Biomedical subjects

W M McClellan

Publications and source records attributed to W M McClellan.

At least 19 recordsLinked to original sources

PubMed2002

Contribution of anaemia to progression of renal disease: a debate.

It is hypothesized that anaemia contributes to the progression of renal disease via hypoxia and oxidative stress. These effects may stimulate the production of extracellular matrix by fibroblasts, increasing interstitial fibrosis and leading to tubular destruction. Recombinant human erythropoietin (r-HuEPO, epoetin) has antioxidative and anti-apoptotic properties, though these effects have yet to be demonstrated in renal cells. In theory, epoetin treatment might slow the progression of renal failure, not only by correcting anaemia but also via direct effects on tubular and vascular cell survival. Alternative hypotheses suggest, however, that epoetin could have negative effects on the kidney because of its vasoconstrictive action, which is independent of haemoglobin levels. Retrospective and prospective clinical studies clearly show that epoetin does not accelerate progression of renal disease, provided that blood pressure is well controlled. Some studies suggest that epoetin slows the progression of renal failure, although this remains a controversial issue, as all these studies have methodological limitations. Larger randomized controlled trials and meta-analysis of the existing trials are required to establish whether treatment of anaemia with epoetin can indeed slow the progression of renal disease.

Anemia↗

PubMed2001

Subcutaneous erythropoietin results in lower dose and equivalent hematocrit levels among adult hemodialysis patients: Results from the 1998 End-Stage Renal Disease Core Indicators Project.

The National Kidney Foundation's Dialysis Outcome Quality Initiative (NKF-DOQI) guidelines recommend that epoetin alfa should be administered by the subcutaneous route in hemodialysis patients. We determined whether hematocrit levels in hemodialysis patients differed by route of epoetin alfa administration after controlling for demographic factors and iron status. Data were available for 7,092 of the 7,658 patients randomly chosen for inclusion in the 1997 Health Care Financing Administration Core Indicators sample. Epoetin alfa was administered to 96% of the study cohort and was administered subcutaneously in 10% of patients. After controlling for hematocrit, patient characteristics, adequacy of dialysis, iron status, serum albumin, postdialysis weight, and duration of dialysis, the epoetin alfa dose by the intravenous route was 193.6 units/kg/wk (95% confidence interval, 189.5 to 197.8 units/kg/wk) compared with 167.4 units/kg/wk (95% confidence interval, 153.9 to 180.8 units/kg/wk) for the subcutaneous route (P < 0.001). The mean hematocrit for the subcutaneous route was 32.7% +/- 3.4% and for the intravenous route was 33.0% +/- 3.2% (P < 0.05). Factors independently associated with increased hematocrit included male gender, white race, older patient age, greater number of years on dialysis, higher serum albumin concentration, higher urea reduction ratio, and percent transferrin saturation (all P < 0.001). After controlling for patient factors and weekly epoetin alfa dose, there was no association between route of epoetin alfa administration and hematocrit level (P = 0.144). Patients receiving epoetin alfa by the subcutaneous route had comparable hematocrit values using a lower epoetin alfa dose than patients receiving epoetin alfa intravenously. These data support the NKF-DOQI recommendation that epoetin alfa be administered subcutaneously in long-term hemodialysis patients.

Age Factors↗

PubMed2001

Family history of end-stage renal disease does not predict dialytic survival.

