Dialysis Stations Research Articles

Five Decades of Indian Nephrology: A Personal Journey

Impressive accomplishments have been made in Indian nephrology during the last 5 decades. The first renal biopsy performed in 1956 ushered in a new era of modern nephrology practice in India and led to the recognition of nephrology as a distinct specialty. The first hemodialysis facility was established in 1961; presently, there are 950 nephrologists, 850 hospitals equipped with dialysis facilities, and 170 institutions recognized for kidney transplantation, with approximately 3,500 transplantations performed every year. The majority of dialysis units are small minimal-care facilities with fewer than 5 dialysis stations, and more than 85% are in the private sector. Government hospitals provide free treatment to poor patients with chronic kidney disease; however, inadequate funding and lack of health insurance schemes pose serious hurdles in providing renal replacement therapy. In contrast, private/corporate hospitals located in big cities have large units with state-of-the-art dialysis and transplantation facilities, similar to advanced centers of the world, but are accessible to only upper-income groups. Of the estimated 175,000 new patients who develop end-stage renal disease annually, less than 10% are able to gain access to renal replacement therapy. Research in the field of renal diseases has evolved slowly and is focused primarily on tropical conditions. The availability of structured nephrology training programs coupled with excellent diagnostic and therapeutic facilities in some academic institutions and tertiary-care private/corporate hospitals have diminished the need for foreign travel by students, patients, and consultants to a considerable extent. The expansion of therapeutic facilities in India is hampered by only economic constraints, not lack of expertise.

Displacement and Emplacement of Health Technology

The provision of “closer-to-patient” services has increased in most industrialized countries. However, the migration of services in non-traditional health care settings implies redefining the role of technical and human entities and transforming the nature and use of technologies and places. Drawing on various scholarly efforts to conceptualize space, place, and technology, this paper compares and contrasts satellite and mobile dialysis units implemented in two regions in the province of Quebec, Canada. The satellite units were hosted in two small, local hospitals where nursing staff had been recently trained. The mobile unit was a bus adapted to host five dialysis stations; nurses traveled back and forth between a university teaching hospital and two sites located within a radius of 7.6 miles. In both projects, nephrologists supervised from a distance via a videoconferencing system. Our aim is to illustrate the ways in which the displacement of technical and human entities gives shape to new forms of emplacement in non-traditional health care settings. The satellite and mobile units contributed to the culture of dialysis care and transformed the identity of nurses, doctors, patients, and technologies. By contrasting two projects involving different spatial and clinical logics, we analyze in what ways certain forms of recombination of human and technical entities can prove incomplete but nevertheless acceptable to providers and project managers.

International Study of Health Care Organization and Financing for end-stage renal disease in France

The major features of ESRD management in France include the predominance of hemodialysis and the resulting competition for dialysis stations. In 2003, the prevalence of ESRD in France was 0.087%. Of the 52,000 ESRD patients, 30,882 were receiving dialysis and 21,233 had functioning renal transplants. The annual expenditure per ESRD patient in 2003 was estimated at euro40,975. Autodialysis, at euro49,133 per patient per year, was much less expensive than dialyzing in-center at either a public or private facility (euro111,006 and euro75,125, respectively). Transplant activity in France has rapidly increased in recent years, reaching 22 donors per million population in 2005.

Designing a better place for patients: Professional struggles surrounding satellite and mobile dialysis units

The professional claims and struggles involved in the design of non-traditional health care places are rarely problematized in applied health research, perhaps because they tend to fade away once the new design is implemented. This paper offers insights into such professional tensions and their impact on health care delivery by examining the design of two dialysis service delivery models in Quebec, Canada. The satellite units were hosted in two small hospitals and staffed by recently trained nurses. The mobile unit was a bus fitted to accommodate five dialysis stations. It was staffed by experienced nurses and travelled back and forth between a university teaching hospital and two sites. In both projects, nephrologists supervised from a distance via a videoconferencing system. In this paper, we draw mainly from interviews with managers (mostly nurses) and physicians ( n=18), and from on-site observations. Nephrologists, medical internists, and managers all supported the goal of providing “closer-to-patient” services. However, they held varying opinions on how to best materialize this goal. By comparing two models involving different clinical and spatial logics, we underscore the ways in which the design of non-traditional health care places opens up space for the re-negotiation of clinical norms. Instead of relatively straightforward conflicts between professions, we observed subtle but inexorable tensions within and beyond professional groups, who sought to measure up to “ideal standards” while acknowledging the contingencies of health care places.

