Decreasing dialysis catheter rates by creating a multidisciplinary dialysis access program.

INTRODUCTION:: Centers for Medicare and Medicaid Services have determined that chronic dialysis units should have <12% of their patients utilizing central venous catheters for hemodialysis treatments. On the Eastern Shore of Maryland, the central venous catheter rates in the dialysis units averaged >45%. A multidisciplinary program was established with goals of decreasing catheter rates in order to decrease central line-associated bloodstream infections, decrease mortality associated with central line-associated bloodstream infection, decrease hospital days, and provide savings to the healthcare system. METHODS:: We collected the catheter rates within three dialysis centers served over a 5-year period. Using published data surrounding the incidence and related costs of central line-associated bloodstream infection and mortality per catheter day, the number of central line-associated bloodstream infection events, the costs, and the related mortality could be determined prior to and after the initiation of the dialysis access program. RESULTS:: An organized dialysis access program resulted in a 82% decrease in the number of central venous catheter days which lead to a concurrent reduction in central line-associated bloodstream infection and deaths. As a result of creating an access program, central venous catheter rates decreased from an average rate of 45% to 8%. The cost savings related to the program was calculated to be over US$5 million. The decrease in the number of mortalities is estimated to be between 13 and 27 patients. CONCLUSION:: We conclude that a formalized access program decreases catheter rates, central line-associated bloodstream infection, and the resultant hospitalizations, mortality, and costs. Areas with high hemodialysis catheter rates should develop access programs to better serve their patient population.

Intraoperative coil embolization reduces transplant nephrectomy transfusion requirement.

Transplant nephrectomy for failed renal transplants can be challenging. Patients often have numerous comorbidities, and the procedure may be associated with considerable blood loss. This study was performed to determine if intraoperative coil embolization of the transplant renal artery reduces blood loss associated with transplant nephrectomy. Data were collected retrospectively on 13 consecutive transplant nephrectomies performed immediately following coil embolization and compared with the 13 most recently performed consecutive transplant nephrectomies without coil embolization. The groups were compared for operative time, estimated blood loss, and transfusion requirements. Mean age was 45 in both groups. There were no major complications in either group. Operative times were not significantly different, although open operative time was reduced in the embolization group (113 vs 96 minutes). Estimated blood loss was 465 mL versus 198 mL (P = .035); packed red blood cell requirements during the operation and subsequent 48 hours were 1.85 units versus 0.31 units (P = .008) and during the operation and subsequent hospital stay were 2.3 units versus 0.69 units (P = .027) in the nonembolized group and embolized group, respectively. Intraoperative embolization of the transplant renal artery immediately prior to surgery facilitates transplant nephrectomy by significantly reducing intraoperative blood loss and transfusion requirements while slightly reducing open operative time.

Live Donor Renal Transplant With Simultaneous Bilateral Nephrectomy for Autosomal Dominant Polycystic Kidney Disease Is Feasible and Satisfactory at Long-term Follow-up.

BACKGROUND: Timing of bilateral nephrectomy (BN) is controversial in patients with refractory symptoms of autosomal dominant polycystic kidney disease (APKD) in need of a renal transplant. METHODS: Adults who underwent live donor renal transplant (LRT) + simultaneous BN (SBN) from August 2003 to 2013 at a single transplant center (n = 66) were retrospectively compared to a matched group of APKD patients who underwent LRT alone (n = 52). All patients received general health and polycystic kidney symptom surveys. RESULTS: Simultaneous BN increased operative duration, estimated blood loss, transfusions, intravenous fluid, and hospital length of stay. Most common indications for BN were pain, loss of abdominal domain, and early satiety. There were more intraoperative complications for LRT + SBN (6 vs 0, P = 0.03; 2 vascular, 2 splenic, and 1 liver injury; 1 reexploration to adjust graft positioning). There were no differences in Clavien-Dindo grade I or II (39% vs 25%, P = 0.12) or grade III or IV (7.5% vs 5.7%, P = 1.0) complications during the hospital course. There were no surgery-related mortalities. There were no differences in readmission rates (68% vs 48%, P = 0.19) or readmissions requiring procedures (25% vs. 20%, P = 0.51) over 12 months. One hundred percent of LRT + SBN allografts functioned at longer than 1 year for those available for follow-up. Survey response rate was 40% for LRT-alone and 56% for LRT + SBN. One hundred percent of LRT + SBN survey responders were satisfied with their choice of having BN done simultaneously. CONCLUSIONS: Excellent outcomes for graft survival, satisfaction, and morbidity suggest that the combined operative approach be preferred for patients with symptomatic APKD to avoid multiple procedures, dialysis, and costs of staged operations.