Familial aggregation of end-stage renal disease (ESRD) is frequently observed in the common causes of kidney failure. It is unknown whether the clinical course of nephropathy differs based on an individual's family history of ESRD. The ESRD Network 6 Family History of ESRD database was analyzed to compare dialytic survival among patients with first- or second-degree relatives on dialysis therapy (positive family history) with those lacking relatives with ESRD (negative family history). Study participants included 3,442 adult, black or white, incident patients with ESRD who initiated dialysis therapy in ESRD Network 6 facilities in 1995 and participated in the Network-sponsored Family History of ESRD study. All deaths were reported to the Network and used to calculate mortality rates. The relative risk for death was used to compare rates between levels of patient characteristics. Multivariate analyses used proportional hazards regression. Overall, 730 patients (21.2%) had a positive family history of ESRD. Black patients, those who were younger at the onset of ESRD, patients with greater degrees of functional status, and women were more likely to have a positive family history. During 9,000 patient-years of follow-up, 1,599 patients died (17.8 deaths/100 dialysis-years). Univariate analyses showed that patients with a positive family history of ESRD had 20% lower mortality than those with a negative family history of ESRD (relative risk, 0.80; 95% confidence interval, 0.7 to 0.9; P = 0.001). Older age, white race, diabetic nephropathy, lower functional status, lower serum albumin level, congestive heart failure, and ischemic heart disease also were associated with greater mortality rates. Multivariate analyses showed that only older age at onset of ESRD, white race, low functional status, ESRD caused by diabetes, and congestive heart failure were associated with increased mortality. A family history of ESRD in either first- or second-degree relatives was no longer a significant determinant of survival. We conclude that familial clustering of ESRD does not significantly impact on dialytic survival after controlling for the competing effects of patient race, age of ESRD onset, and the presence of diabetes mellitus.

Adolescent↗

PubMed2001

Duration of dialysis and its relationship to dialysis adequacy, anemia management, and serum albumin level.

An analysis of the relationship between intermediate outcomes and duration of dialysis therapy in hemodialysis patients was performed by linking Health Care Financing Administration (HCFA) Core Indicators data with data obtained from HCFA form 2728 at the initiation of dialysis therapy. Patients who recently initiated hemodialysis therapy were less likely to meet Dialysis Outcomes Quality Initiative guidelines than patients with a longer duration of dialysis therapy. For both urea reduction ratio and Kt/V, odds ratios for adequate dialysis were approximately 0.20 for a duration of dialysis therapy less than 0.5 years and 0.42 to 0.63 for a duration of dialysis therapy of 0.5 to 1.0 years compared with a duration of dialysis therapy of 2.0 years or greater. For patients with a duration of dialysis therapy less than 0.5 years (compared with >/=2.0 years), the odds ratio for a hematocrit less than 28% was approximately 3.0, that for a hematocrit 33% or greater was approximately 0.6, and that for a serum albumin level of 3.5 g/dL or greater (bromcresol green method) or 3.2 g/dL or greater (bromcresol purple method) was approximately 0.4. There was a direct relationship between glomerular filtration rate at the initiation of dialysis therapy and both serum albumin and hematocrit values. Patients administered recombinant human erythropoietin (rHuEPO) predialysis were more likely to have greater hematocrits. There also was a direct relationship between hematocrit and serum albumin level. Therefore, several actionable items in regard to attentive overall medical care can result in an improvement in the percentage of patients newly started on hemodialysis therapy who meet intermediate outcomes, including the administration of rHuEPO predialysis, correction of iron deficiency, and timely placement of a permanent dialysis access.

Adolescent↗

PubMed2001

Continuous quality improvement in dialysis units: basic tools.

Physicians and allied health professionals are expected to understand and participate in the assessment and improvement of the quality of care delivered to patients in end-stage renal disease (ESRD) treatment centers. Participating in the quality improvement process will bring clinicians into contact with special knowledge and skills drawn from the areas of statistical process control and industrial engineering. Some of the more frequently encountered of these concepts and tools are described.

Humans↗

PubMed2000

Racial variation in autosomal dominant polycystic kidney disease.

