Longer treatment time and slower ultrafiltration in hemodialysis: associations with reduced mortality in the DOPPS.

Longer treatment time (TT) and slower ultrafiltration rate (UFR) are considered advantageous for hemodialysis (HD) patients. The study included 22,000 HD patients from seven countries in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Logistic regression was used to study predictors of TT > 240 min and UFR > 10 ml/h/kg bodyweight. Cox regression was used for survival analyses. Statistical adjustments were made for patient demographics, comorbidities, dose of dialysis (Kt/V), and body size. Europe and Japan had significantly longer (P < 0.0001) average TT than the US (232 and 244 min vs 211 in DOPPS I; 235 and 240 min vs 221 in DOPPS II). Kt/V increased concomitantly with TT in all three regions with the largest absolute difference observed in Japan. TT > 240 min was independently associated with significantly lower relative risk (RR) of mortality (RR = 0.81; P = 0.0005). Every 30 min longer on HD was associated with a 7% lower RR of mortality (RR = 0.93; P < 0.0001). The RR reduction with longer TT was greatest in Japan. A synergistic interaction occurred between Kt/V and TT (P = 0.007) toward mortality reduction. UFR > 10 ml/h/kg was associated with higher odds of intradialytic hypotension (odds ratio = 1.30; P = 0.045) and a higher risk of mortality (RR = 1.09; P = 0.02). Longer TT and higher Kt/V were independently as well as synergistically associated with lower mortality. Rapid UFR during HD was also associated with higher mortality risk. These results warrant a randomized clinical trial of longer dialysis sessions in thrice-weekly HD.

The dialysis outcomes and practice patterns study (DOPPS): how can we improve the care of hemodialysis patients?

Outcomes among dialysis patients vary considerably internationally and across regions within the United States. The Dialysis Outcomes and Practice Patterns Study (DOPPS) is a large, prospective, observational study of representative samples of hemodialysis patients in France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States. The DOPPS collects a wealth of data regarding the patients' demographic characteristics, medical histories, laboratory values, prescriptions, dialysis unit practices, and outcomes. The study seeks to clarify which dialysis practices contribute to improved mortality rates, hospitalization rates, health related quality of life, and vascular access outcomes, after adjusting for the effects of comorbid disease and demographic variables. Over 18,000 patients have been enrolled to date. This paper describes the initial findings and outlines the plans to expand the trial.

Health care management strategies of long-term dialysis survivors.

This qualitative, exploratory-descriptive study describes self-management strategies of long-term survivors of dialysis. Data were collected via long, semi-structured interviews with 18 individuals, 10 male and 8 female, who had been on dialysis for more than 15 years. Of these, 10 participants were Caucasian, 4 were African-American, and 4 were Hispanic. Respondents ranged in age from 38 to 63 years. Interviews were audio-recorded, and verbatim transcriptions of interviews were analyzed according to a content analytic procedure, with movement from specific to general. Six broad patient self-management strategies were identified: impression management, selective symptom report/management, vigilant oversight of care, self-proposal of treatments, active self-advocacy, and independent adoption of treatments/use of alternative therapies. For the individuals interviewed, self-management was largely constituted as management of the health care system and health care providers who represent it. Although the small sample size and the exploratory-descriptive methodology limit generalizability, valuable insights into techniques for self-management were derived. Such insights pave the way for future research into characteristics that distinguish dialysis patients who have the potential to be effective self-managers. More importantly, understanding of successful self-management by individuals on dialysis lays the groundwork for development of interventions to help other patients develop similar positive self-management strategies.

[Dialysis Outcomes and Practice Patterns Study: data on the use of central venous catheters in chronic hemodialysis]. / Dialysis Outcomes and Practice Patterns Study: données sur l'utilisation des cathéters veineux centraux en hémodialyse chronique.