Solving the Puzzle How to Cut Costs and Improve Service

Solving the Puzzle How to Cut Costs and Improve Service

Chronic kidney disease and its prevention in India

Chronic kidney disease (CKD) is an important, chronic, noncommunicable disease epidemic that affects the world, including India. Because of the absence of a renal registry in India, the true magnitude of CKD/end-stage renal disease (ESRD) is unknown. Two community-based studies, although methodologically different, have shown a prevalence of chronic renal failure of 0.16% and 0.79%. The cost of maintenance hemodialysis for a single session varies between 10 US dollars to 40 between government-run and private hospitals. The average cost of erythropoetin is approximately 150 US dollars to 200 per month. The cost of chronic ambulatory peritoneal dialysis with "Y" set at 3 exchanges per week, which most patients in India do, is US 400 US dollars per month. The cost of a renal transplant (RT) procedure is approximately US 700 US dollars to 800 in the government sector and 6000 US dollars in the private sector. The cost of immunosuppression with basic triple immunosuppression drugs (cyclosporine, steroid, and azathioprin) is US 250 US dollars per month. There are hardly any state-funded medical treatment and medical insurance facilities for CKD and ESRD patients in India. India has nearly 700 nephrologists and approximately 400 dialysis units with 1000 dialysis stations, with the majority being in the private sector. A maximum of 2% of patients can be subjected to maintenance hemodialysis. Until now, approximately 3000 patients have been initiated on chronic ambulatory peritoneal dialysis. India has approximately 100 RT centers, mostly in private setup, and not more than 3000 to 4000 RTs are performed annually. Thus, only 3% to 5% of all patients with ESRD in India get some form of renal replacement therapy. Thus, planning for prevention of CKD on a long-term basis is the only practical solution for India. It appears that even in India, diabetes and hypertension are responsible for 40% to 50% of all cases of chronic renal failure. Screening for these 2 diseases and CKD is simple and easy to perform. The best approach will be to start screening for CKD in a high-risk group, like first-degree relatives of patients with diabetes, hypertension, and CKD, and simultaneously making a platform to run the program through the existing health care system of the country. The key issue of funding the program needs to be explored. Initial funding may come from international agencies like the World Health Organization, World Bank, and International Society of Nephrology, along with support from the country itself. Ultimately, funding has to be sustained from our own existing health care system.

Routine disinfection of the total dialysis fluid system.

The importance of bacteria and endotoxin free, sterile dialysis fluid for long term, high quality haemodialysis treatment is obvious and very much demanded (1,2). Dead spaces and connections between units (segments) of fluid production and delivery in elder systems are a continuous source for bacteria growth, biofilm generation and endotoxin release (3). After varying success with routine disinfection of system components showing partly fast recovery and growth of bacteria (i.e. < 48 hours) we changed to routine disinfection of the entire fluid production and distribution system. We call this'system disinfection'. We report the methods and results from observation of practice over 28 months of disinfection. The fluid system is composed of a soft water tank, reverse osmosis (double RO), RO fluid loop, central bicarbonate production and delivery system and dialysis stations with and without ultrafilter and citric-thermal disinfection before and after each haemodialysis. The system disinfection is carried out bimonthly with peracetic acid 3.5% in > 0.1% solution at a mean temperature of > 15 degrees C and at a minimum of 60 minutes of disinfection time. Samples for microbiological testing and endotoxin measurement were assessed 3-4 monthly at 7 measurement points. The tests were carried out 7 times on the 11th day (mean value [MV]) after routine system disinfection. The result was in 0.2 CFU/ml (MV) in 40 tests. The endotoxin levels (IU/L) were all < 0.25 except one at 0.325 in RO water. Endotoxin was assessed 5 times in 26 tests over 28 months. Samples were taken at 10.5 (MV) days after system disinfection. The Gel Clot or turbometric method was used. Efficient and preventive routine system disinfection of an entire dialysis fluid production and distribution system as standard in modern equipment - can support sufficient quality in dialysis fluid produced and distributed by elder and composed systems.

