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At least 19 recordsLinked to original sources
PubMed2003

Response to inadequate dialysis in chronic peritoneal dialysis patients. Results from the 2000 Centers for Medicare and Medicaid (CMS) ESRD Peritoneal Dialysis Clinical Performance Measures (PD-CPM) Project.

BACKGROUND: It is not known if patient prescriptions are being changed if patients are receiving an inadequate dose of peritoneal dialysis. METHODS: Data from the 2000 Centers for Medicare and Medicaid were used to obtain data on dialysis adequacy and dialysis prescriptions. RESULTS: A total of 359 of 1,268 (28%) adult peritoneal dialysis patients had a total weekly Kt/V urea (twKt/V) less than 2.0 and 436 of 1,245 (35%) patients had a total weekly creatinine clearance (twCrCl) less than 60 L/wk/1.73 m2, defined as "inadequate dialysis." Among chronic ambulatory peritoneal dialysis (CAPD) patients, 81 of 188 (43%) patients had inadequate dialysis and a change in the peritoneal dialysis prescription within 6 months of the initial adequacy value. Among cycler patients, 106 of 197 (54%) patients had inadequate dialysis and a change in the prescription. Thirty-six of 46 (78%) CAPD patients and 48 of 56 (86%) cycler patients had an improvement in twKt/V after the prescription was revised. Thirty-two of 42 (76%) CAPD patients and 45 of 57 (79%) cycler patients had an improvement in twCrCl after the prescription was changed. For these patients, twKt/V increased from 1.6 +/- 0.3 to 2.1 +/- 0.5, with an increase in the peritoneal Kt/V urea from 1.5 +/- 0.3 to 1.9 +/- 0.4. Similarly, twCrCl increased from 46.3 +/- 7.5 to 59.1 +/- 10.6 L/wk/1.73 m2 with an increase in the peritoneal CrCl dose from 42.0 +/- 9.1 to 52.7 +/- 9.9 L/wk/1.73 m2. CONCLUSION: About half of peritoneal dialysis patients with inadequate dialysis did not have a prescription change and could benefit from modifications in their dialysis prescription.

Adult↗
PubMedDate not supplied

Effects of amino acid dialysis compared to dextrose dialysis in children on continuous cycling peritoneal dialysis.

OBJECTIVE: To compare the biochemical and nutritional effects of amino acid dialysis with dextrose dialysis in children receiving continuous cycling peritoneal dialysis (CCPD). DESIGN: A prospective randomized cross-over study. SETTING: Nonhospitalized patients. PATIENTS: Seven children aged 1.8 to 16.0 years (mean 8.1 years) with end-stage renal disease who were receiving CCPD. INTERVENTIONS: Each patient received nighttime automated CCPD of dextrose, plus a single daytime dwell of either amino acid dialysate or dextrose dialysate. After 3 months, subjects crossed over to the alternative regimen for a subsequent 3 months. MAIN OUTCOME MEASURES: Creatinine clearance, ultrafiltration, urea, creatinine, electrolytes, total protein, albumin, fasting plasma amino acids, anthropometrics, total body nitrogen. RESULTS: Amino acid dialysis was comparable to dextrose dialysis for creatinine clearance and ultrafiltration. Plasma urea concentrations were higher during amino acid dialysis. No clinical side effects or worsening of metabolic acidosis was observed. Caloric intake increased and protein intake improved. Appetite and total body nitrogen increased in at least half the children during amino acid dialysis. Total plasma protein and albumin concentrations did not change significantly. Fasting plasma concentrations of amino acids after 3 months of amino acid dialysis were comparable to baseline values. For several amino acids, the dose-response curve was blunted after a single amino acid exchange following 3 months of amino acid dialysis, which may, in part, be due to the induction of hepatic enzyme synthesis. CONCLUSIONS: Amino acid dialysis is an efficient form of peritoneal dialysis that should be considered for children with poor nutritional status for whom enteral nutrition supplementation has been unsuccessful. Further study is needed to determine the optimal amount of amino acids to deliver, the best time to administer the amino acid dialysis fluid, and the benefits of adding dextrose to the amino acid solution.

Adolescent↗
PubMed2003

[Adequacy of dialysis at the Department of Nephrology and Dialysis of the Sveti Duh General Hospital in Zagreb and the Dialysis Outcomes Quality Initiative (DOQI) guidelines--comparison of the years 1998 and 2002].