These analyses were undertaken to determine whether racial variation contributes to the risk of end-stage renal disease (ESRD) in close relatives of incident dialysis patients with autosomal dominant polycystic kidney disease (ADPKD)-associated ESRD. A family history of ESRD was recorded in 14,769 incident ESRD patients in Network 6 (Georgia, North Carolina, South Carolina) between September 1993 and November 1997. Two hundred thirty-seven patients with ADPKD-ESRD comprised the study population (180 white and 57 black). Differences in patient populations were analyzed using the chi-squared and Student's t-tests, and multiple regression analysis was performed. Correlation in age at ESRD onset in families was performed by linear regression analysis. A positive family history (FH) of ESRD in first- or second-degree relatives was reported by 38.6% (22 of 57) of blacks and 55% (99 of 180) of whites (P = 0.03). The 22 blacks with a positive FH had a mean of 2.0 additional ESRD relatives and 10.4 total first-degree relatives, whereas the 99 whites with a positive FH had a mean of 2.6 additional ESRD relatives and 7.0 total first-degree relatives (P = 0.14 and P < 0.001, respectively). Mean age in years at first dialysis was similar in blacks and whites, regardless of FH (black FH positive, 63.8; black FH negative, 66.3; P = 0.66; white FH positive, 60.8; white FH negative, 62.8; P = 0. 48). On average, 57.9% of the first- and second-degree relatives of white cases had ADPKD-associated ESRD, compared with 28.6% of the relatives of black cases (P < 0.001). In the multivariate analysis, white race (P = 0.004) and increasing family size (P = 0.002) were positively correlated with the number of relatives having ADPKD-associated ESRD, whereas age at ESRD onset (P = 0.50) and gender (P = 0.94) were not. Age at onset of ESRD was correlated within members of multiply affected white (P < 0.001) but not black families (P = 0.80). We conclude that blacks with ADPKD-associated ESRD are less likely than whites to have relatives with ESRD, and there is no correlation in age at onset of ADPKD-ESRD in black families.

Adult↗

PubMed2000

Peritoneal dialysis adequacy and risk of death.

BACKGROUND: The purpose of this study was to evaluate the relationship between dialysis dose, patient characteristics, and medical comorbidities on mortality in chronic peritoneal dialysis patients. METHODS: This work comprised a study cohort of 1446 patients obtained from a random sample of chronic peritoneal dialysis patients from each dialysis center in three southeastern states. Data collected on a standardized form were used to calculate weekly Kt/V urea and creatinine clearance. Data were linked to Network files containing data on patient demographic and medical comorbidities. RESULTS: Both weekly Kt/V urea and creatinine clearance were measured at least once in only 60.5% of continuous ambulatory peritoneal dialysis (CAPD) patients and 63.7% of cycler patients. Among the 873 patients who had at least one calculable adequacy measure, the mean (+/-SD) weekly Kt/V urea was 2.13 +/- 0.55, and the normalized mean weekly creatinine clearance was 62.9 +/- 20.4 L/week/m2. During the seven month period of follow-up, there were 140 deaths. In separate logistic regression models that included all of the studied risk factors, using separate variables for the urinary and peritoneal components of dialysis adequacy, each 10 L/week/1.73 m2 increase in the urinary component of weekly creatinine clearance was associated with a 40% decreased risk of death, and each 0.1 unit increase in the urinary component of weekly Kt/V urea was associated with a 12% decreased risk of death. In contrast, the dialysate components of neither weekly creatinine clearance nor weekly Kt/V urea were predictive of death. Other factors that were associated with an increased risk of death included increasing age, diabetes mellitus as the cause of end-stage renal disease (ESRD), and a history of myocardial infarction. CONCLUSIONS: Residual renal function, as expressed by weekly creatinine clearance or Kt/V urea, is an important predictor of death in chronic peritoneal dialysis patients. The nonsignificant findings regarding peritoneal clearances and mortality may possibly be secondary to the narrow range of peritoneal clearances in this study cohort.

Adolescent↗

PubMed2000

Risk factors for microalbuminuria in black americans with newly diagnosed type 2 diabetes.

