RESUMO
Background: Pulmonary edema is prevalent and may be a common cause of hospital readmissions in hemodialysis patients. We aimed to estimate the national burden of, and identify correlates of, readmissions related to pulmonary edema among hemodialysis patients. Methods: In this retrospective cohort study using national registry data, we identified prevalent US hemodialysis patients (n = 215 251) with index admissions while under Medicare primary coverage in 2011-13. We defined readmissions as admissions occurring within 30 days of the index discharge and pulmonary edema-related readmissions as readmissions with discharge diagnoses of fluid overload, heart failure or pulmonary edema. Multivariable logistic regression models were used to determine odds ratios (ORs) for pulmonary edema-related readmissions by patient and index admission characteristics. Results: About one-quarter (23%) of index hospital admissions were followed by a readmission, with nearly half (44%) of the readmissions being associated with pulmonary edema. The strongest independent correlate of pulmonary edema-related readmission was a pulmonary edema-related index admission [OR = 2.32; 95% confidence interval (CI) 2.22-2.41]. With the exception of dialysis vintage <1 year (OR = 1.18; 95% CI 1.14-1.22), chronic obstructive pulmonary disease (OR = 1.34; 95% CI 1.29-1.38), dialysis non-compliance (OR = 1.53; 95% CI 1.41-1.64) and congestive heart failure (OR = 1.85; 95% CI 1.77-1.93), patient characteristics were not generally associated with higher risk of pulmonary edema-related readmission. Conclusions: Readmissions related to pulmonary edema are common in hemodialysis patients. Interventions aimed at preventing such readmissions could have a substantial impact on readmissions overall, particularly targeted at incident hemodialysis patients with a prior history of heart failure and patients initially admitted for pulmonary edema.
Assuntos
Insuficiência Cardíaca/etiologia , Hospitalização/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Edema Pulmonar/etiologia , Diálise Renal/efeitos adversos , Desequilíbrio Hidroeletrolítico/etiologia , Feminino , Insuficiência Cardíaca/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Edema Pulmonar/patologia , Estudos Retrospectivos , Fatores de Risco , Desequilíbrio Hidroeletrolítico/patologiaRESUMO
BACKGROUND: Both dialysis facilities and hospitals are accountable for 30-day hospital readmissions among U.S. hemodialysis patients. We examined the association of post-hospitalization processes of care at hemodialysis facilities with pulmonary edema-related and other readmissions. METHODS: In a retrospective cohort comprised of electronic medical record (EMR) data linked with national registry data, we identified unique patient index admissions (n = 1056; 2/1/10-7/31/15) that were followed by ≥3 in-center hemodialysis sessions within 10 days, among patients treated at 19 Southeastern dialysis facilities. Indicators of processes of care were defined as present vs. absent in the dialysis facility EMR. Readmissions were defined as admissions within 30 days of the index discharge; pulmonary edema-related vs. other readmissions defined by discharge codes for pulmonary edema, fluid overload, and/or congestive heart failure. Multinomial logistic regression to estimate odds ratios (ORs) for pulmonary edema-related and other vs. no readmissions. RESULTS: Overall, 17.7% of patients were readmitted, and 8.0% had pulmonary edema-related readmissions (44.9% of all readmissions). Documentation of the index admission (OR = 2.03, 95% CI 1.07-3.85), congestive heart failure (OR = 1.87, 95% CI 1.07-3.27), and home medications stopped (OR = 1.81, 95% CI 1.08-3.05) or changed (OR = 1.69, 95% CI 1.06-2.70) in the EMR post-hospitalization were all associated with higher risk of pulmonary edema-related vs. no readmission; lower post-dialysis weight (by ≥0.5 kg) after vs. before hospitalization was associated with 40% lower risk (OR = 0.60, 95% CI 0.37-0.96). CONCLUSIONS: Our results suggest that some interventions performed at the dialysis facility in the post-hospitalization period may be associated with reduced readmission risk, while others may provide a potential existing means of identifying patients at higher risk for readmissions, to whom such interventions could be efficiently targeted.
Assuntos
Unidades Hospitalares de Hemodiálise/tendências , Hospitalização/tendências , Falência Renal Crônica/terapia , Readmissão do Paciente/tendências , Avaliação de Processos em Cuidados de Saúde/tendências , Diálise Renal/tendências , Idoso , Estudos de Coortes , Feminino , Humanos , Falência Renal Crônica/diagnóstico , Masculino , Pessoa de Meia-Idade , Avaliação de Processos em Cuidados de Saúde/métodos , Sistema de Registros , Diálise Renal/métodos , Estudos RetrospectivosRESUMO
Dialysis providers in the United States may soon be held accountable for their patients' 30-day hospital readmissions. However, few studies have evaluated the timing of readmissions, which determines the window in which dialysis providers could act to prevent readmission. We therefore examined the timing of readmissions of hemodialysis patients in the United States and its association with mortality among 285,795 prevalent adult Medicare-primary hemodialysis patients from a national registry. Patients had at least one hospitalization in 2010-2013 (first index) and survived for 30 days or more. Readmission timing was defined as 0-7, 8-14, or 15-30 days after the index discharge. Multivariable Cox proportional hazards models were used to estimate the association between readmission timing (referent no readmission) and mortality, censored at one year. Overall, 23.1% of patients had readmissions within 30 days of the index discharge, of which over one-third (35.9%) were within the first week. Regardless of timing, patients with readmissions had a higher risk of death within one year, compared to those with no readmissions, with hazard ratios of 2.04 (95% confidence interval 2.00-2.09) for being readmitted within 15-30 days; 1.98 (1.93-2.04) for being readmitted within 8-14 days; and 1.76 (1.71-1.80) for being readmitted within 0-7 days. Thus, opportunities for dialysis providers to intervene and prevent early readmission may be limited. Regardless of the timing, readmission appears independently associated with a substantially increased risk of mortality in this population.