Every year ever more and more patients in our country receive some form of dialysis, which provides life-saving renal replacement therapy for end-stage renal disease. In an effort to improve the quality and outcomes of dialysis care, the National Kidney Foundation--Dialysis Outcomes Quality Initiative (NKF-DOQI) have developed clinical practice guidelines for care of dialysis patients regarding hemodialysis adequacy, peritoneal dialysis adequacy, treatment of anemia, and vascular access. The morbidity and mortality of patients is strongly connected with dialysis adequacy and degree of anemia. We compared 180 patients on hemodialysis (HD) in 1998 and 177 patients in 2002, who are regularly treated in our Center with the use of DOQI guidelines. Dialysis adequacy was assessed by use of urea reduction ratio URR = 1-(post. urea/pre. urea), and overall wellbeing according to the degree of anemia, number of blood transfusions, presence of elevated blood pressure, and number of antihypertensives in therapy. In year 2002, 50% of the patients had adequate dialysis compared with 30% in 1998. The average duration on dialysis and the age of patients did not change. We recorded a rise in hemoglobin from 80 g/L to 92 g/L, and in the use of EPO (from 18% to 30%). No case of hypoalbuminemia was observed. The aim of dialysis is to improve the overall wellbeing of uremic patients. Comparing our results with DOQI-guidelines, we demonstrated that dialysis therapy could be improved to prevent complications and early mortality in dialysis patients.

Guideline Adherence↗
PubMed1994

Effects of 3-month amino acid dialysis compared to dextrose dialysis in children on continuous ambulatory peritoneal dialysis.

OBJECTIVES: To compare the nutritional and biochemical effects of amino acid dialysis to dextrose dialysis in children receiving continuous ambulatory peritoneal dialysis (CAPD). DESIGN: Prospective randomized crossover study. SETTING: Pediatric Nephrology Unit in a tertiary care, teaching hospital of the University of Toronto. PATIENTS: Seven children aged 0.7-16.5 years receiving CAPD. All patients had poor linear growth, with 5 patients showing evidence of energy deficit. INTERVENTIONS: Each patient received either amino acid or dextrose dialysate for 3 months, then crossed over to the alternate regimen for a subsequent 3 months. MAIN OUTCOME MEASURES: Nutritional and biochemical data were obtained on each patient during each dialysis regimen. RESULTS: Analysis of the patients' nutritional data showed comparable weight gain with both regimens but no significant improvement in lean body mass with either regimen. Appetite improved in most patients during amino acid dialysis. Biochemical data during amino acid dialysis showed a tendency to higher plasma potassium and urea levels with no clinical side effects or worsening of acidosis; however, there was a reduced anion gap and increased total plasma protein, due mostly to a rise in plasma albumin and a smaller increase in immunoglobulins. With the exception of tryptophan, fasting amino acid levels at the start and end of amino acid dialysis did not show any significant change. An interesting phenomenon of early blunting of the rise in amino acid levels, following a single amino acid dialysate exchange, was noticed at the end of the amino acid dialysis period. This newly described phenomenon could have been due to tolerance or hepatic enzyme induction. CONCLUSIONS: Overall amino acid dialysis was comparable to dextrose dialysis with no additional proven nutritional benefit, was equally effective in ultrafiltration and creatinine clearance, and produced no adverse clinical or biochemical effects.

Acid-Base Equilibrium↗
PubMed1999

Trends in initiation of dialysis in an urban dialysis clinic in the United States: a long way from dialysis outcomes quality initiative guidelines.

