Care Of Hemodialysis Patients Research Articles

Epidemiology of hemodialysis vascular access in the United States

Reemergence of the importance of vascular access in the care of the chronic hemodialysis patient has gained prominence due to renewed interest in clinical outcomes and evidence-based interventions. Further fueled by anticipated regulatory changes in the reimbursement for dialysis care in the United States by 2011 and beyond, the drive to improve quality of care for hemodialysis patients has identified vascular access issues as a key contributor to outcomes. Focus has shifted from simply providing any hemodialysis vascular access to a strong preference for the use of native arteriovenous fistulas and subsequently to a need for reducing exposure to central venous catheters. Combined, these goals have forced a reevaluation of the role of arteriovenous grafts. The context and events associated with the evolution of thinking on these issues as well as available data supporting them are discussed. The key leadership role of nephrologists is emphasized along with a summary of problems and proposed solutions.

PCT recertification—Pathway for professional growth

How do we define “professionalism” in our workplace? Ask this question and you will receive a number of meanings based on the individual’s experiences in the workplace. Professionalism in practice has been described as committing to teamwork, adhering to ethical principles and practices, demonstrating sensitivity to diverse patient populations and end-oflife care, and taking personal responsibility for professional growth and development to enhance patient care. When Centers for Medicare & Medicaid Services (CMS) released a final rule for Medicare conditions for coverage (CfC) in 2008, certification of hemodialysis patient care technicians (PCTs) was mandated. Certification could be obtained by passing a CMSapproved exam and is required in order for a PCT to provide direct patient care in a hemodialysis clinic.1 Beyond the

The Subjective Sleep Quality and Heart Rate Variability in Hemodialysis Patients

Introduction: Sleep disturbances and cardiovascular autonomic dysfunction are major complications of hemodialysis (HD). The goal of this study is to identify clinical, heart rate variability (HRV) or laboratory parameters that are independently associated with subjective sleep quality. Patient and methods: Forty-six stable HD patients filled out sleep questionnaires – Pittsburgh sleep quality index (PSQI), Athens insomnia scale (AIS), and Epworth sleepiness scale (ESS). In addition, they received analyses of 5-minute HRV twice, in lying posture before and after HD. We also recruited 50 healthy subjects who received 5-min HRV. Results: The patients with end-stage renal disease have a high rate of poor sleep quality according to PSQI, AIS, and ESS. The activities of total power (0–0.5 Hz), high-frequency power (HF, 0.15–0.40 Hz), low-frequency power (0.04–0.15 Hz), and very-low-frequency power (0.003–0.04 Hz) in HD patients are obviously lower than that in the healthy people. The poor sleepers (PSQI > 5) show lower heart rate, higher HF and variance before HD, but did not show a significant difference after HD. There is no significant difference between HRV and global score of AIS, but the insomnia group (AIS > 5) has higher BMI. These patients with sleepiness (ESS > 9) only reveal lower hemoglobin, although the global score of ESS reveals no significant relationship with HRV. Conclusion: HD patients have a high rate of poor sleep quality and autonomic dysfunction. Greater attention for the evaluation of sleep quality is needed for the better care of HD patients.

A study of the decision-making processes for the medical care of chronic hemodialysis patients

目的：慢性透析患者（以下，透析患者）の医療・療養における意思決定希求度・情報希求度の現状と，医療・療養における意思決定場面においての医療者の関わりを透析患者がどう感じているかを明らかにすることで，透析患者の意思決定を支援する医療者の役割についての示唆を得る．方法：S病院・Sクリニック外来に通院中の透析患者で，研究の同意が得られた63名を対象とし自記式質問紙調査を行った．意思決定希求度・情報希求度の測定はEndeらが開発したAutonomy Preference Index（以下，API尺度）をOhkiらが邦訳版に作成したものを使用した．また，意思決定場面における医療者の関わりについては研究者がCharlesらの提唱するThe Shared Treatment Decision-Making Modelをもとに独自に作成した質問項目（以下，SDM質問項目）を用いた．なお，本研究は医療法人衆和会桜町病院倫理委員会の承認を得て実施した．結果と考察：1．API尺度により透析患者は医療における意思決定場面において，医師に決定を委ねたいと思う傾向にあることが明らかになった．2．透析患者の意思決定希求度は年齢・職業の有無により有意差が生じることが明らかになった．3．SDM質問項目により，医療者から十分な情報の提供と不安や悩みの傾聴が行われた透析患者は医療者との信頼関係の構築ができ，透析患者の納得のいく意思決定が行われることが推察された．結論：意思決定場面において医療者が慢性透析患者の不安や悩みを十分に傾聴し共感することが，医療者と透析患者との信頼関係を形成する上で不可欠であるということ，また，透析患者が決定において独断と偏見の中で誤った決定を下したり後悔の念を抱いたりすることを防ぐために必要であることが示唆された．