We conducted a cross-sectional analysis to describe the prevalence of and risk factors for microalbuminuria among blacks with newly diagnosed type 2 diabetes. Black adults with diagnosed type 2 diabetes mellitus of 2 years' duration or less who presented for care to the Grady Diabetes Clinic (Atlanta, GA) between January 1, 1994, and December 31, 1996, were eligible (n = 1,167). Information obtained at the initial visit included age; sex; body mass index (BMI); serum total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride, C-peptide, serum creatinine, and hemoglobin A1c (HbA(1c)) levels; and seated systolic and diastolic blood pressures. Outcome was urine albumin-creatinine (Alb/Cr) ratio at the initial visit. Alb/Cr ratios were categorized as normal (Alb/Cr <25 microgram/mg), microalbuminuric (Alb/Cr, 25 to 250 microgram/mg), and macroalbuminuric (Alb/Cr >250 microgram/mg). Patients with macroalbuminuria or creatinine levels of 2 mg/dL or greater were excluded. We used multiple linear regression to assess the joint association between HbA(1c) level, mean arterial pressure (MAP), and log-transformed Alb/Cr, controlling for other covariates. Of 1,044 patients studied, macroalbuminuria was present in 3.8%, and microalbuminuria, in 23.4%. Alb/Cr was independently associated with increased HbA(1c) level (P = 0.0070), MAP (P = 0.0001), BMI (P = 0.0156), log-transformed triglyceride levels (P = 0.0031), C-peptide level of 6.5 ng/mL or greater (P = 0.0007), serum creatinine level (P: = 0.0068), and male sex (P = 0.0220). The relationship between HbA(1c) level and microalbuminuria was stronger in patients with lower BMIs. Microalbuminuria prevalence was high in this population of urban blacks with newly diagnosed type 2 diabetes. Risk factors associated with increased Alb/Cr included male sex, poor glycemic control, endogenous hyperinsulinemia, high blood pressure, elevated triglyceride levels, and obesity.

Black or African American↗

PubMed2000

Patient-reported quality of life early in dialysis treatment: effects associated with usual exercise activity.

The purpose of this study was to investigate factors associated with quality of life (QoL) early in treatment in a cohort of incident (i.e. newly diagnosed) dialysis patients. This multicenter study investigated QoL reported by patients on chronic hemodialysis (HD) and peritoneal dialysis (PD) at approximately 60 days following the start of treatment. QoL was assessed by the Medical Outcomes Study Short-Form 36 (MOS-SF 36) and by disease-targeted scales from the Kidney Disease Quality of Life (KDQOL). Patient's QoL as measured by the SF-36 was substantially impaired compared to norms for the general population. In univariate analyses, patients' QoL scores were related to demographic variables (age, race, sex, educational level), clinical variables (predialysis BUN and serum creatinine, primary diagnosis of diabetes, cardiovascular comorbidity, average hematocrit and serum albumin in first months of treatment), dialysis variables (HD/PD modality, PD dialysis adequacy, facility patient-staff ratio) and patient's level of usual exercise activity. In multivariate analyses, the most important independent QoL predictor was patient's usual level of exercise activity. Exercise activity independently predicted two performance measures of physical functioning, maximal gait speed and repeated chair rises, as well as patient-perceived physical functioning. Continued study of patient outcomes in relation to adequacy of delivered dialysis, early versus late diagnosis of chronic renal failure (CRF), and patient's usual exercise activity is important because these variables can be the focus for intervention strategies to prevent early deterioration in dialysis patients' functional health status.

Adult↗

PubMed1999

Can dialysis therapy be improved? A report from the ESRD Core Indicators Project.

We assessed the association between quality improvement interventions conducted during the End-Stage Renal Disease (ESRD) Core Indicators Project and changes in the adequacy of hemodialysis between 1993 and 1996. Improvement of hemodialysis adequacy was measured by baseline and annual urea reduction ratios (URRs) in representative samples of ESRD Network patients. Random samples of in-center hemodialysis patients aged 18 years and older who had received hemodialysis during the fourth quarters of 1993, 1994, 1995, and 1996 were used to calculate Network-specific outcomes. A mean URR was calculated for each patient using the first pretreatment and posttreatment blood urea nitrogen for October, November, and December of each study year. Both national and Network-specific interventions were used to provide feedback reports and technical assistance to treatment centers to foster improvement in hemodialysis adequacy. All Networks distributed reports on the patterns of treatment center URR levels and physician and patient educational materials to each center in the Network. Each Network selected an annual 10% sample of treatment centers in 1994 and 1995 and conducted quality improvement activities to assist the selected centers to improve dialysis adequacy. We defined Network-specific interventions by a survey of the 18 Networks conducted during 1995 to determine the characteristics of Network-specific activities used to improve adequacy of hemodialysis. The outcome of interest was the change over time in Network-specific URR value. Sustained improvement in the URR occurred within all 18 Networks between 1993 and 1996. The mean national URR increased from 62.7% in 1993 to 66. 8% in 1996. The proportion of patients with URR >/= 65% increased from 43% in 1993 to 68% in 1996. Networks reported implementing a variety of intervention strategies that included educational activities, continuous quality improvement workshops, on-site assistance, and supervision of selected treatment facilities until care improved. Network-specific interventions independently associated with an increased rate of improvement in URR included prolonged supervision of the selected facilities. We concluded that the sustained improvement in hemodialysis care that occurred after the inception of the ESRD Core Indicators Project was associated with specific ESRD Network interventions.

