCV seroconversion. HCV RNA viremia by PCR analysis was intermittently and even negative in some cases. Ten out of 32 patients received 1 mcg/kg dose of pegylated interferon alfa-2b treatment for 24 weeks. All dialysis personnel were re-trained to strictly follow the regulations and recommendations regarding infection control, proper methods to clean and disinfect equipment were reviewed and HCV-positive patients were isolated. CONCLUSION: Laboratory tests results showed variable ALT preceding anti-HCV seroconversion and intermittent viremia. The applied recommendations contributed importantly to restrain the appearance of new cases of acute hepatitis C in this center and the last case was diagnosed in May 2004.

Assessment of quality guidelines implementation using a continuous quality improvement programme.

BACKGROUND: Data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) study suggest that the level of implementation of the European Best Practice Guidelines (EBPG) is at best partial. The main aim of this study is to describe the level of implementation of the EBPG in the European Fresenius Medical Care (FME) clinic network. METHODS: Data presented in this investigation were gained through the FME database EuCliD (European Clinical Database). Patient data from 4 countries (Great Britain, France, Italy, Spain) were selected from the EuCliD database. The parameters chosen were haemodialysis adequacy, biocompatibility, anaemia control and serum phosphate control, which are surrogate indicators for quality of care. They were compared, by country, between the first quarter (Q1) 2002 and the fourth quarter (Q4) 2005. RESULTS: During Q1 2002 and Q4 2005, respectively, a total of 7,067 and 9,232 patients were treated in FME clinics located in France, Italy, Spain and the UK. This study confirms variations in haemodialysis practices between countries as already described by the DOPPS study. A large proportion of patients in each country achieved the targets recommended by the EBPG in Q4 2005 and this represented a significant improvement over the results achieved in Q1 2002. CONCLUSIONS: Differences in practices between countries still exist. The FME CQI programme allows some of these differences to be overcome leading to an improvement in the quality of the treatment delivered.

[Census 2004 of the Italian renal and dialysis units. Basilicata - Calabria - Puglia]. / Censimento 2004 dei Centri di Nefrologia e Dialisi Italiani. Basilicata - Calabria - Puglia.

The Italian Society of Nephrology (SIN) sponsored in 2004 a National Census of the Italian renal and dialysis units. This paper presents the main structural, technical, organizational features, as well as the human resources and the activities of three South-East regions of Italy: Basilicata (B), Calabria (C), and Puglia (P). EPIDEMIOLOGY: incidence of dialysis patients was 149 per million population (pmp) in B, 134 pmp in C and 172 pmp in P; prevalence of dialysis patients 729, 694 and 886 pmp, respectively; prevalence of transplanted patients 188 in B, 264 in C and 249 pmp in P; gross mortality rate of dialysis patients was 12.7% (B), 12.2% (C) and 10.8% (P). TYPE OF VASCULAR ACCESS IN PREVALENT DIALYSIS PATIENTS: arteriovenous fistula: 83.9% (B), 87.7% (C) and 86.5% (P); central venous catheter: 14.2% (B), 8.4% (C) and 11.2% (P); vascular graft 1.9% (B), 3.9% (C) and 2.3% (P). STRUCTURAL RESOURCES: nephrological beds 37, 34 and 88 pmp, respectively; dialysis stations 265, 209 and 207 pmp. PERSONNEL RESOURCES: renal physicians 45 (B), 67 (C) and 64(P) pmp; renal nurses 189, 190 and 207 pmp; each nephrologist cares for 16 (B), 10 (C) and 14 (P) dialysis patients, whereas each renal nurse takes care of 3.8 (B), 3.7 (C) and 4.3 (P) dialysis patients. ACTIVITY: hospitalizations 1378, 1834 and 3439 pmp, respectively; renal biopsies 40 (B), 64 (C) and 107 (P) pmp. The main goal of this project was to create a reference for benchmarking studies. Therefore, data from the Puglia region were compared to data from other regions with similar population size (such as Piemonte and Emilia-Romagna). Moreover, a Census may became a useful qualitative tool for renal registries: this report compares data from the Census with data collected by the dialysis and transplantation registry of the Puglia region. Generally speaking, prevalence for Basilicata and Calabria is close to the Italian one, whereas incidence is inferior; things are opposite in Puglia. Furthermore, compared to Basilicata, Calabria and Italy on average, the Puglia region shows a significant higher number of in-patient beds and a lower DRG weight. Compared to Piemonte, Emilia Romagna and Italy on average, all the three South-East regions do not show differences in number/pmp of dialysis centres. More physicians (nephrologists = 80%) are reported to be active in Puglia and Calabria, compared to Piemonte and Emilia Romagna. Nurses in Puglia look after a greater number of dialysis patients than in Calabria and Basilicata. The number of renal biopsies/ pmp is similar to the Italian mean only in Puglia; it is inferior in the other two regions. These data highlight many differences among these three South-East regions, as well as among Piemonte, Emilia Romagna and Puglia. A relevant inequality in health care structures and resources has been found and discussed.

National haemodialysis guidelines: an assessment of compliance from 2001-2003.