Percutaneous treatment of thrombosed arteriovenous fistulas: clinical and economic implications.

Maintenance of previously thrombosed arteriovenous fistulas (AVFs) as functional vascular accesses can be highly expensive, with relevant financial implications for healthcare systems. The aim of our study was to evaluate the costs and health outcomes of vascular access care in hemodialysis patients with AVF thrombosis. A retrospective, controlled cohort study was performed among local hemodialysis patients with completely thrombosed AVFs between August 1, 2007, and July 1, 2008. Detailed clinical and demographic information was collected and a comprehensive measure of total vascular access costs was obtained. Costs are reported in 2009 U.S. dollars. A total of 63 consecutive hemodialysis patients with thrombosed AVFs were identified--a cohort of 37 patients treated with percutaneous thrombectomy and a historic cohort of 25 patients with abandoned thrombosed AVFs. The mean cost of all vascular access care at 6 months was $2479. Salvage of thrombosed AVFs led to a near two-fold reduction in access-related expenses, per patient-month at risk ($375 versus $706; P = 0.048). The costs for access-related hospitalizations ($393 versus $91; P = 0.050), management of access dysfunction ($106 versus $28; P = 0.005), and surgical interventions ($35 versus $6; P = 0.001) were also significantly lower in the percutaneous treatment group. At 6 months, most of these patients had a functional AVF as permanent vascular access (91% versus 33%, P = 0.0001). Salvage of thrombosed AVF is a highly efficient procedure; therefore, intensive efforts should be undertaken to universalize these interventions.

Hemodialysis Vascular Access Ultrasonography: Tips, Tricks, Pitfalls and a Quiz

Duplex ultrasonography (DU) is a useful tool to optimize vascular access care in hemodialysis patients. However, the professional training of most healthcare workers caring for dialysis patients does not routinely include the teaching of DU (in this setting), thus limiting its use. The aim of this article is to provide some practical tips, tricks and potential pitfalls of this technique, both to the trainee ultrasonographer and to the healthcare worker already applying this technique in practice. The topics covered are 1) basic ultrasound principles (physics, machines and transducers), 2) the modes needed in vascular access DU in combination with the respective ways to optimize image quality, and 3) the assessment of access flow, stenosis and access induced ischemia by ultrasonography. This is done in the format of a quiz with 12 questions and answers.

Nephrology literature watch

Nephrology literature watch

Gain de vie potentiel pour les patients hémodialysés français attribuable aux modifications des pratiques et la mise en conformité avec les cibles recommandées : une estimation permise par l’étude DOPPS

In this study, we used a prevalent cross-sectional sample of French hemodialysis patients from Dialysis Outcomes and Practice Patterns Study (DOPPS) 2 (2002-2004) to determine the percentage of patients whose values failed to meet targets in six different areas of hemodialysis practice (dialysis dose, anemia, serum phosphorus (PO(4)), serum calcium (Ca), serum albumin and catheter use for vascular access). Cox survival models, with adjustments for patient characteristics, were used for these analyses to estimate mortality hazard ratios (HR). Based on the mortality HR, the fraction of patients outside each target and the total HD population in France, we estimated the number of patient life years that could potentially be gained if every chronic, in-center hemodialysis patient in France who is currently outside of the specified target was able to achieve it. The proportion of patients failing to meet one of the six practice targets in France varied from 15% (dialysis dose) to 75% (albumin) while the percentage of patients complying with all six targets was restricted to 1.2%. The relative risk of mortality (RR) associated with being outside these targets varied from 1.12 to 1.46. Based on these two measures the life-years survival was estimated. The projected number of patients and life years potentially gained from adherence to the six targets was estimated close to 10,600 years-patient. In conclusion, this study suggests large opportunities to improve hemodialysis patient care in France still exist. Compliance with two major practice targets, such as albumin and restriction of catheter use will save highly significant life years of hemodialysis patient. Implementing and strict adherence to national and international guidelines should serve as a basic inspiration for continual improvement of hemodialysis patient care.