Assuntos
Mortalidade Hospitalar , Falência Renal Crônica/mortalidade , Readmissão do Paciente/estatística & dados numéricos , Diálise Renal/efeitos adversos , Feminino , Humanos , Falência Renal Crônica/terapia , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Arteriovenous accesses (AVA) in patients performing hemodialysis (HD) are labeled "permanent" for AV fistulas (AVF) or grafts (AVG) and "temporary" for tunneled central venous catheters (TCVC). Durability and outcomes of permanent vascular accesses based on the sequence in which they were placed or used receives little attention. This study analyzed longitudinal transitions between TCVC-based and AVA-based HD outcomes according to the order of placement. METHODS: All 391 patients initiating chronic HD via a TCVC between 2012 and 2013 at 12 outpatient academic dialysis units were included in this study. Chronological distributions of HD vascular accesses were recorded over a mean (SD) of 2.8 (0.9) years and sequentially grouped into periods for TCVC-delivered and AVA-delivered (AVF or AVG) HD. Primary AVA failure and cumulative access survival were evaluated based on access placement sequence and type, adjusting for age. RESULTS: In total, 92.3% (361/391) of patients underwent 497 AVA placement surgeries. Analyzing the initial 3 surgeries, primary AVF failure rates increased with each successive fistula placement (p = 0.008). Among the 82.9% (324/391) of TCVC patients successfully converted to an AVA, 30.9% returned to a TCVC, followed by a 58.0% conversion rate to another AVA. Annual per-patient vascular access transition rates were 2.02 (0.09) HD periods using a TCVC and 0.54 (0.03) HD periods using an AVA. Comparing the first AVA used with the second, cumulative access survivals were 701.0 (370.0) vs. 426.5 (275.0) days, respectively. Excluding those never converting to an AVF or AVG, 169 (52.2%) subsequently converted from a TCVC to a permanent access and received HD via AVA for ≥80% of treatments. CONCLUSIONS: HD vascular access outcomes differ based on the sequence of placement. In spite of frequent AVA placements, only half of patients effectively achieved a "permanent" vascular access and used an AVA for the majority of HD treatments.
Assuntos
Derivação Arteriovenosa Cirúrgica/estatística & dados numéricos , Cateterismo Venoso Central/estatística & dados numéricos , Cateteres Venosos Centrais/efeitos adversos , Falência Renal Crônica/terapia , Diálise Renal/efeitos adversos , Idoso , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/métodos , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/métodos , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Relative to European Americans, evidence supports that African Americans with end-stage renal disease (ESRD) survive longer on dialysis. Renal-risk variants in the apolipoprotein L1 gene (APOL1), associated with nondiabetic nephropathy and less subclinical atherosclerosis, may contribute to dialysis outcomes. Here, APOL1 renal-risk variants were assessed for association with dialytic survival in 450 diabetic and 275 nondiabetic African American hemodialysis patients from Wake Forest and Emory School of Medicine outpatient facilities. Outcomes were provided by the ESRD Network 6-Southeastern Kidney Council Standardized Information Management System. Dates of death, receipt of a kidney transplant, and loss to follow-up were recorded. Outcomes were censored at the date of transplantation or through 1 July 2015. Multivariable Cox proportional hazards models were computed separately in patients with nondiabetic and diabetic ESRD, adjusting for the covariates age, gender, comorbidities, ancestry, and presence of an arteriovenous fistula or graft at dialysis initiation. In nondiabetic ESRD, patients with 2 (vs. 0/1) APOL1 renal-risk variants had significantly longer dialysis survival (hazard ratio 0.57), a pattern not observed in patients with diabetes-associated ESRD (hazard ratio 1.29). Thus, 2 APOL1 renal-risk variants are associated with longer dialysis survival in African Americans without diabetes, potentially relating to presence of renal-limited disease or less atherosclerosis.