Adolescent↗

PubMed1999

Relationship between urea reduction ratio, demographic characteristics, and body weight for patients in the 1996 National ESRD Core Indicators Project.

The 1996 Health Care Financing Administration's (HCFA) Core Indicators Project for in-center, hemodialysis patients collects information on the quality of care delivered in four clinical areas that were anticipated to predict patient outcomes. Included among these clinical performance measurements is the delivered dose of hemodialysis, measured by the fractional reduction of urea achieved during a single hemodialysis session (urea reduction ratio [URR]). A random sample (N = 7,310) of adult (aged > or =18 years), in-center hemodialysis patients was selected, and a one-page data collection form for each patient was sent to the dialysis facility in which care was provided during the last quarter of 1995. The dialysis facilities provided information for 6,861 (94%) patients, and at least one paired predialysis and postdialysis blood urea nitrogen (BUN) concentration was reported for 6,655 (97%) of these patients. The URR of this cohort was 65.5% +/- 8.0% (mean +/- SD), and 41% of patients had a URR less than 65%. The mean dialysis session length was 203 minutes, and more than half of the patients received dialysis with a dialyzer membrane with a KUf less than 10 mL/mm Hg/h. The patients with a URR less than 65% had a mean body weight approximately 10 kg greater than patients with a URR of 65% or greater. This relationship was present for all demographic characteristics studied, including age, gender, race, and primary cause of end-stage renal disease (ESRD). Patients receiving dialysis for less than 6 months were more likely to have a URR less than 65% than patients on dialysis for longer periods. By multivariate analysis, variables significantly associated with a delivered URR less than 65% were body weight in the heaviest quartile (odds ratio [OR] = 6.1), male gender (OR = 2.6), on dialysis therapy less than 6 months (OR = 2.5), youngest quartile of age (<49 years) (OR = 2.0), lowest quartile of serum albumin values less than 3.6 g/dL (bromcresol green method) or less than 3.3 g/dL (bromcresol purple method) (OR = 1.6), black (OR = 1.5), dialyzed with a dialyzer KUf less than 20 mL/mm Hg/h (OR = 1.8), lowest quartile hematocrit (<29.7%) (OR = 1.2), and shorter dialysis session length (OR = 1.02/min). In conclusion, both patient-specific demographic variables and treatment-specific parameters are significantly associated with ESRD patients receiving a URR less than 65%. Furthermore, these data suggest statistically significant linkages between the delivered dose of hemodialysis and other independent outcome predictors such as serum albumin concentration. Prospective study is required to determine whether intervention strategies to improve the delivered dose of hemodialysis will affect this outcome predictor or whether serum albumin and dialysis dose share a common cause not amenable to increasing the URR.

Adult↗

PubMed1999

Racial/ethnic analysis of selected intermediate outcomes for hemodialysis patients: results from the 1997 ESRD Core Indicators Project.