Personality types and coping style in hemodialysis patients

The aim of this study was to obtain information that would enable caregivers to provide the necessary psychological care for hemodialysis patients. A total of 608 hemodialysis patients completed the questionnaire of the Neuroticism, Extroversion, Openness-Five Factor Inventory and were subsequently classified by personality types using cluster analysis. In comparison to the norms for the general Japanese adult population, the four-dimensional average of extroversion, openness, agreeableness, and conscientiousness among hemodialysis patients was significantly lower (P < 0.001), especially for openness. The openness score correlated with each of the following: age (P < 0.001), employment (P < 0.01), and diabetes (P < 0.001). Four personality types were defined based on these dimensions. High scores for agreeableness, extroversion and conscientiousness characterized the agreeable type (22.6%). The patients in this type will likely accept their own experiences in a positive manner. Submissive types (22.0%) received the lowest scores for conscientiousness, though extroversion, openness, and agreeableness were also low. It is necessary to enhance a sense of independence and responsibility in patients with submissive type personalities. Sensitive types (21.5%) were characterized by the highest neuroticism scores and low scores for the other four dimensions. The patients in this type were likely to be persistent with changes in conditions. The last type was the balanced type (33.9%), which was defined by scores within mean range. In clinical practice, it is particularly important that the submissive and sensitive types should receive appropriate mental health care.

DOPPS ESTIMATE OF PATIENT LIFE YEARS ATTRIBUTABLE TO MODIFIABLE HAEMODIALYSIS PRACTICES IN BELGIUM

Background: Various organizations have published clinical practice guidelines for the care of haemodialysis patients. However, it is unknown to what extent improving or even reaching perfect compliance with guidelines would improve the survival of HD patients in Belgium.Methods: Using data from the second phase of the Dialysis Outcomes and Practice Patterns Study (DOPPS), the proportion of haemodialysis patients failing to meet six key practice targets (Kt/V ≥1,2, haemoglobin ≥11 g/dl, phosphate 1,1-1,5 mmol/l, calcium 2,1-2, 4 mmol/l, albumin ≥40 g/l, and facility catheter use ≤10 %) was calculated along with the relative risk of mortality associated with being outside these targets. The life years potentially gained from adherence to the six targets, both separately and all six together were then estimated.Results: The percentage of patients outside the targets were as follows: 30,3%, Kt/V; 33,6%, haemoglobin; 56,2%, phosphate; 58,2%, calcium; 67,1%, albumin; and 91,1%, catheter. Estimated patient life years gained with improved compliance with guidelines was highest for albumin (3.670) and catheter use (2.331) but still substantial for the other four targets (ranging from 551 to 1.258). The total of patient years gained if 100% of patients have all six practices brought within target reaches 7.516 years. A conservative estimate of 50% of patients within all targets still yields an improvement of survival of 3.958 patient years.Conclusion: This analysis suggests large opportunities to improve HD patient care in Belgium. The avoidance of HD catheters, with the use of AV fistulas whenever possible, should be given a high priority. Admittedly, these calculations assume causality or partial causality that has not been definitively proven. Still, if causality is only partial, the results emphasize that the improvement of patient care through adherence to targets of clinical guidelines might be substantial and all Belgian nephrologists and staff members of dialysis units should carefully pursue every potential effort.