Assuntos
Apolipoproteínas/genética , Negro ou Afro-Americano/genética , Nefropatias Diabéticas/mortalidade , Falência Renal Crônica/mortalidade , Lipoproteínas HDL/genética , Diálise Renal , Idoso , Apolipoproteína L1 , Nefropatias Diabéticas/genética , Nefropatias Diabéticas/terapia , Feminino , Genótipo , Humanos , Falência Renal Crônica/genética , Falência Renal Crônica/terapia , Transplante de Rim , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Análise de Sobrevida , População Branca/genéticaRESUMO
Hypertension is a cardinal feature of end-stage renal disease (ESRD). Hypertensive nephropathy is the primary cause of ESRD for nearly 30% of patients, and the prevalence of hypertension is >85% in new patients with ESRD. In contemporary hemodialysis (HD) patients, mean predialysis systolic blood pressure (SBP) is nearly 150mmHg, and about 70%, 50%, and 40% use ß-blockers, calcium channel blockers, and renin-angiotensin system inhibitors, respectively. Predialysis SBP generally exhibits a U-shaped association with mortality risk. Interdialytic ambulatory SBP is more strongly associated with risk. Hypertension is multifactorial; key causes include persistent hypervolemia and elevated peripheral resistance. With 3 HD sessions per week, blood pressure (BP) climbs during the interdialytic interval, in step with interdialytic weight gain, particularly among elderly patients and those with higher dry weight. Elevated peripheral resistance can be attributed to inappropriate activation of the sympathetic nervous system due to higher plasma norepinephrine concentrations. Multiple randomized clinical trials show that intensive HD reduces BP and the need for oral medications indicated for hypertension. In the first 2 months of the Frequent Hemodialysis Network trial, the short daily schedule reduced predialysis SBP by 7.7mmHg, whereas the nocturnal schedule reduced predialysis SBP by 7.3mmHg, both relative to 3 sessions per week. Improvements were sustained after 12 months. Both schedules reduced antihypertensive medication use relative to 3 sessions per week. In FREEDOM (Following Rehabilitation, Economics, and Everyday-Dialysis Outcome Measurements), a prospective cohort study of short daily HD, the mean number of prescribed antihypertensive agents decreased from 1.7 to 1.0 in 1 year, whereas the percentage of patients not prescribed antihypertensive agents increased from 21% to 47%. Nocturnal HD appears to markedly reduce total peripheral resistance and plasma norepinephrine and restore endothelium-dependent vasodilation. In conclusion, intensive HD reduces BP and the need for antihypertensive medications.
Assuntos
Anti-Hipertensivos/uso terapêutico , Hipertensão/complicações , Hipertensão/tratamento farmacológico , Falência Renal Crônica/complicações , Falência Renal Crônica/terapia , Diálise Renal , Humanos , Hipertensão/epidemiologia , Hipertensão/etiologia , Prevalência , Diálise Renal/métodosRESUMO
The prevalence of cardiovascular disease, including cardiac arrhythmia, coronary artery disease, cardiomyopathy, and valvular heart disease, is higher in hemodialysis (HD) patients than in the US resident population. Cardiovascular disease is the leading cause of death in HD patients and the principal discharge diagnosis accompanying 1 in 4 hospital admissions. Furthermore, the rate of hospital admissions for either heart failure or fluid overload is persistently high despite widespread use of ß-blockers and renin-angiotensin system inhibitors and attempts to manage fluid overload with ultrafiltration. An important predictor of cardiovascular mortality and morbidity in dialysis patients is left ventricular hypertrophy (LVH). LVH is an adaptive response to increased cardiac work, typically caused by combined pressure and volume overload, resulting in cardiomyocyte hypertrophy and increased intercellular matrix. In new dialysis patients, the prevalence of LVH is 75%. Regression of LVH may reduce cardiovascular risk, including the incidence of heart failure, complications after myocardial infarction, and sudden arrhythmic death. Multiple randomized clinical trials show that intensive HD reduces left ventricular mass, a measure of LVH. Short daily and nocturnal schedules in the Frequent Hemodialysis Network trial reduced left ventricular mass by 14 (10%) and 11 (8%) g, respectively, relative to 3 sessions per week. Comparable efficacy was observed in an earlier trial of nocturnal HD. Intensive HD also improves cardiac rhythm. Clinical benefits have been reported only in observational studies. Daily home HD is associated with 17% and 16% lower risks for cardiovascular death and hospitalization, respectively; admissions for cerebrovascular disease, heart failure, and hypertensive disease, which collectively constitute around half of cardiovascular hospitalizations, were less likely with daily home HD. Relative to peritoneal dialysis, daily home HD is likewise associated with lower risk for cardiovascular hospitalization. In conclusion, intensive HD likely reduces left ventricular mass and may lead to lower risks for adverse cardiac events.
Assuntos
Doenças Cardiovasculares/complicações , Hipertrofia Ventricular Esquerda/complicações , Falência Renal Crônica/complicações , Falência Renal Crônica/terapia , Diálise Renal , Doenças Cardiovasculares/epidemiologia , Humanos , Hipertrofia Ventricular Esquerda/fisiopatologia , Diálise Renal/métodosRESUMO
Although intensive hemodialysis (HD) can address important clinical problems, increasing treatment also introduces risks. In this review, we assess risks pertaining to 6 domains: vascular access complications, infection, mortality, loss of residual kidney function, solute balance, and patient and care partner burden. In the Frequent Hemodialysis Network (FHN) trials, short daily and nocturnal schedules increased the incidence of access complications, although the incidence of access loss was not statistically higher. Observational studies indicate that infection-related hospitalization is an ongoing challenge with short daily HD. Excess risk may be catalyzed by poor infection control practices in the home setting in which intensive HD is typically delivered, but with fixed probability of bacterial contamination per cannulation, greater treatment frequency necessarily increases the risk for infectious complications. Buttonhole cannulation may increase the risk for metastatic infections. However, intensive HD in the home setting is associated with lower risk for infection than peritoneal dialysis. Data regarding mortality are equivocal. With extended follow-up of individuals in the FHN trials, short daily HD was associated with lower risk relative to the usual schedule, whereas nocturnal HD was associated with higher risk. In many, but not all, observational studies, short daily HD has been associated with lower risk than both in-center HD and peritoneal dialysis; however, observational studies are subject to unmeasured confounding. Intensive HD can accelerate the loss of residual kidney function in new dialysis patients with substantial urine output and can deplete solutes (eg, phosphorus) to the extent that supplementation is necessary. Finally, intensive HD may increase burden on patients and caregivers, possibly leading to technique failure. Some of these problems might be addressed with careful monitoring, so that relevant interventions (eg, antibiotics, retraining, and respite care) can be delivered. Ultimately, intensive HD is not a panacea for end-stage renal disease. Potential benefits and risks of treatment should be jointly considered.