Comparison between Tinzaparin and Standard Heparin for Chronic Hemodialysis in a Canadian Center

Background: Low-molecular-weight heparins offer several advantages over standard heparins, but their use for maintenance hemodialysis has been limited in North America because of their higher cost. Our objective was to compare tinzaparin to standard heparin during maintenance hemodialysis over an 8-week period, in regard to the visual aspect of the extracorporeal circuit, filter reuse, bleeding and time for compression of vascular access at the end of hemodialysis session, nursing time devoted to anticoagulation administration, level of satisfaction of patients and nurses, and relative cost. Methods: Thirty-two chronic hemodialysis adult patients with peripheral accesses were randomly divided into two groups in a cross-over design: tinzaparin for 4 weeks followed by standard heparin for 4 weeks, or vice versa. Hemodialysis was performed thrice weekly over 3.5–4 h using large surface reused filters. Standard heparin was administered as an initial bolus of 50–75 units per kilogram followed by an infusion to maintain an activated clotting time (ACTESTER) between 150 and 200 s and discontinued 30–45 min before the end of the session. The initial dose of tinzaparin was 3,500 IU anti-Xa for patients usually receiving 7,500 units or less of standard heparin, or 4,500 IU anti-Xa for patients receiving more than 7,500 units of standard heparin, and it was injected as a bolus in the arterial line at the beginning of hemodialysis. Dosage adjustments were made by increments or decrements of 500 IU. Results: A total of 6 patients did not require any adjustment in their dose of tinzaparin and remained at the initial dose, while the remaining 26 necessitated adjustments of the initial dose of tinzaparin: 20 patients required increments from the initial dose whereas 6 required reductions. For most patients, 27 of them, the standard heparin dose was kept at the same level throughout the study period (since it was their usual regimen and they were in stable medical conditions). According to the monitoring scale, the visual aspects of the tubing of the extracorporeal circuit and of the dialyzers at the end of the session were similar for both tinzaparin and standard heparin. The time of compression of the vascular access at the end of the hemodialysis sessions was not significantly different with tinzaparin than with standard heparin. However, as indicated below, most patients noted less bleeding (or oozing) from their access (during compression and thereafter, in the few hours after hemodialysis) with tinzaparin than with standard heparin. Clotting was observed more frequently in the arterial and venous bubble traps with tinzaparin than with standard heparin. The presence of clot(s) was observed in the arterial and venous bubble traps in, respectively, 18 ± 12 and 10 ± 6% of the sessions with tinzaparin, while in, respectively, 3 ± 4 and 2 ± 4% of the sessions with standard heparin (p < 0.005). Despite a tendency for a reduced reuse number of the dialyzers, the difference did not reach statistical significance. Among the 30 patients who completed the study, 2 reported excessive bleeding from their vascular access with tinzaparin whereas 8 reported such an excessive bleeding with standard heparin. The level of satisfaction of patients and nurses for tinzaparin was extremely good. The main reasons stated by the patients was reduced bleeding from their access after dialysis. The nurses preferred tinzaparin because of the simplicity and the rapidity of its administration, the lack of monitoring required, and the decreased bleeding/oozing tendency from the vascular access sites. The time spent for anticoagulation during a hemodialysis session was reported as 5 min with standard heparin (if no ACTESTER monitoring), 25–30 min with standard heparin (if ACTESTER monitoring required), and 1 min with tinzaparin. The cost analysis revealed that although tinzaparin is more than six times more expensive than standard heparin, the use of tinzaparin becomes similar to the use of standard heparin (USD 7.33 vs. USD 7.62 Canadian dollars for one hemodialysis session) if ACTESTER monitoring is performed (assuming that 22% of the sessions are routinely monitored and that one ACTESTER device is necessary for 8–10 dialysis stations, as applied in our unit). Conclusion: Our experience with tinzaparin was positive: it represents a simple and easy way to offer anticoagulation during maintenance hemodialysis, it seems associated with less postdialysis bleeding, it saves precious nursing time and is widely appreciated by patients and staff.