Hemodialysis Complications

Hemodialysis Complications

Improving Quality of Vascular Access Care for Hemodialysis Patients

Because quality of care for patients with end-stage renal disease (ESRD) has improved, they require long-term vascular access for hemodialysis. Construction of a native vein arteriovenous fistula (AVF) on the arm is considered best practice; a prosthetic graft (PG) AVF on the arm is a good alternative, although insertion of a central venous catheter (CVC), the third choice, is sometimes necessary. A quality improvement project was initiated at the dialysis unit of Rijnland Hospital (The Netherlands) to improve quality of vascular access care. Seventy-four patients were treated from January 2001 through June 2002. The list of preferred access operations was adapted from evidence-based guidelines. The percentages of CVCs and PGs were chosen as quality indicators. Twelve of 19 patients (34%) appeared to be using CVCs unnecessarily. Actions were taken, and the CVC indicator decreased by 11%. The PG indicator decreased gradually from 24% to 8%. Reductions in the use of CVCs and PGs suggest that the vascular access improvement project resulted in improvement of long-term vascular access for hemodialysis patients. A considerable decrease in the use of PGs and CVCs was achieved in 2001. However, a decrease of CVCs to < 20% has still not been realized, perhaps because new hemodialysis patients referred to the dialysis unit have already had CVCs inserted. Considerable improvement, as reflected in the number of hemodialysis patients with CVCs or PGs, can be achieved with a minimum of costs.

Factors associated with medication-related problems in ambulatory hemodialysis patients

Background: Hemodialysis (HD) patients are at risk for medication-related problems. Patient characteristics associated with the number of medication-related problems in HD patients have not been investigated. Methods: Patient records were reviewed to identify medical problems, prescribed medications, medication indication(s), and medication-related problems. Medication classes and medication-related problems were compared between patients with and without diabetes mellitus (DM). Correlations were performed to determine whether associations exist between medication-related problems, number of medications, number of medication doses per day, number of comorbid conditions, patient age, and duration of end-stage renal disease while controlling for DM status. Results: Medical records of 133 patients were evaluated. Patients were 60.5 ± 15.2 years old, prescribed 11.0 ± 4.2 medications, and had 6.0 ± 2.3 comorbidities. Medication-related problems were identified in 97.7% of patients. Four hundred seventy-five medication-related problems were identified, averaging 3.6 ± 1.8 medication-related problems per patient. Patients with DM had more medication-related problems identified than those without DM (303 versus 172 medication-related problems, respectively; P < 0.05). Medication-related problems correlated positively with number of patient comorbidities (P < 0.001). Conclusion: Medication-related problems are prevalent in virtually all HD patients. The number of medication-related problems in an individual patient increases as the number of comorbid conditions increases. The most frequent medication-related problems were drug without indication (30.9%), laboratory (27.6%), indication without drug use (17.5%), and dosing errors (15.4%). Patients with DM are at increased risk for medication-related problems. Health care providers taking care of HD patients should be aware of this problem, and efforts to avoid or resolve medication-related problems should be undertaken at all HD clinics. Am J Kidney Dis 41:386-393.

The provision and outcomes of diabetic care of hemodialysis patients

Background: Approximately 40% of hemodialysis patients have diabetes, yet little is known about their diabetic care. We sought to examine the provision and outcomes of diabetic care of hemodialysis patients. Methods: We randomly selected 188 hemodialysis patients with diabetes from nine facilities and identified the physicians providing their diabetic care. Patients and physicians reported on the care provided for six domains (diet, diabetes medications, hypertension, cholesterol, feet, and eyes). Chart abstraction was used to determine four outcomes (glucose control, blood pressure, albumin level, and cholesterol level). Results: Most patients had a nephrologist, primary care physician, eye specialist, and podiatrist. Each domain of care generally was addressed on a regular basis. Nephrologists and primary care physicians differed on who should provide care for specific domains. For example, only 12% of nephrologists believed primary care physicians should manage hypertension, whereas 74% of primary care physicians believed they should manage hypertension (P < 0.001). Patient outcomes often were suboptimal, with one fourth to one half of patients having elevated glucose, blood pressure, or lipid levels. Many patients were not administered insulin, appropriate antihypertensives, or lipid-lowering medications. Primary care physicians felt frustrated by a lack of communication from nephrologists about laboratory results, medication changes, and procedures. Conclusion: Although hemodialysis patients with diabetes appear to receive timely care from a variety of physicians, patient outcomes often are poor. Medication use is suboptimal, nephrologists and primary care physicians disagree on their roles, and communication among physicians is limited. Interventions to improve outcomes of hemodialysis patients with diabetes should address these impediments. Am J Kidney Dis 41:125-131. © 2003 by the National Kidney Foundation, Inc.