Assuntos
Falência Renal Crônica/terapia , Diálise Renal/efeitos adversos , Diálise Renal/métodos , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Cateterismo Venoso Central/efeitos adversos , Humanos , Infecções/etiologia , Rim/fisiopatologia , Falência Renal Crônica/mortalidade , Falência Renal Crônica/fisiopatologia , Fatores de RiscoRESUMO
BACKGROUND: The impact of the United States Prospective Payment System (PPS) "bundle payment system" on anemia management within small dialysis organizations (SDOs) was studied to evaluate the financia burden on SDOs. METHODS: Facilities enrolled in the original study on SDOs were grouped into three hemoglobin (Hb) categories by subject-months: > 25% of subjectmonths with Hb < 10 g/dL (sub-10); > 25% of subject-months with Hb > 12 g/dL (super-12); remaining facilities (10 - 12 group). Subjectlevel data aggregated to facility level for Hb concentration, intravenous (IV) epoetin ± (EA) dose per administration, dose titration, and EA administration frequency during the baseline and follow-up periods were described. RESULTS: Baseline demographic characteristics were imbalanced between the sub-10 (n = 7) and super-12 facilities (n = 5). Mean (SD) Hb concentrations were similar for sub-10 (11.1 (3.0) g/dL) and super-12 (11.6 (2.2) g/dL) facilities during the baseline period, but differed during the follow-up period (10.4 (2.7) vs. 11.4 (2.3) g/dL). The median (Q1, Q3) EA IV dose per administration during follow-up was 3,726 (3,467, 3,961) and 5,712 (4,816, 7,324) units in the sub-10 and super-12 facilities, respectively. A small trend toward upward titration was seen. CONCLUSIONS: Results suggest a difference in anemia management between sub-10 and super-12 facilities during the first year of PPS implementation. Future analyses evaluating patterns of reimbursement and shifts in clinical practice guidelines are warranted globally.
Assuntos
Anemia/tratamento farmacológico , Falência Renal Crônica/terapia , Sistema de Pagamento Prospectivo , Diálise Renal , Adulto , Idoso , Anemia/sangue , Eritropoetina/uso terapêutico , Feminino , Hemoglobinas/análise , Humanos , Falência Renal Crônica/sangue , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica , Estudos ProspectivosRESUMO
BACKGROUND: Launched in January 2011, the prospective payment system (PPS) for the US Medicare End-Stage Renal Disease Program bundled payment for services previously reimbursed independently. Small dialysis organizations may be particularly susceptible to the financial implications of the PPS. The ongoing Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS) was designed to describe trends in care and outcomes over the period of PPS implementation. This report details early results between October 2010 and June 2011. STUDY DESIGN: Prospective observational cohort study of patients from a sample of 51 small dialysis organizations. SETTING & PARTICIPANTS: 1,873 adult hemodialysis and peritoneal dialysis patients. OUTCOMES: Secular trends in processes of care, anemia, metabolic bone disease management, and red blood cell transfusions. MEASUREMENTS: Facility-level data are collected quarterly. Patient characteristics were collected at enrollment and scheduled intervals thereafter. Clinical outcomes are collected on an ongoing basis. RESULTS: Over time, no significant changes were observed in patient to staff ratios. There was a temporal trend toward greater use of peritoneal dialysis (from 2.4% to 3.6%; P = 0.09). Use of cinacalcet, phosphate binders, and oral vitamin D increased; intravenous (IV) vitamin D use decreased (P for trend for all <0.001). Parathyroid hormone levels increased (from 273 to 324 pg/dL; P < 0.001). Erythropoiesis-stimulating agent doses decreased (P < 0.001 for IV epoetin alfa and IV darbepoetin alfa), particularly high doses. Mean hemoglobin levels decreased (P < 0.001), the percentage of patients with hemoglobin levels <10 g/dL increased (from 12.7% to 16.8%), and transfusion rates increased (from 14.3 to 19.6/100 person-years; P = 0.1). Changes in anemia management were more pronounced for African American patients. LIMITATIONS: Limited data were available for the prebundle period. Secular trends may be subject to the ecologic fallacy and are not causal in nature. CONCLUSIONS: In the period after PPS implementation, IV vitamin D use decreased, use of oral therapies for metabolic bone disease increased, erythropoiesis-stimulating agent use and hemoglobin levels decreased, and transfusion rates increased numerically.