Preparing for the challenges of the millennium

This paper describes a retrospective view of the challenges the two authors were faced with as Nurse managers when the haemodialysis unit was expanded from ten dialysis stations to thirty-one within a period of three years. This expansion involved changes to the environment and management strategies. There were four issues identified that helped to face these challenges and they are described in depth. The authors claim the skill of communication within the team and the proactive approach to change was the key to their success.

Multidisciplinary predialysis programs: Quantification and limitations of their impact on patient outcomes in two Canadian settings

A 1993 National Institutes of Health Consensus statement stressed the importance of early medical intervention in predialysis populations. Given the need for evidence-based practice, we report the outcomes of predialysis programs in two major Canadian cities. The purpose of this report was to determine whether the institution of a multidisciplinary predialysis program is of benefit to patients, and to analyze those factors that are important in actualizing those benefits. Data from two different studies is presented: (1) a prospective, nonrandomized cohort study comparing patients who were or were not exposed to an ongoing multidisciplinary predialysis team (St Paul's Hospital) and (2) a retrospective review of outcomes before and after the institution of a predialysis program (The Toronto Hospital). Although created independently in major academic centers in Canada, the programs both aimed to reduce urgent dialysis starts, improve preparedness for dialysis, and improve resource utilization. The Vancouver study was able to demonstrate significantly fewer urgent dialysis starts (13% v 35%; P < 0.05), more outpatient training (76% v 43%; P < 0.05), and less hospital days in the first month of dialysis (6.5 days v 13.5 days; P < 0.05). Cost savings of the program patients in 1993 are conservatively estimated to be $173,000 (Canadian dollars) or over $4,000 per patient. The Toronto study demonstrated success in predialysis access creation (86.3% of patients), but could not realize any benefit in terms of elective dialysis initiation due to well-documented hemodialysis resource constraints. We conclude that an approach to predialysis patients involving a multidisciplinary team can have a positive impact on quantitative outcomes, but essential elements for success include (1) early referral to a nephrology center, (2) adequate resources for dedicated predialysis program staff and infrastructure, and (3) available resources for patients with end-stage renal disease (ESRD) (dialysis stations). In times of economic constraints, objective data are necessary to justify resource-intensive proactive programs for patients with ESRD. Future studies should confirm and extend our observations so that optimum and cost-effective care for patients approaching ESRD is uniformly available.

Evolution of renal replacement therapy in East Germany from 1989 to 1992

Diminished availability of facilities for renal replacement therapy is known to cause spuriously low acceptance and treatment rates. In this context the evolution of renal replacement therapy in the former German Democratic Republic is a useful model to study and to quantify some of the relevant factors. We performed a survey in all dialysis units for adults in East Germany (excluding East Berlin) by questionnaire, achieving a response rate of 97%. From December 1989 to December 1992 the number of dialysis centres increased from 53 to 96 (+81%), reaching 6.7 centres p.m.p. Of these facilities, 45% were hospital units, 29% private units, and 26% dialysis units run by non-profit health care organizations. The number of dialysis stations for regular dialysis treatment increased from 602 to 1276 (+112%), i.e. 89 stations p.m.p. In parallel, the number of chronic dialysis patients increased from 2127 to 3848 (+81%), i.e. 267 patients p.m.p. A more detailed survey was carried out in Thüringen and part of Sachsen, in a region covering 5 million inhabitants. The acceptance rate for chronic dialysis treatment has increased from 49 to 107 patients p.m.p. (+115%). The average age of new patients increased from 49 to 59 years, the proportion of patients aged > or = 65 years increased from 16 to 42% and the proportion of diabetics from 13 to 35%. Introduction of alternative treatment modalities became possible, with 2.3% of the patients receiving haemofiltrations and 3% CAPD. The proportion of HBs-antigen-positive patients decreased from 14.2% to 5%.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodialysis-Associated Febrile Episodes: Surveillance before and after Major Alteration in the Water Treatment System