Principal goals of the End-Stage Renal Disease (ESRD) Core Indicators Project are to improve the care provided to ESRD patients and to identify categorical variability in intermediate outcomes of dialysis care. The purpose of the current analysis is to extend our observations about the variability of intermediate outcomes of ESRD care among different racial and gender groups to a previously unreported group, Hispanic Americans. This group is a significant and growing minority segment of the ESRD population. A random sample of Medicare-eligible adult, in-center, hemodialysis patients was selected and stratified from an end-of-year ESRD patient census for 1996. Of the 6,858 patients in the final sample, 45% were non-Hispanic whites, 36% were non-Hispanic blacks, and 11% were Hispanic. Whites were older than blacks or Hispanics (P < 0.001). Hispanics were more likely to have diabetes mellitus as a primary diagnosis than either blacks or whites (P < 0.001). Even though they received longer hemodialysis times and were treated with high-flux hemodialyzers, blacks had significantly lower hemodialysis doses than white or Hispanic patients (P < 0.001). The intradialytic weight losses were greater for blacks (P < 0.05). The delivered hemodialysis dose was lower for blacks than for whites or Hispanics whether measured as a urea reduction ratio (URR) or as the Kt/V calculated by the second generation formula of Daugirdas (median 1. 32, 1.36, and 1.37, respectively, P < 0.001). Hispanics and whites had modestly higher hematocrits than blacks (33.2, 33.2, and 33.0%, respectively, P < 0.01). There was no significant difference among groups in the weekly prescribed epoetin alfa dose ( approximately 172 units/kg/week). A significantly greater proportion of Hispanic patients had transferrin saturations >/=20% compared with the other two groups (P < 0.001). Logistic regression modeling revealed that whites were significantly more likely to have serum albumin <3. 5(BCG)/3.2(BCP) gm/dL (OR 1.4, p < 0.01); blacks were significantly more likely to have a delivered Kt/V < 1.2 (OR 1.4, P < 0.001) and hematocrit <30%, (OR 1.2; P < 0.05) and both blacks and Hispanics were significantly more likely to have a delivered URR < 65% (OR 1.5, P < 0.001 and 1.2, P < 0.05, respectively).

Adolescent↗

PubMed1999

Validation of the pneumonia severity index. Importance of study-specific recalibration.

OBJECTIVE: To evaluate the predictive validity and calibration of the pneumonia severity-of-illness index (PSI) in patients with community-acquired pneumonia (CAP). PATIENTS: Randomly selected patients (n = 1,024) admitted with CAP to 22 community hospitals. MEASUREMENTS AND MAIN RESULTS: Medical records were abstracted to obtain prognostic information used in the PSI. The discriminatory ability of the PSI to identify patients who died and the calibration of the PSI across deciles of risk were determined. The PSI discriminates well between patients with high risk of death and those with a lower risk. In contrast, calibration of the PSI was poor, and the PSI predicted about 2.4 times more deaths than actually occurred in our population of patients with CAP. CONCLUSIONS: We found that the PSI had good discriminatory ability. The original PSI overestimated absolute risk of death in our population. We describe a simple approach to recalibration, which corrected the overestimation in our population. Recalibration may be needed when transporting this prediction rule across populations.

Adult↗

PubMed1999

Preliminary survey of the occurrence of anaphylactoid reactions during haemodialysis.

Explore the source record for details and available documents.

Adult↗

PubMed1998

Patterns of patient care reported by nephrologists: implications for nephrology training.

The recent estimate of the nephrology workforce indicates that more nephrologists must be trained to care for the increasing number of patients with end-stage renal disease (ESRD). This conclusion was based on a 1996 survey indicating that nephrologists devote an average of 35% of their activities caring for ESRD patients. We compared data in that survey with those from a 1991 survey of members of the American Society of Nephrology to determine similarities between the different periods. The 1,590 responders in the 1991 survey (35% of the American Society of Nephrology membership) indicated that 50% devoted more than 75% of their effort to patient care, predominately for patients with general nephrology and hypertension problems. Approximately 69% of respondents cared for fewer than 50 hemodialysis patients, and the majority of respondents felt the maximum number of dialysis patients for whom they could provide adequate medical care would be 50. Most respondents felt that there would be a deficiency of nephrologists in their community within 5 years. Results from both the 1991 and 1996 surveys indicate that practice patterns have not changed markedly; combining results from the two surveys makes it clear that more nephrologists are needed to care for the projected increase in dialysis patients. Because nephrologists should be involved in the management of the pre-ESRD patient, training programs will have to broaden the preparation of future nephrologists.

Adult↗

PubMed1998

Improving the care of patients treated with hemodialysis: a report from the Health Care Financing Administration's ESRD Core Indicators Project.