The emergency department care of hemodialysis patients.

To describe the emergency department (ED) presentation, evaluation and disposition of maintenance hemodialysis (HD) patients. A retrospective review of adult HD patients seen 1/1-12/31/97. The following was collected: demographics, mode of arrival, chief complaint, etiology of renal failure, evaluation, treatment, disposition, length of stay and facility charges. During the study period, this tertiary care ED had an annual adult census of 45,000. No clinical pathways were in place. 143 patients made 355 visits: 351 charts were available. Mean patient age was 51 (range 20-86), 62% were male, 51% were white. 70% presented from home, 26% from dialysis. EMS transported 32%. Medicare insured 78%. Etiologies of renal failure included hypertension (33%), diabetes (27%), HIV (7%) and glomerulonephritis (8%). Complaints were related to infection (18%), dyspnea (17%), vascular access (16%). chest pain or dysrhythmia (15%) and gastrointestinal complaints (12%). ED evaluation included CBC (79%), electrolytes (75%), CXR (57%) and EKG (48%). Antibiotics were administered to 21%. HD was performed earlier than scheduled in 14%. Two hundred and eighteen patients (62%) were admitted (ICU 11%, telemetry 22%), 19 (5%) refused admission and 2 expired in the ED. The average hospital length of stay was 7.8 days (range 1-59), with 29% hospitalized more than 1 week, compared to 6.54 days for non-HD patients. The mean facility charge for admitted subjects was $14,758, while the average cost for non-HD admissions was $7,152. Of the 133 patients (38%) who were discharged directly from the ED, the mean length stay was 223 minutes (range 30 to 750) and the mean charge was $658. The mean length of stay for non-HD patients was 124 minutes. The ED evaluation of adult HD patients involves multiple diagnostic modalities, and patients are usually admitted. The admit rate, ED length of stay for discharged patients and hospital charges for care were substantially higher in the HD patients than in the general population. Further research in the ED care of these complex patients should be undertaken.

Current management of anemia in adult hemodialysis patients with end-stage renal disease.

The management of anemia in adult end-stage renal disease (ESRD) patients receiving hemodialysis in dialysis facilities is examined. Clinical information was collected for a random sample of adult (age > or = 18 years) patients who received hemodialysis for ESRD between October and December 1999 and included hemoglobin concentrations, epoetin alfa doses and routes of administration, iron prescribing patterns, transferrin saturation levels, and serum ferritin concentrations. Patients whose data did not include hemoglobin concentrations with the weekly epoetin dose were excluded from the analysis. Associations by patient characteristics and geographic region were examined for clinical intermediate outcomes and epoetin alfa and iron prescribing practice patterns. Data were submitted for 8154 patients, and hemoglobin values linked to weekly epoetin alfa doses were available for 7573 of those patients. The mean hemoglobin concentration for patients in the sample was 11.4 +/- 1.3 g/dL. Sixty-seven percent of patients had mean hemoglobin values > or = 11 g/dL. Females, blacks, patients 18-44 years old, and patients receiving hemodialysis for less than six months exhibited significantly lower mean hemoglobin values despite being prescribed, on average, significantly higher epoetin alfa doses than males, whites, older patients, and patients receiving hemodialysis for six months or more (p < 0.001). There was significant regional variation in the prescribing patterns for s.c. epoetin alfa and i.v. iron (p < 0.001). Multivariable logistic regression analysis found significant associations between mean hemoglobin values > 11 g/dL and certain patient characteristics, including white race, hemodialysis for six months or longer, lower prescribed weekly epoetin alfa doses, prescription of i.v. iron, mean transferrin saturation levels > or = 20%, mean Kt/V > or = 1.2, and higher mean serum albumin values. Prescribing patterns for i.v. iron did not vary by the status of patients' iron stores. Regional and patient-specific variations in parameters of anemia management provide pharmacists with the opportunity to contribute to a multidisciplinary team approach to improve the care of hemodialysis patients.

