Dialysate bicarbonate variation in maintenance hemodiafiltration patients: Impact on serum bicarbonate, intradialytic hypotension and interdialytic weight gain.

INTRODUCTION: The dialysate bicarbonate (DB) influences the acid-base balance in dialysis patients. Very low and high serum bicarbonate (SB) have been related with a higher mortality. Acid-base balance also has been associated with hemodynamic effects in these patients. The trial aim was to compare the effect of DB concentration variation on SB levels in maintenance hemodiafiltration (HDF) patients and the effect on intradialytic hypotension and interdialytic weight gain. METHODS: A prospective study, with 9 months of follow-up, involving 93 patients, divided in two groups: group 1 and group 2 with a DB of 34 mmol/L and 30 mmol/L, respectively, with monitoring of pre and post HDF SB, intradialytic hypotension, and interdialytic weight gain. FINDINGS: Pre dialysis SB was higher in group 1: median concentration of 22.7 mmol/L vs. 21.1 mmol/L (P < 0.001). Post dialysis SB levels were higher in group 1: median concentration of 28.0 mmol/L vs. 25.3 mmol/L (P < 0.001). Post dialysis SB in alkalotic range was only detected in group 1 (51.2% of the patients). No significant differences were detected in intradialytic hypotension rate [28.0 vs. 27.4 episodes per 1000 sessions in group 1 and 2, respectively, (P = 0.906)] or in average interdialytic weight gain [2.9% vs. 3.0% in group 1 and 2, respectively, (P = 0.710)]. DISCUSSION: DB of 30 mmol/L appears to be associated with SB levels closer to physiological levels than 34 mmol/L. The bicarbonate dialysate, in the tested concentrations, did not appear to have a significant impact on intradialytic hypotension and interdialytic weight gain in maintenance HDF patients.

Implementation of a quality and safety checklist for haemodialysis sessions.

BACKGROUND: Patient survival and quality of life depend on each haemodialysis session being performed without fault. Monthly assessments of dialysis dose adequacy often fall short of this. This study reports the results of a feasibility study for the achievement of improved safety and quality in a haemodialysis session with the implementation of a 15-point checklist. METHODS: Fifteen quality indicators were compiled and tested in a Portuguese dialysis clinic from 1 February 2012 to 30 June 2013. The checklist was completed by the nursing staff and comprised three parts: Pre-session Safety Checks; Session Initiation Checks and Post-session Quality Checks. The maximum score that could be reached per session was 15. RESULTS: One hundred and twenty-eight patients were distributed over 2-3 shifts. Of the 16 nurses employed, 4 were full time. The final average score was between 14 and 15. No nurse-specific and no shift-specific significant differences were detected. Four issues were identified that had a major effect on the results as a whole: delays in connection time; incompletely delivered treatment time; non-achievement of final body weight and failure to reach a Kt/V of at least 1.4. Improvements were most consistent in the Monday-Wednesday-Friday morning shifts compared with other shifts, and were temporarily compromised by the opening of a new shift. CONCLUSIONS: The implementation of checklists for haemodialysis is feasible in routine clinical practice, even in clinics where only part of the staff is employed full time. The application of such checklists enhances the overall quality and safety of the delivered treatment.