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      Identifying Patients at Risk for Hemodialysis Underprescription

      a , a,b

      American Journal of Nephrology

      S. Karger AG

      Hemodialysis, Prescription, Adequacy of dialysis

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          Abstract

          Underprescription of hemodialysis is an important barrier to adequate delivery of dialysis. We sought to determine which patient factors are associated with hemodialysis underprescription and to examine variation in prescription across facilities. For 721 randomly selected patients from all 22 chronic hemodialysis units in northeast Ohio, we calculated prescribed Kt/V based on dialyzer urea clearance at prescribed blood and dialysate flow (K), prescribed treatment time (t), and anthropometric volume (V). A minimum ‘prescribed Kt/V’ of 1.3 has been recommended to ensure an adequate ‘delivered Kt/V’ of 1.2. Using this criterion, 15% of patients had a low prescribed Kt/V. Prescribed Kt was strongly related to patient anthropometric volume but not to other patient characteristics (age, gender, race, cause of renal failure, number of years on dialysis, number of comorbid conditions). A 10-liter increase in V was associated with an 8.3-liter increase in prescribed Kt. However, a 13-liter increase in prescribed Kt would be needed to maintain a prescribed Kt/V of 1.3. As a result, the proportion of patients with low prescriptions increased from 2% of patients with V <35 liters to 42% of patients with V ≧50 liters. In addition, the prevalence of low prescriptions varied dramatically across facilities (range 0–47%) even after accounting for volumes of individual patients. Of the 109 patients with low prescription, 75% would achieve a prescribed Kt/V of 1.3 with less than 30 min of additional treatment time. In conclusion, large patients and patients at specific facilities are at increased risk for underprescription of hemodialysis. Most patients with low prescriptions would achieve a prescribed Kt/V of 1.3 with a modest increase in treatment time.

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          Most cited references 3

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          The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis.

          Among patients with end-stage renal disease who are treated with hemodialysis, solute clearance during dialysis and nutritional adequacy are determinants of mortality. We determined the effects of reductions in blood urea nitrogen concentrations during dialysis and changes in serum albumin concentrations, as an indicator of nutritional status, on mortality in a large group of patients treated with hemodialysis. We analyzed retrospectively the demographic characteristics, mortality rate, duration of hemodialysis, serum albumin concentration, and urea reduction ratio (defined as the percent reduction in blood urea nitrogen concentration during a single dialysis treatment) in 13,473 patients treated from October 1, 1990, through March 31, 1991. The risk of death was determined as a function of the urea reduction ratio and serum albumin concentration. As compared with patients with urea reduction ratios of 65 to 69 percent, patients with values below 60 percent had a higher risk of death during follow-up (odds ratio, 1.28 for urea reduction ratios of 55 to 59 percent and 1.39 for ratios below 55 percent). Fifty-five percent of the patients had urea reduction ratios below 60 percent. The duration of dialysis was not predictive of mortality. The serum albumin concentration was a more powerful (21 times greater) predictor of death than the urea reduction ratio, and 60 percent of the patients had serum albumin concentrations predictive of an increased risk of death (values below 4.0 g per deciliter). The odds ratio for death was 1.48 for serum albumin concentrations of 3.5 to 3.9 g per deciliter and 3.13 for concentrations of 3.0 to 3.4 g per deciliter. Diabetic patients had lower serum albumin concentrations and urea reduction ratios than nondiabetic patients. Low urea reduction ratios during dialysis are associated with increased odds ratios for death. These risks are worsened by inadequate nutrition.
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            Hemodialysis access failure: a call to action.

             R Hakim,  J Himmelfarb (1998)
            Recent evidence suggests that the cost as well as the morbidity associated with the maintenance of hemodialysis access is increasing rapidly; currently, the cost exceeds 1 billion dollars and access related hospitalization accounts for 25% of all hospital admissions in the U.S.A. This increase in cost and morbidity has been associated with several epidemiological trends that may contribute to access failure. These include late patient referral to nephrologists and surgeons, late planning of vascular access as well as a shift from A-V fistulaes to PTFE grafts and temporary catheters, which have a higher failure rate. The reasons for this shift in the types of access is multifactorial and is not explained by changes in the co-morbidities of patients presenting to dialysis. Surgical preference and training also appear to play an important role in the large regional variation and patency rate of these PTFE grafts. We propose a program for early placement of A-V fistulae, a continuous quality improvement, multidisciplinary program to monitor access outcome, the development of new biomaterials, and a research plan to investigate pharmacological intervention to reduce development of stenosis and clinical interventions to treat those that do develop, prior to thrombosis.
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              The End Stage Renal Disease Program

               John Iglehart (1993)
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                Author and article information

                Journal
                AJN
                Am J Nephrol
                10.1159/issn.0250-8095
                American Journal of Nephrology
                S. Karger AG
                0250-8095
                1421-9670
                2001
                June 2001
                25 June 2001
                : 21
                : 3
                : 200-207
                Affiliations
                aDivision of Nephrology and Center for Health Care Research and Policy, MetroHealth Medical Center, and bDepartment of Medicine, Center for Biomedical Ethics, and Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio, USA
                Article
                46248 Am J Nephrol 2001;21:200–207
                10.1159/000046248
                11423689
                © 2001 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 4, Tables: 4, References: 35, Pages: 8
                Product
                Self URI (application/pdf): https://www.karger.com/Article/Pdf/46248
                Categories
                Clinical Study

                Cardiovascular Medicine, Nephrology

                Adequacy of dialysis, Prescription, Hemodialysis

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