Solitary renal allografts from pediatric cadaver donors less than 2 years of age transplanted into adult recipients.

BACKGROUND: Transplantation of solitary pediatric renal allografts from donors 2 years of age or younger into adult recipients is controversial. METHODS: Between 1998 and 2001, 15 solitary renal allografts from pediatric donors 2 years of age or younger were transplanted into adult recipients. Thirty-three en bloc renal allografts transplanted between 1994 and 2001 were used for comparison. En bloc kidneys were considered for separation if they measured greater than or equal to 6 cm in length. Renal function (creatinine clearance [CrCl]) was estimated using the Cockroft-Gault formula. RESULTS: Two-year graft survival for the solitary and en bloc groups were 93% and 77%, respectively (P =0.405). Five grafts were lost because of arterial thrombosis (four en bloc and one solitary). Ureteral complications occurred in three grafts in the en bloc group. One-year postoperative CrCl of the surviving solitary (n=14) and en bloc (n=26) grafts were 51.4+/-26.2 mL/min and 55.1+/-27.5 mL/min (P >0.05), respectively. Donor weight and kidney length were greater in the solitary group (14.3+/-3.5 kg and 6.3+/-0.4 cm, respectively) compared with the en bloc group (10.8+/-2.6 kg and 5.9+/-0.3 cm, respectively) (P =0.001 and P <0.001). CONCLUSIONS: Separation of en bloc pairs into solitary allografts can be considered when the graft measures greater than or equal to 6 cm in length and donor weight is greater than or equal to 14 kg. The transplantation of solitary pediatric kidneys into adult recipients is successful, and the majority of pediatric en bloc allografts can be separated before transplantation.

Reconciliation of the cloud computing model with US federal electronic health record regulations.

Cloud computing refers to subscription-based, fee-for-service utilization of computer hardware and software over the Internet. The model is gaining acceptance for business information technology (IT) applications because it allows capacity and functionality to increase on the fly without major investment in infrastructure, personnel or licensing fees. Large IT investments can be converted to a series of smaller operating expenses. Cloud architectures could potentially be superior to traditional electronic health record (EHR) designs in terms of economy, efficiency and utility. A central issue for EHR developers in the US is that these systems are constrained by federal regulatory legislation and oversight. These laws focus on security and privacy, which are well-recognized challenges for cloud computing systems in general. EHRs built with the cloud computing model can achieve acceptable privacy and security through business associate contracts with cloud providers that specify compliance requirements, performance metrics and liability sharing.

Deceased-donor renal transplantation in the geriatric population demonstrates equal graft survival compared with younger recipients.

BACKGROUND: Renal transplantation (RTx) in the geriatric population (age >65 years) accounts for 14% of all RTx performed nationally in 2007. METHODS: We reviewed 3297 RTx recipients from our database over a 15-year period to evaluate recipient and donor age, date of transplant and graft loss, cause of graft loss, and cold ischemic time in the geriatric population. RESULTS: Since 1991, we have performed 468 living donor RTx (LDRTx) and deceased donor RTx (DDRTx) in patients more than 65 years: 280 (65-69 years), 128 (70-74 years), and 60 (>75 years). Geriatric recipients of DDRTx demonstrated 83.0%, 74.1%, and 64.1% uncensored graft survival at 1, 3, and 5 years, respectively. Interestingly, these rates were similar compared with DDRTx in adults (18-64 years, P=0.49). Geriatric recipients of LDRTx demonstrated 1-year, 3-year, and 5-year graft survival rates of 94.3%, 88.8%, and 72.3%, respectively. Although better than geriatric DDRTx recipients, these results were not equal to the success of adult LDRTx recipients, potentially because of poorer graft survival in LDRTx recipients more than 75 years (P=0.004). Death-censored graft survivals were similar between adult and geriatric recipients of LDRTx (P=0.28). Graft loss secondary to death was twice as great in geriatric versus adult recipients (P<0.01). CONCLUSIONS: DDRTx geriatric recipients of each group showed similar uncensored graft survivals to adult DDRTx recipients. LDRTx had better outcomes than DDRTx in geriatric recipients. Death-censored outcomes were similar between adult and geriatric LDRTx recipients. These data support the equivalent outcomes of RTx in appropriately selected geriatric recipients.

Kidney transplantation as primary therapy for end-stage renal disease: a National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQITM) conference.