To determine the impact of a quality improvement intervention on dialysis care delivered to hemodialysis patients, we studied 213 hemodialysis facilities in North Carolina, South Carolina, and Georgia. Dialysis adequacy measurements made on two random samples of 30 patients per treatment center, or all patients if fewer than 30 were treated, selected in October 1994 (preintervention) and October 1995 (postintervention) were used to estimate the facility mean urea reduction ratio (URR) and the proportion of patients with a mean URR less than 50%. The 10% of facilities (n = 22) with the highest proportion of patients with a mean URR less than 50% in the facility at preintervention were selected for an intervention that included feedback of facility-specific mean URR, educational programs, a quality improvement workshop, and monitoring until improvement was attained. Changes between preintervention and postintervention facility mean URR and proportions of patients with a URR less than 60% and 65% were used to assess the impact of the intervention. After 1 year, the mean URR had increased an average of 7% in intervention centers compared with an increase of 1.4% (P < 0.001) in the remainder of the treatment centers in the Network. There was an average reduction of 17.2% in the proportion of patients with a URR less than 65% in intervention centers compared with 4.8% in the other facilities (P < 0.001). Comparable reductions in the proportion of patients with a mean URR of less than 60% were 16.2% in intervention centers and 2.0% in comparison facilities (P < 0.001). After controlling for facility case mix and other characteristics, the intervention was independently associated with an absolute 2.4% increase in facility-specific mean URR. We conclude that the intervention was associated with improvement in hemodialysis care.

Ambulatory Care Facilities↗

PubMed1998

Mortality in end-stage renal disease is associated with facility-to-facility differences in adequacy of hemodialysis.

Death rates of end-stage renal disease (ESRD) patients treated with hemodialysis vary substantially among treatment centers. The association between facility-to-facility differences in delivered hemodialysis dose and facility-specific mortality rates was examined among 5817 randomly selected patients treated with hemodialysis on October 1, 1994, from all 213 hemodialysis treatment centers reporting to ESRD Network 6. The mean urea reduction ratio (URR) for each treatment center, a measure of hemodialysis adequacy, was calculated for each facility, using measurements made by center staff members during one treatment for each of the randomly selected patients. During 7 mo of follow-up (ending April 30, 1995), 441 (7.6%) patients died. The average URR among the treatment centers was 64.9%. There was a strong, inverse association between increasing treatment center URR and adjusted mortality count (P = 0.009). Other treatment center characteristics associated with increased mortality included free-standing status (P = 0.009) and decreasing frequency of reported physician supervision of care (P = 0.01). It was concluded that lower average levels of dialysis adequacy in treatment centers are associated with higher rates of death, and this association persists after controlling for facility-to-facility differences in patient and nonpatient characteristics.

Adolescent↗

PubMed1997

Report from the 1995 Core Indicators for Peritoneal Dialysis Study Group.

The 1995 Peritoneal Dialysis Core Indicators Study was conducted by the Health Care Financing Administration to ascertain standard practices and outcomes in chronic peritoneal dialysis patients. Data from 1,202 patients who did not receive hemodialysis but who were on chronic ambulatory peritoneal dialysis (CAPD) for at least part of the 6-month period between November 1, 1994, and April 30, 1995, are reported. The mean serum albumin level for this cohort was 3.5 g/dL by the bromcresol green method and 3.2 g/dL by the bromcresol purple method. Data sufficient to calculate a weekly Kt/V(urea) or weekly creatinine clearance were available for only 34% of patient submissions. In these patients, the median weekly Kt/V(urea) was 1.7 using a fixed value for V of 0.58 x body weight and was 2.0 using the Watson equation to calculate V; the median weekly creatinine clearance was 60.7 L/wk/1.73 m2. The mean hematocrit for this cohort was 32% and the average weekly recombinant human erythropoietin (rHmEPO) dose was 115 u/kg. Hematocrit values < or = 30% were found in 50% of black patients and 31% of white patients. The average blood pressure among peritoneal dialysis patients was 139/80 mm Hg, with 29% of patients having a systolic blood pressure exceeding 150 mm Hg and 18% a diastolic blood pressure greater than 90 mm Hg. In summary, serum albumin levels were significantly lower in peritoneal dialysis patients than in hemodialysis patients. Approximately one third of peritoneal dialysis patients did not have an adequacy measure obtained during the 6-month observation period. A significant minority of patients had either inadequately treated anemia of chronic renal disease or hypertension. There is an opportunity to substantially improve the medical care provided to chronic peritoneal dialysis patients.

Adolescent↗