Central venous catheters are widely used as vascular accesses for chronic haemodialysis. Different factors may lead to catheter use, whether clinical such as emergency dialysis, or related to practices specific to each dialysis unit or country. The Dialysis Outcomes and Practice Patterns Study is an observational study of more than 10,000 representative patients treated by haemodialysis followed over a two-year period in the United States, Japan, and in five European countries (France, Germany, Italy, Spain, United Kingdom). DOPPS data from the United States and Europe about catheters are reported in this paper. Catheter use is less frequent in Europe than in the US, both in incident and prevalent patients, and in patients who have been seen by a nephrologist in the pre-dialysis period. Tunneled and untunneled catheters are each associated with a significantly higher frequency of access infection compared to native arteriovenous fistulae and grafts. Patients with important comorbidities such as diabetes, cardiovascular diseases, malnutrition or dementia are more likely to be dialysed with tunneled catheters. Furthermore, patients initiating hemodialysis with a tunneled catheter display higher mortality risk compared to patients starting hemodialysis with a permanent access. In summary, DOPPS data indicate that central venous catheters are used for chronic haemodialysis in patients with a high level of morbidity, and that their utilisation is associated to an additional risk, particularly of infection, and to a lower survival for tunneled catheters. Appropriate care should limit the utilisation of central venous catheters to clinically undisputable indications.

Development of subscales from the symptoms/problems and effects of kidney disease scales of the kidney disease quality of life instrument.

BACKGROUND: The Kidney Disease Quality of Life Instrument (KDQOL) was developed to provide clinicians with a comprehensive assessment of the important domains of health-related quality of life (HRQOL) for patients with end-stage renal disease who are undergoing hemodialysis. OBJECTIVE: The purpose of this study was to develop subscales from the 55 items comprising the Symptoms/Problems and Effects of Kidney Disease scales of the KDQOL and to measure the internal consistency reliability of these subscales. METHODS: The 55 items from the Symptoms/Problems and Effects of Kidney Disease scales were arranged into substantively meaningful clusters using an affinity mapping procedure. The resulting subscales were assessed for internal consistency reliability using data from a sample of 165 individuals with kidney disease who had completed the KDQOL. RESULTS: Eleven multi-item subscales were identified: pain, psychological dependency, cognitive functioning, social functioning, dialysis-related symptoms, cardiopulmonary symptoms, sleep, energy, cramps, diet, and appetite. Four items (clotting or other problems with access site, high blood pressure, numbness in hands or feet, and blurred vision) were not included in any of these subscales. Internal consistency reliability estimates for the 11 subscales ranged from 0.66 to 0.92. These subscales correlated with the scales from the 36-Item Short-Form Health Survey as hypothesized (ie, corresponding pain, energy, and social functioning scales had the highest correlations). In addition, several subscales were significantly associated, as hypothesized, with other variables such as the number of disability days. CONCLUSIONS: The results of this study further support the reliability and validity of the KDQOL. The 11 subscales identified yield more detailed information on the HRQOL of patients with kidney disease and provide a basis for specific improvements in the quality of care delivered to these patients.

Development of the kidney disease quality of life (KDQOL) instrument.

This paper describes the Kidney Disease Quality of Life (KDQOL) Instrument (dialysis version), a self-report measure that includes a 36-item health survey as the generic core, supplemented with multi-item scales targeted at particular concerns of individuals with kidney disease and on dialysis (symptom/problems, effects of kidney disease on daily life, burden of kidney disease, cognitive function, work status, sexual function, quality of social interaction, sleep). Also included were multi-item measures of social support, dialysis staff encouragement and patient satisfaction, and a single-item overall rating of health. The KDQOL was administered to 165 individuals with kidney disease (52% female; 48% male; 47% White; 27% African-American; 11% Hispanic; 8% Asian; 4% Native American; and 3% other ethnicities), sampled from nine different outpatient dialysis centres located in Southern California, the Northwest, and the Midwest. The average age of the sample was 53 years (range from 22 to 87), and 10% were 75 years or older. Internal consistency reliability estimates for the 19 multi-item scales exceeded 0.75 for every measure except one. The mean scores for individuals in this sample on the 36-item health scales were lower than the general population by one-quarter (emotional well-being) to a full standard deviation (physical function, role limitations due to physical health, general health), but similar to scores for dialysis patients in other studies. Correlations of the KDQOL scales with number of hospital days in the last 6 months were statistically significant (p < 0.05) for 14 of the 19 scales and number of medications currently being taken for nine of the scales. Results of this study provide support for the reliability and validity of the KDQOL.