BACKGROUND AND OBJECTIVES: Kidney transplantation is the most desired and cost-effective modality of renal replacement therapy for patients with irreversible chronic kidney failure (end-stage renal disease, stage 5 chronic kidney disease). Despite emerging evidence that the best outcomes accrue to patients who receive a transplant early in the course of renal replacement therapy, only 2.5% of incident patients with end-stage renal disease undergo transplantation as their initial modality of treatment, a figure largely unchanged for at least a decade. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The National Kidney Foundation convened a Kidney Disease Outcomes Quality Initiative (KDOQI) conference in Washington, DC, March 19 through 20, 2007, to examine the issue. Fifty-two participants representing transplant centers, dialysis providers, and payers were divided into three work groups to address the impact of early transplantation on the chronic kidney disease paradigm, educational needs of patients and professionals, and finances of renal replacement therapy. RESULTS: Participants explored the benefits of early transplantation on costs and outcomes, identified current barriers (at multiple levels) that impede access to early transplantation, and recommended specific interventions to overcome those barriers. CONCLUSIONS: With implementation of early education, referral to a transplant center coincident with creation of vascular access, timely transplant evaluation, and identification of potential living donors, early transplantation can be an option for substantially more patients with chronic kidney disease.

A decade of experience with renal transplantation in African-Americans.

OBJECTIVE To evaluate the strategies instituted by the authors' center to decrease the time to transplantation and increase the rate of transplantation for African-Americans, consisting of a formal education program concerning the benefits of living organ donation that is oriented to minorities; a laparoscopic living donation program; use of hepatitis C-positive donors in documented positive recipients; and encouraging vaccination for hepatitis B, allowing the use of hepatitis B core Ab-positive donors. SUMMARY BACKGROUND DATA The national shortage of suitable kidney donor organs has disproportional and adverse effects on African-Americans for several reasons. Type II diabetes mellitus and hypertension, major etiologic factors for end-stage renal disease, are more prevalent in African-Americans than in the general population. Once kidney failure has developed, African-Americans are disadvantaged for the following reasons: this patient cohort has longer median waiting times on the renal transplant list; African-Americans have higher rates of acute rejection, which affects long-term allograft survival; and once they are transplanted, the long-term graft survival rates are lower in this population than in other groups. METHODS From March 1990 to November 2001 the authors' center performed 2,167 renal transplants; 944 were in African-Americans (663 primary cadaver renal transplants and 253 primary Living donor renal transplants). The retransplants consisted of 83 cadaver transplants and 17 living donor transplants. Outcome measures of this retrospective analysis included median waiting time, graft and patient survival rates, and the rate of living donation in African-Americans and comparable non-African-Americans. Where applicable, data are compared to United Network for Organ Sharing national statistics. Statistical analysis employed appropriate SPSS applications. RESULTS One- and 5-year patient survival rates for living donor kidneys were 97.1% and 91.3% for non-African-Americans and 96.8% and 90.4% for African-Americans. One- and 5-year graft survival rates were 95.1% and 89.1% for non-African-Americans and 93.1% and 82.9% for African-Americans. One- and 4-year patient survival rates for cadaver donor kidneys were 91.4% and 78.7% for non-African-Americans and 92.4% and 80.2% for African-Americans. One- and 5-year graft survival rates for cadaver kidneys were 84.6% and 73.7% for non-African-Americans and 84.6% and 68.9% for African-Americans. One- and 5-year graft and patient survival rates were identical for recipients of hepatitis C virus-positive and anti-HBc positive donors, with the exception of a trend to late graft loss in the African-American hepatitis C virus group due to higher rates of noncompliance, an effect that disappears with censoring of graft loss from that cause. The cadaveric renal transplant median waiting time for non-African-Americans was 391 days compared to 734 days nationally; the waiting time for African-Americans was 647 days compared to 1,335 days nationally. When looking at all patients, living and cadaver donor, the median waiting times are 220 days for non-African-Americans and 462 days for African-Americans. CONCLUSIONS Programs specifically oriented to improve volunteerism in African-Americans have led to a marked improvement in overall waiting time and in rates of living donation in this patient group. The median waiting times to cadaveric renal transplantation were also significantly shorter in the authors' center, especially for African-American patients, by taking advantage of the higher rates of hepatitis C infection and encouraging hepatitis B vaccination. These policies can markedly improve end-stage renal disease care for African-Americans by halving the overall waiting time while still achieving comparable graft and patient survival rates.