Assuntos
Instituições de Assistência Ambulatorial/economia , Falência Renal Crônica/economia , Medicare/economia , Sistema de Pagamento Prospectivo/economia , Diálise Renal/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anemia/tratamento farmacológico , Anemia/economia , Conservadores da Densidade Óssea/economia , Conservadores da Densidade Óssea/uso terapêutico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/tratamento farmacológico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/economia , Estudos de Coortes , Transfusão de Eritrócitos/economia , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Hematínicos/economia , Hematínicos/uso terapêutico , Hemodiálise no Domicílio/economia , Humanos , Masculino , Pessoa de Meia-Idade , Diálise Peritoneal/economia , Diálise Peritoneal/tendências , Sistema de Pagamento Prospectivo/tendências , Estudos Prospectivos , Diálise Renal/tendências , Estados Unidos , Adulto JovemRESUMO
Renal cell carcinoma (RCC) is more common in renal transplant and dialysis patients than the general population. However, RCC in transplanted kidneys is rare, and treatment has previously consisted of nephrectomy with a return to dialysis. There has been recent interest in nephron-sparing procedures as a treatment option for RCC in allograft kidneys in an effort to retain allograft function. Four patients with RCC in allograft kidneys were treated with nephrectomy, partial nephrectomy, or radiofrequency ablation. All of the patients are without evidence of recurrence of RCC after treatment. We found nephron-sparing procedures to be reasonable initial options in managing incidental RCCs diagnosed in functioning allografts to maintain an improved quality of life and avoid immediate dialysis compared with radical nephrectomy of a functioning allograft. However, in non-functioning renal allografts, radical nephrectomy may allow for a higher chance of cure without the loss of transplant function. Consequently, radical nephrectomy should be utilized whenever the allograft is non-functioning and the patient's surgical risk is not prohibitive.
Assuntos
Carcinoma de Células Renais/cirurgia , Ablação por Cateter , Falência Renal Crônica/cirurgia , Neoplasias Renais/cirurgia , Transplante de Rim , Nefrectomia , Complicações Pós-Operatórias/cirurgia , Idoso , Carcinoma de Células Renais/etiologia , Feminino , Humanos , Neoplasias Renais/etiologia , Masculino , Pessoa de Meia-Idade , Nefrectomia/métodosRESUMO
Background:Hospital readmissions are common among in-center hemodialysis patients, but little is known about readmissions among peritoneal dialysis (PD) patients. Using national administrative data, we aimed to examine the burden and correlates of hospital readmissions among U.S. PD patients.Methods:Among 10,505 adult U.S. PD patients with an index admission (first admission after 120 days on dialysis) between 31 January 2011 and 30 November 2014, readmissions were defined as new hospital admissions within 30 days of index discharge. Multivariable logistic regression was used to obtain adjusted odds ratios (ORs) for readmission.Results:Overall, 26.8% of index admissions were followed by a readmission. Readmitted patients were more likely to have congestive heart failure (31.0% vs 25.4%; p < 0.001) and peripheral arterial disease (11.6% vs 8.6%; p < 0.001) and had longer index admission length of stay (median = 4 vs 3 days; p < 0.001) than those who were not; age, sex, and race did not differ by readmission status. After adjustment for patient and index admission characteristics, longer length of stay (≥ 4 vs < 4 days, OR = 1.48, 95% confidence interval [CI] 1.35 - 1.62), peripheral arterial disease (OR = 1.31, 95% CI 1.16 - 1.57), congestive heart failure (OR = 1.25, 95% CI 1.13 - 1.39), and ischemic heart disease (OR = 1.12, 95% CI 1.01 - 1.24) were associated with higher likelihood of readmission; index admission due to peritonitis vs other causes was associated with lower likelihood of readmission (OR = 0.80, 95% CI 0.70 - 0.92).Conclusions:Our results suggest that, particularly in the absence of a PD-related cause of hospitalization such as peritonitis, PD patients may be at high risk for readmission and may benefit from closer post-discharge monitoring.