Surveillance for bacteremic or pyrogenic episodes associated with hemodialysis was undertaken before and after the reconstruction of the water treatment system at our University medical center. The new water system included a holding tank with iodination treatment. The water delivered to individual dialysis stations had only occasional positive bacterial cultures (3 of 21 samples before completion of construction, 2 of 16 samples afterwards) and intermittent detection of endotoxin (6 of 21 samples before completion of construction, 9 of 16 samples afterwards) at monthly sampling. Among 51 individual dialysis treatments (25 patients) before reconstruction and 56 treatments (29 patients), after, only 2 and 3 febrile events were identified, respectively. All of these were associated with underlying infectious illness and not with the hemodialysis procedure itself. Overall, we conclude that pyrogenic episodes associated directly with hemodialysis treatment are infrequent, and that the addition of a water storage tank with iodination treatment does not appear to increase the risk of bacteremia or pyrogenic episodes.

Correction of microcytosis following elimination of an occult source of aluminum contamination of dialysate.

A higher prevalence of aluminum-associated microcytic anemia was noted in hemodialysis unit A (n = 67) compared to unit B (n = 39). This finding could not be explained by differences in the aluminum content of reverse osmosis (RO) water or intake of antacids containing aluminum by patients in the two units. An intermittent source of aluminum contamination was suspected when water aluminum and total dissolved solutes (TDS) were measured at several sites in the water treatment facility of unit A. A one-way valve that maintained unidirectional flow in an RO bypass circuit was found missing. Intermittent pressure changes in this circuit altered the direction of water flow causing mixing of partially purified water with RO water. Installation of the valve stopped contamination and resulted in a decrease in plasma aluminum concentration from 183 +/- 12 micrograms/L to 76 +/- 7.3 micrograms/L, erythrocyte aluminum concentration from 210 +/- 31 micrograms/L to 61 +/- 9 micrograms/L and microcytosis from 58% to 8% in patients (n = 48) when measured 6 months later. Because contamination was missed in spite of water testing at the RO site, these findings underscore the importance of measuring water aluminum and TDS content at the dialysis stations. Frequent water testing at dialysis stations, familiarity with the design of water treatment facilities, and recognition of aluminum overload can lead to early detection and correction if similar types of aluminum contamination should occur.

Using a Dialysis Need-Projection Model for Health Planning in Massachusetts

More than $5.1 million in unnecessary kidney dialysis facilities, equipment, and staff has been saved in Massachusetts during the past two years as a result of a model used by the Massachusetts Department of Public Health (DPH) to predict future need for dialysis in the state. These savings constitute 63% of the total proposed capital and manpower costs for the two-year period, accomplished mainly through the denial of 59% of the 163 requests for new dialysis stations. In addition to substantial savings in construction, new equipment and staff, the denial of these requests had several other benefits: Existing facilities have operated at more efficient levels, with lower per-patient treatment costs. Through the restriction of center dialysis supply, more patients were encouraged to utilize home dialysis. Greater reliance on home dialysis could translate into an annual savings of at least $2.6 million and an additional 333 person years as a result of the enhanced life expectancy for home dialysis patients. The need model has also been useful in more equitably distributing dialysis resources to regions in Massachusetts which have previously been underserved. The model has been successful in predicting the need for kidney dialysis services to within 1% of actual demand. Versions of the model are now being used by the US Department of Health and Human Services and by the six Health Systems Agencies of Massachusetts. Similar models can also be used to forecast the need for other types of specialized medical care technology, such as cardiac pacemakers.

Evaluation of ultra-short dialysis.

A study was carried out to compare the effects of three dialysis regimens of different durations. Nineteen patients dialysed over 1975--7 for an average of only 11.2 hours per week were compared with nine dialysed for 24 hours per week (1974--6) and 10 dialysed for 27 hours (1971--3). Clinical, biochemical, and haematological results showed that the short dialysis regimen was as effective as the longer regimens, except that patients had to take a phosphate binder regularly, and that it was considerably cheaper. Short dialysis has social and economic benefits, since patients have more free time and more patients can be treated with the same number of staff and dialysis stations. As in many areas there is a shortage of places for patients needing dialysis, a short regimen is recommended.