Influence of self-efficacy and other factors on dietary behaviours in Japanese haemodialysis patients.

In Japan, haemodialysis patients are required to adhere to a fairly rigid dietary regimen. Guided by Bandura's theory of self-efficacy, this study tested a prediction model of dietary behaviour. A total of 325 individuals completed a self-administered survey containing nine scales, which were used to measure the six constructs in the model. Using multiple regression analysis, 24% of the variance on the Dietary Behaviour Scale could be accounted for by three predictor scales, Dietary Management Self-efficacy, Support from Family, and Self-Repressive Behaviour Patterns. Multiple regression analysis identified that four scales, Character Image of Dialysis Staff, Support from Family, Dialysis Acceptance, and Somatic Symptoms, contributed to 13% of the variance of the Dietary Management Self-efficacy Scale. These results might provide direction to those who are involved in the support and care of haemodialysis patients, some of whom require life-long treatment, as is common in Japan.

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.

Central Venous Catheter Placement in Hemodialysis: Evaluation of Electrocardiography using a Guide-Wire

Internal jugular vein cannulation has become a routine and clinically important aspect of medical care in hemodialysis patients. Mismanagement in the location of a central venous catheter may occur in up to 20% of cases. The aim of the study was to evaluate the utility of endocavitary electrocardiography in right internal jugu-lar vein placement of central venous catheters. We examined 327 central venous catheterizations performed in two Dialysis Units; all catheters were positioned using intra-atrial ECG monitoring by guide-wire and after, by catheter filled with NaCl solution. EC-ECG via guide-wire was successful on 321 occasions (98.1%). Correct placement of the catheter was confirmed by EC-ECG via catheter in each case, and by plain chest-X-ray only in the first hundred cases. In 314 patients (98.1%), insertion of the catheter was successful at the first attempt. In 6 catheterizations, no atrial trace was obtained due to atrial fibrillation in 4 cases, and in 2 cases technical error and guide-wire looping into a right jugular vein. Complications as a direct result of guide-wire or catheter placement were not observed. In our opinion this method can be used safely and makes radiological control usually unnecessary. (The Journal of Vascular Access 2001; 2: 45-50).

Comparison of Dietary Intake Estimates in Hemodialysis Patients

In providing nutrition care for hemodialysis patients, it is essential to obtain accurate estimation of true intake in order to evaluate patient compliance and assess the outcome of dietary intervention. In this clinic-based, cross-sectional study, all stable patients capable of verbal communication present for a regular hemodialysis treatment during a given midweek shift were included in the sample. Thirty patients participated (11 females, 19 males, mean age 64.8 years). Patients were randomized to receive a dietitian administered, semi-quantitative food frequency questionnaire (FFQ) or the ‘Typical day” (TD) technique. One week later, the patients received the method of dietary query not used the week before. Finally, the patients were randomly assigned to repeat either the food frequency questionnaire or the ‘‘typical day” method. All dietary intake reports were analyzed using commercially available nutrition analysis software with an updated database including local food products. Reproducibility of results did not significantly differ by query technique; however, reports of intake were significantly higher for all nutrients analyzed (except cholesterol) using the FFQ than the TD method. Dietary intake estimates obtained using the FFQ also correlated more strongly with biochemical indices of dietary intake (albumin, potassium, phosphorus, and urea) and with energy needs as predicted by the Harris-Bennedict equation. The TD method appears to produce systematic under-reporting of infrequently consumed food items that nevertheless significantly contribute to the nutrient density of the diet. The FFQ appears to more accurately represent the conceptually relevant exposure to nutrient intake and to thereby reduce misclassification bias. Use of the FFQ in clinical practice may better assess patient compliance to a therapeutic diet and dietary intervention outcome in maintenance hemodialysis patients.