Assuntos
Insuficiência Cardíaca/epidemiologia , Falência Renal Crônica/terapia , Readmissão do Paciente/estatística & dados numéricos , Diálise Peritoneal/efeitos adversos , Peritonite/epidemiologia , Adulto , Idoso , Bases de Dados Factuais , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/terapia , Humanos , Incidência , Falência Renal Crônica/diagnóstico , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Diálise Peritoneal/métodos , Peritonite/etiologia , Peritonite/terapia , Prognóstico , Estudos Retrospectivos , Medição de Risco , Estados UnidosRESUMO
INTRODUCTION: The dose of unfractionated heparin (UFH) administered during hemodialysis (HD) varies widely. This prospective study evaluated the safety and efficacy of UFH dose de-escalation. METHODS: Sixty-six prevalent patients on HD receiving UFH per standard-dose protocol (load dose [LD] 50-75 units/kg, maintenance dose [MD] 500-1000 units/hour) had heparin prescription converted to low-dose protocol (start LD 15 units/kg and MD 500 units/hour; dose adjusted in small increments based on assessments of extracorporeal blood circuit). Coagulation parameters, dialysis adequacy, dialyzer clotting, anemia management, and dialyzer reuse rates were compared based on the heparin protocol. FINDINGS: Mean(SD) UFH dose per HD session, before and after protocol conversion, was 6178(2644) and 2913(1116) units, respectively (P < 0.0001). This corresponded to LD 52.1(16.6) units/kg and MD 615(207) units/hour with standard-dose protocol, and LD 18.3(6.5) units/kg and MD 505(27) units/hour with low-dose protocol (P < 0.0001). Mid and postdialysis aPTT was 55.3(31.2) and 35.1(7.8) seconds before, and 37.3(12.9) and 31.5(5.3) seconds after conversion (P = 0.007 and 0.003, respectively); no significant changes in D-dimer levels occurred. Low-dose UFH was associated with a small increase in URR and spKt/V (73.0 and 1.54) compared with dialysis clearance on standard-dose UFH (71.2 and 1.48, respectively, P = 0.02). Weekly dose of ESA decreased by 2388 units postconversion (P = 0.03), while hemoglobin levels and the weekly dose of intravenous iron did not change (P = 0.16 and 0.78). A small rise in the rate of moderate dialyzer clotting at the end of HD was noted with low-dose UFH (5.7% vs. 7.5%, P = 0.002); the rate of severe dialyzer clotting events did not change (P = 0.91). No change in the dialyzer reuse rate was noted (18.5 vs. 17.0 treatments, P = 0.26). DISCUSSION: Low-dose heparinization did not compromise dialysis adequacy and permitted ESA dose reduction. Our findings suggest that in prevalent patients on HD, UFH dose of 15-20 units/kg loading and 500 units/hour maintenance was medically safe and effective.
Assuntos
Anticoagulantes/uso terapêutico , Heparina/uso terapêutico , Diálise Renal/métodos , Anticoagulantes/farmacologia , Feminino , Heparina/farmacologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
INTRODUCTION: High ultrafiltration (UF) rates can result in intradialytic hypotension and are associated with increased mortality. The effects of a weight-based UF rate limit on intradialytic hypotension and the potential for unwanted fluid weight gain and hospitalizations for volume overload are unknown. METHODS: This retrospective cohort study examined 123 in-center hemodialysis patients at one facility who transitioned to 13 mL/kg/h maximum UF rates. Patients were studied for an 8 week UF rate limit exposure period and compared to the 8-week period immediately prior, during which the cohort served as its own historical control. The primary outcomes were frequency of intradialytic hypotension events and percentage of treatments with a hypotension event. FINDINGS: The delivered UF rate was lower during the exposure compared to the baseline period (mean UF rate 7.90 ± 4.45 mL/kg/h vs. 8.92 ± 5.64 mL/kg/h; P = 0.0005). The risk of intradialytic hypotension was decreased during the exposure compared to baseline period (event rate per treatment 0.0569 vs. 0.0719, OR 0.78 [95% CI 0.62-1.00]; P = 0.0474), as was the risk of having a treatment with a hypotension event (percentage of treatments with event 5.2% vs. 6.8%, OR 0.75 [95% CI 0.58-0.96]; P = 0.0217). Subgroup analyses demonstrated that these findings were attributable to patients with high baseline UF rates. Statistically significant differences in all-cause or volume overload-related hospitalization were not observed during the exposure period. DISCUSSION: A weight-based UF rate limit of 13 mL/kg/h was associated with a decrease in the rate of intradialytic hypotension events among in-center hemodialysis patients.
Assuntos
Hipotensão/fisiopatologia , Diálise Renal/métodos , Ultrafiltração/métodos , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Vascular access infections are of concern to hemodialysis patients and nurses. Best demonstrated practices (BDPs) have not been developed for home hemodialysis (HHD) access use, but there have been generally accepted practices (GAPs) endorsed by dialysis professionals. We developed a survey to gather information about training provided and actual practices of HHD patients using the NxStage System One HHD machine. We used GAP to assess training used by nurses to teach HHD access care and then assess actual practice (adherence) by HHD patients. We also assessed training and adherence where GAPs do not exist. We received a 43% response rate from patients and 76% response from nurses representing 19 randomly selected HHD training centers. We found that nurses were not uniformly instructing HHD patients according to GAP, patients were not performing access cannulation according to GAP, nor were they adherent to their training procedures. Identification of signs and symptoms of infection was commonly trained appropriately, but we observed a reluctance to report some signs and symptoms of infection by patients. Of particular concern, when aggregating all steps surveyed, not a single nurse or patient reported training or performing all steps in accordance with GAP. We also identified practices for which there are no GAPs that require further study and may or may not impact outcomes such as infection. Further research is needed to develop strategies to implement and expand GAP, measure outcomes, and ultimately develop BDP for HHD to improve infectious complications.