The guidelines issued for peritoneal dialysis by the National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DOQI) suggest initiation of dialysis at a glomerular filtration rate (GFR) of 10.5 mL/min/1.73 m2. We undertook this study to determine trends at a center in Philadelphia. Using the MDRD (Modification of Diet in Renal Disease) formula, we estimated the GFR (mL/min/1.73 m2) at the time of first dialysis for patients starting on dialysis at the center between 1994 and 1996. Data on 72 of the 86 new patients were available. Of the 72, 69 patients (96%) were black and 29 (40%) were diabetic. The estimated GFR at the time of dialysis initiation was 6.3 +/- 0.3 mL/min/1.73 m2. Only 3 patients (4%) had a GFR > 10.5; 25 patients (35%) had GFR < 5.0. Patients with a lower GFR had more severe acidosis (HCO3 15.8 +/- 0.5 mmol/L vs 19.5 +/- 0.9 mmol/L, p = 0.0023) and greater impairment in divalent ion metabolism (PO4: 7.6 +/- 0.2 mg/dL vs 5.6 +/- 0.3 mg/dL, p < 0.0001). Diabetic patients were initiated on dialysis at a higher level of GFR than non diabetic patients (7.2 +/- 0.3 mL/min/1.73 m2 vs 5.7 +/- 0.4 mL/min/1.73 m2, p = 0.0087). Even though diabetic patients had higher GFR and lower serum creatinine (8.6 +/- 0.5 mg/dL vs 11.8 +/- 0.9 mg/dL, p = 0.0021) than non diabetic patients, blood urea nitrogen (BUN) was similar in the two groups (89 +/- 3.7 mg/dL vs 96.8 +/- 5.8 mg/dL, p = 0.73). This difference may indicate that nondiabetic patients had a greater decline in protein intake. Finally, a trend towards initiation of dialysis at higher levels of renal function was seen with time (GFRs 5.5 +/- 0.4 mL/min/1.73 m2, 6.4 +/- 0.4 mL/min/1.73 m2, and 6.9 +/- 0.6 mL/min/1.73 m2 for 1994, 1995, and 1996 respectively; p = 0.058, 1994 vs 1996). The trend was stronger for diabetic patients (GFR 6.3 +/- 0.4 mL/min/1.73 m2 and 8.1 +/- 0.7 mL/min/1.73 m2 for 1994 and 1996 respectively; p = 0.06) than for non diabetic patients (GFR 5.1 +/- 0.5 mL/min/1.73 m2 and 6.2 +/- 0.7 mL/min/1.73 m2 for 1994 and 1996 respectively; p = 0.22). We conclude that initiation of dialysis is delayed in urban centers, particularly in non diabetic patients, and that the current practice is far below the DOQI recommendations.

Diabetes Mellitus↗
PubMed1999

Can dialysis adequacy be achieved by tailoring the dialysis prescription in an Asian pediatric population on nightly intermittent peritoneal dialysis?

This study was undertaken to determine whether tailoring the dialysis prescription in Asian children on nightly intermittent peritoneal dialysis (NIPD), without adding high-dose therapy for cost-savings purposes, was able to achieve dialysis adequacy and improvement in nutrition. Eight children (age range: 5.5-20 years) on NIPD for a mean of 2.1 +/- 0.6 years, were studied at baseline and at 3 months and 9 months after their dialysis dose was tailored. Dialysis adequacy was measured by weekly Kt/Vurea and creatinine clearance (CCr). Fat-free mass (FFM) and percent body fat (%FAT) as measured by bioelectrical impedance, together with anthropometric measurements, serum total protein, and albumin, were used as indicators of nutrition. After the dialysis prescription was tailored, the mean weekly Kt/Vurea increased from 1.89 +/- 0.35 to 2.12 +/- 0.54 at 9 months, and total CCr increased from 36.4 +/- 11.51 L/1.73 m2 to 48.30 +/- 14.30 L/1.73 m2. The increase occurred despite a decline in residual renal function and was attributable to significant improvements in the peritoneal clearances of urea and creatinine (p < 0.05). The mid arm muscle circumference (MAMC) increased significantly (p = 0.006), while FFM increased from 25.68 +/- 7.92 kg to 26.95 +/- 9.83 kg, and %FAT decreased from 21.56% +/- 8.41% to 18.66% +/- 8.16%. The increase in FFM correlated significantly with a decrease in serum creatinine (r = -0.94, p = 0.005). In conclusion, tailoring the dialysis prescription in NIPD, without adding high-dose therapy, resulted in a trend of improvement in dialysis adequacy and some nutritional parameters.

Adolescent↗
PubMed2003

Hemodialysis and peritoneal dialysis: comparison of adjusted mortality rates according to the duration of dialysis: analysis of The Netherlands Cooperative Study on the Adequacy of Dialysis 2.