AIM: The Caring for Australians with Renal Impairment (CARI) clinical practice guidelines were established in 2000 to provide recommended ranges for parameters associated with anaemia management in patients with chronic kidney disease. This study used data from the Renal Anaemia Management (RAM) database to determine the level of compliance with the CARI Guidelines in Australia since their implementation. METHODS: De-identified data from haemodialysis patients at 15 dialysis centres were obtained from the RAM database provided by Janssen-Cilag Pty Ltd, Australia. Validated data were extracted over 6 months (April-September) in 2001 (n = 2586 patients) and 2003 (n = 3190 patients). The percentage of patients with biochemical and haematological parameters that were within the ranges recommended in the CARI Guidelines was compared from 2001-2003. RESULTS: There was a significant increase in the number of patients with values within the recommended ranges for serum ferritin, phosphate, calcium phosphate product and urea reduction ratio from 2001-2003. There was no change in the proportion of patients with values within the recommended ranges for haemoglobin, transferrin saturation, calcium or parathyroid hormone. There was considerable variation in compliance with recommended ranges between and within individual dialysis centres. Compliance to the target haemoglobin level (> or =110 g/L) ranged from 42-78% of patients at different centres in 2003. CONCLUSION: Although the number of patients with values within those recommended in the CARI guidelines has increased for some parameters, many patients in Australia have clinical parameters outside the ranges recommended in the CARI Guidelines.

Equity of access to dialysis facilities in Wales.

BACKGROUND: Demand for dialysis, particularly, in-centre haemodialysis (HD), is growing, and more units will be needed. Travel time to treatment is consistently a major area of concern for patients. AIM: To analyse access to current dialysis facilities in Wales, and use the data to help plan for new dialysis units. METHODS: We analysed a combination of UK Renal Registry, Welsh population census data, the Welsh Index of Multiple Deprivation 2005 (WIMD), travel time and geographical information systems. RESULTS: Prevalence of HD fell significantly with increasing travel time from units. This was not influenced by the WIMD. Prior to the opening of a new HD unit in Aberystwyth, prevalence in the surrounding area was significantly lower than for Wales as whole, but within 2 years, prevalence had risen to approximate national levels. In Haverfordwest, an area >30 min drive from any current facility, prevalence is consistently and significantly lower than for Wales as a whole, and has not shown the growth seen elsewhere in the country. DISCUSSION: The ability to combine data has enabled modelling of the likely immediate impact of opening a new unit in Haverfordwest, and also provided an estimate of its required capacity. This multidisciplinary approach to demand analysis should help to highlight areas of under-provision, and facilitate the planning of the sites and sizes of new dialysis units in Wales.

[Census 2004 of the Italian Renal and Dialysis Units. Veneto, Friuli Venezia Giulia and Trentino Alto Adige]. / Censimento 2004 dei Centri di Nefrologia e Dialisi Italiani. Veneto - Friuli Venezia Giulia - Trentino Alto Adige.

The Italian Society of Nephrology (SIN) promoted a national survey of the Renal and Dialysis Units using an online questionnaire on some aspects of structural, technological and personnel resources, as well as organisation and activity. The major aim of this initiative was to obtain a reference benchmark on a national and regional basis. In this paper the data of the northestern regions of Italy (Veneto, Friuli-Venezia Giulia and Trentino-Alto Adige) are reported and compared with the recently published results of the northwestern regions (Piedmont, Liguria and Valle d'Aosta). From an epidemiologic point of view, the prevalence of dialysis patients was 534 pmp (per million population) in Veneto, 667 pmp in Friuli VG and 545 in Trentino AA, the prevalence of transplanted patients was 265, 294 and 404 pmp, respectively; the incidence of dialysis patients was 137, 182 and 130 pmp; gross mortality was 12.5, 14.3 and 16.5%; the distribution of vascular accesse in prevalently dialysis patients was: arteriovenous fistulas = 84.5, 70.4 and 80.9%, central venous catheters = 10.6, 20.0 and 10.2%, vascular graft = 4.9, 9.6 and 8.8%. Regarding structural resources, the distribution of hospital bed numbers was 38, 42 and 43 pmp; dialysis places were 137, 181 and 172 pmp. Human resources were given by renal physicians = 28.3, 38.2 and 23.6 pmp and renal nurses = 138, 200 and 172 pmp; each renal physician took care of 19, 17 and 23 dialysis patients and each renal nurse cared for 3.9, 3.3 and 3.2 dialysis patients. Activity data showed 1436, 1328 and 974 pmp hospital admissions, kidney biopsies were 106, 114 and 31 pmp. Overall, the Italian Northeast shows a significantly lower prevalence and incidence of end-stage renal disease patients than the Northwest; on the contrary, the incidence of patients with acute renal failure is significantly higher. In the Italian Northeast a significantly lower number of hospital beds devoted to renal patients is observed, while dialysis places are more frequent. In the Northeast fewer renal physicians are present than in the Northwest, whereas renal nurses are equivalent if related to the number of dialysis patients. Activity indexes, intended as amount of hospital admissions and renal biopsies standardised per population, are less significant in the Northeast. The results of the survey in Veneto, Friuli VG and Trentino AA show some discrepancies in the treatment of chronic kidney disease between the three regions and even more among different areas of Italy. Despite similar health care models, a relevant inequality in health care resources is evident.