Assuntos
Educação em Enfermagem/normas , Fidelidade a Diretrizes , Hemodiálise no Domicílio , Enfermeiras e Enfermeiros , Inquéritos e Questionários , Dispositivos de Acesso Vascular , Educação em Enfermagem/métodos , Feminino , Hemodiálise no Domicílio/educação , Hemodiálise no Domicílio/métodos , Humanos , Controle de Infecções/métodos , Controle de Infecções/normas , MasculinoRESUMO
OBJECTIVE: To determine the clinical experience of using combined-modality [simultaneous hemodialysis (HD) and peritoneal dialysis (PD)] treatment in patients with end-stage renal disease. DESIGN: We reviewed data on 4 patients from our center that were treated with "combined-mode therapy." We then conducted a retrospective survey by sending questionnaires to nephrologists in the US and Canada by mail and by posting the survey on the Internet. Data queried included number of patients on combined modality, solute clearances, albumin levels pre and post combined therapy, reasons for using combined therapy, duration and success of combined therapy, and reimbursement issues. SETTING AND PARTICIPANTS: Ours is a tertiary-care center. Patients that were not doing well on PD alone were put on combined modality of treatment between 1992 and 1998. MAIN OUTCOME MEASURES: Clinical improvement in the indication for which the participant was started on combined modality. RESULTS: In response to the survey, data on 27 patients were collected. These data were combined with data on 4 patients from our unit that had previously been treated with combined HD and PD. Most patients were reported to have more than one clinical reason for changing from PD to combined therapy. The main clinical reason for offering combined treatments was inadequate solute clearance (34%), followed by ultrafiltration problems (16%) and neuropathy (11%). Mean duration of time followed on combined treatment was 8.5 +/- 0.12 months. Most patients tolerated combined treatment well and were reported to show improvement in the clinical reasons for which they needed the combined modality. Dual access and reimbursement issues were not a problem. There was no single method used for calculating total (HD, PD, and residual renal) solute clearance. No universal total solute clearance goal was reported. CONCLUSION: Hemodialysis and PD are not mutually exclusive. They can be used in combination to achieve targeted solute clearances, to improve certain clinical conditions, and to control volume and blood pressure in a subset of patients. Further evaluation is needed to better establish the long-term outcomes of using combined modality. Total solute clearance goals and methods for determining total solute clearance need to be standardized.
Assuntos
Falência Renal Crônica/terapia , Diálise Peritoneal , Diálise Renal , Quimioterapia Combinada , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Satisfação do Paciente , Qualidade de Vida , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de TempoRESUMO
BACKGROUND: Ultrafiltration (UF) failure develops over time in some patients on peritoneal dialysis. The workup of UF failure can be difficult and the 4.25% peritoneal equilibration test (PET) has been suggested to be more useful than the 2.5% PET for the workup of UF failure. It is unknown how a 4.25% PET compares to a 2.5% PET in individual patients. OBJECTIVES: To assess the differences in drain volumes and sodium sieving using a 4.25% PET compared to a 2.5% PET, and to determine whether peritoneal transport rates, in terms of dialysate-to-plasma (D/P) ratios, are comparable between the two. DESIGN: Pilot study with each patient serving as his or her own control. SETTING: Outpatient dialysis facility of Wake Forest University Baptist Medical Center. PATIENTS: 47 patients, all of whom had a 2.5% PET and a 4.25% PET performed within 1 week of each other. OUTCOME MEASURES: Dialysate-to-plasma ratios of urea and creatinine, dialysate total protein, and dialysate glucose compared to time zero (D/D0) at 0, 2, and 4 hours. Four-hour drain volumes and sodium sieving at 2 hours were also measured. RESULTS: There was reproducibility between the 2.5% and 4.25% PET for D/P ratios of urea and creatinine and for dialysate total protein. There were expected differences in drain volume, sodium sieving, and D/D0 glucose between the two methods. CONCLUSIONS: The use of a 4.25% PET may be more useful for the workup of UF failure because of the accentuation of drain volume and sodium sieving, while remaining useful for prescription management.
Assuntos
Transporte Biológico Ativo/fisiologia , Glucose/farmacocinética , Hemofiltração/efeitos adversos , Falência Renal Crônica/fisiopatologia , Falência Renal Crônica/terapia , Peritônio/fisiopatologia , Desequilíbrio Hidroeletrolítico/diagnóstico , Desequilíbrio Hidroeletrolítico/fisiopatologia , Glicemia/análise , Creatinina/sangue , Soluções para Diálise/análise , Humanos , Falência Renal Crônica/sangue , Projetos Piloto , Reprodutibilidade dos Testes , Fatores de Tempo , Falha de Tratamento , Ureia/sangue , Desequilíbrio Hidroeletrolítico/sangueRESUMO
Previous theoretic and clinical studies have shown that continuous flow peritoneal dialysis (CFPD) provides a high dose of small-solute removal; however, the dose of middle-molecule removal with CFPD therapy has not been evaluated. We used a variable-volume, two-compartment model to calculate theoretical steady-state solute kinetic profiles during CFPD, continuous ambulatory peritoneal dialysis (CAPD), and hemodialysis using a high-flux dialyzer (HFHD), for an anuric 70-kg patient and two measures of dose: equivalent renal clearance (EKR) and standard Kt/V (stdKt/V). Dose measures during each therapy were calculated for five solutes: urea, creatinine, vitamin B12, inulin, and beta 2-microglobulin. Fluid (1 L daily) was assumed to accumulate in and to be removed from the extracellular space, and non renal clearance was assumed to be zero for all solutes except beta 2-microglobulin. Calculated doses for CFPD were higher than for CAPD or HFHD when assessed by either EKR or stdKt/V. Dose enhancements for CFPD were highest for small solutes, but were still considerable for middle molecules. We conclude that CFPD achieves higher doses than CAPD or HFHD for both small-solute and middle-molecule removal.
Assuntos
Soluções para Diálise/metabolismo , Rim/metabolismo , Diálise Peritoneal , Anuria/metabolismo , Anuria/terapia , Simulação por Computador , Creatinina/metabolismo , Soluções para Diálise/química , Humanos , Inulina/metabolismo , Modelos Teóricos , Peso Molecular , Diálise Peritoneal Ambulatorial Contínua , Diálise Renal , Ureia/metabolismo , Vitamina B 12/metabolismo , Microglobulina beta-2/metabolismoRESUMO
BACKGROUND AND OBJECTIVES: Elderly patients require tunneled central vein dialysis catheters more often than younger patients. Little is known about the risk of catheter-related bloodstream infection in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This study identified 464 patients on hemodialysis with tunneled central vein dialysis catheters between 2005 and 2007 and excluded patients who accrued <21 catheter-days during this period. Outpatient and inpatient catheter-related bloodstream infection data were collected. A Cox proportional hazards regression analysis adjusting for sex, ancestry, comorbidites, dialysis vintage, dialysis unit, immunosuppression, initial catheter site, and first antimicrobial catheter lock solution was performed for risk of catheter-related bloodstream infection between nonelderly (18-74 years) and elderly (≥ 75 years) patients. RESULTS: In total, 374 nonelderly and 90 elderly patients with mean (SD) ages of 54.8 (12.3) and 81.3 (4.9) years and dialysis vintages of 1.8 (3.3) and 1.5 (2.9) years (P=0.47), respectively, were identified. Mean at-risk catheter-days were 272 (243) in nonelderly and 318 (240) in elderly patients. Between age groups, there were no significant differences in initial catheter site, type of catheter lock solution, or microbiology results. A total of 208 catheter-related bloodstream infection events occurred (190 events in nonelderly and 18 events in elderly patients), with a catheter-related bloodstream infection incidence per 1000 catheter-days of 1.97 (4.6) in nonelderly and 0.55 (1.6) in elderly patients (P<0.001). Relative to nonelderly patients, the hazard ratio for catheter-related bloodstream infection in the elderly was 0.33 (95% confidence interval, 0.20 to 0.55; P<0.001) after multivariate analysis. CONCLUSION: Elderly patients on hemodialysis using tunneled central vein dialysis catheters are at lower risk of catheter-related bloodstream infection than their younger counterparts. For some elderly patients, tunneled central vein dialysis catheters may represent a suitable dialysis access option in the setting of nonmaturing arteriovenous fistulae or poorly functioning synthetic grafts.
Assuntos
Infecções Relacionadas a Cateter/microbiologia , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/instrumentação , Cateteres de Demora/efeitos adversos , Cateteres Venosos Centrais/efeitos adversos , Falência Renal Crônica/terapia , Diálise Renal , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/epidemiologia , Feminino , Humanos , Incidência , Falência Renal Crônica/diagnóstico , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , North Carolina/epidemiologia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: Prophylactic gentamicin 0.1% cream has demonstrated efficacy in preventing both exit-site infection (ESI) and peritonitis attributable to gram-positive and gram-negative organisms; however, the effect of this practice on the gentamicin susceptibility patterns of bacterial pathogens isolated from such infections is unknown. We therefore examined the effect of a change in our prophylactic topical antibiotic exit-site protocol (from mupirocin 2% cream to gentamicin 0.1% cream) on infection rates and susceptibility patterns. METHODS: This retrospective observational cohort study examined two periods of time: before and after the change in exit-site protocol. Each period was 30 months in duration, with a 2-month implementation period between, during which patient data were excluded. Demographic, clinical, and microbiology data were collected for each patient and episode of infection. RESULTS: Overall, 377 patients were evaluated. In the mupirocin period (MUP), 145 infections occurred in 79 patients, and in the gentamicin period, 145 infections occurred in 93 patients. No significant effect was found either in overall episodes of infection (0.53 per year) or in episodes of peritonitis (0.429 vs 0.375 per year), but episodes of ESI increased significantly (0.098 vs 0.153 per year; p = 0.024; odds ratio: 1.55; 95% confidence interval: 1.05 to 2.28). Episodes of Staphylococcus aureus peritonitis increased by 38% (0.018 vs 0.025 per year), and episodes of S. aureus ESI increased significantly by 150% (0.022 vs 0.055 per year; p = 0.03; hazard ratio: 3.00; 95% confidence interval: 1.09 to 8.26). Episodes of pseudomonal peritonitis declined by 68% (0.022 vs 0.007 per year), and episodes of pseudomonal ESI increased by 150% (0.007 vs 0.018 per year). The gentamicin susceptibility for gram-positive isolates demonstrated no significant change; however, the gentamicin susceptibility for Enterobacteriaceae decreased by 12% and for Pseudomonas, by 14%. CONCLUSIONS: The significant increase in episodes of ESI and the decrease in susceptibility for both Enterobacteriaceae and Pseudomonas isolates represent a concerning trend. Centers should examine trends in infection rates and in bacterial susceptibilities to determine the most appropriate agent for ESI prophylaxis.