Various studies indicate that fair comparisons of mortality rates between hemodialysis (HD) patients and peritoneal dialysis (PD) patients are difficult because of differences in patient characteristics, because of nonconstant relative risks of death (RR), and because the survival times of patients who switch treatment modalities can be censored in different ways. The differences in mortality rates between HD and PD patients were investigated in an analysis in which these potential sources of bias were taken into account. The Netherlands Cooperative Study on the Adequacy of Dialysis is a multicenter, prospective, observational, cohort study in which new patients with ESRD are monitored until transplantation or death. A multivariate Cox regression analysis was used to analyze the mortality data according to treatment modality (HD, n = 742; PD, n = 480). No statistically significant differences in adjusted mortality rates between HD and PD patients were observed during the first 2 yr of dialysis. In the years thereafter, increases in mortality rates for PD patients and resulting decreases in RR in favor of HD were observed (e.g., months 24 to 36, adjusted RR, 0.53; 95% confidence interval, 0.31 to 0.91). This tendency was observed especially among patients >/=60 yr of age and was not influenced by the censoring strategy. These results suggest that long-term use of PD, especially among elderly patients, is associated with increases in mortality rates. Further analyses are required to determine the potential role of dialysis adequacy in the observed long-term differences in mortality rates between HD and PD patients and to establish the possible survival benefits for PD patients who switch to HD in time.

Adult↗
PubMed1991

Effect of dialysis membrane and patient's age on signs of dialysis-related amyloidosis. The Working Party on Dialysis Amyloidosis.

This 12 center study was designed to assess factors affecting the development and progression of beta 2-microglobulin amyloidosis in long-term dialysis. A total of 221 patients who were on hemodialysis for more than five years, and who were treated the entire time only with AN69, a biocompatible, highly permeable membrane, or cuprophane, a less permeable, poorly biocompatible membrane (Cell) were evaluated for time on dialysis, development of carpal tunnel syndrome, and cystic bone lesions. X-ray documentation was taken in a minimum of four of the six following joints: both hips, wrists and shoulders. The data demonstrate that patients treated solely by AN69 membranes display signs of bone amyloidosis less frequently than do those treated by Cell membranes. Age at onset of dialysis was found to have a striking correlation with the development of carpal tunnel syndrome and bone amyloidosis, while no significant influence was found for hyperparathyroidism, sex or year of first dialysis.

Acrylic Resins↗
PubMed1999

Peritoneal transport properties and dialysis dose affect growth and nutritional status in children on chronic peritoneal dialysis. Mid-European Pediatric Peritoneal Dialysis Study Group.

To evaluate a possible effect of peritoneal transport properties and dialysis dose on the physical development of children on chronic peritoneal dialysis, a cohort of 51 children was prospectively followed for 18 mo. Peritoneal transport characteristics were assessed by serial peritoneal equilibration tests (PET), dialysis efficacy by dialysate and residual renal clearance measurements, and growth and nutritional status by the longitudinal changes (delta) of height SD score (SDS), body mass index (BMI) SDS, and serum albumin. delta height SDS was negatively correlated with the creatinine equilibration rate observed in the initial PET (r = -0.31, P < 0.05). Multiple regression analysis confirmed the negative effect of the high transporter state (partial r2 = 0.07), and disclosed an additional positive effect of dialytic C(Cr) (partial r2 = 0.11) and a weak negative effect of daily dialysate volume (partial r2 = 0.04) on delta height SDS. delta BMI SDS was strongly age-dependent (r = -0.48, P < 0.001); while relative body mass gradually increased below 4 yr of age, it remained stable in older children. Positive changes in BMI SDS were associated with rapid PET creatinine equilibration rates (univariate r = 0.35, P < 0.05) and/or large dialysate volumes (multivariate partial r2 = 0.11), suggesting a role of dialytic glucose uptake in the development of obesity. The change in serum albumin concentrations was positively correlated with dialysate volume (partial r2 = 0.14), and negatively affected by dialytic protein losses (partial r2 = 0.06). In conclusion, the peritoneal transporter state is a weak but significant determinant of growth and body mass gain in children on chronic peritoneal dialysis. Rapid small solute equilibration contributes to impaired growth but enhanced acquisition of body mass. Dialytic small solute clearance has a weak positive effect on statural growth independent of the transporter state, but does not affect body mass gain.

Adolescent↗
PubMed1996

Adequacy of dialysis and nutrition in continuous peritoneal dialysis: association with clinical outcomes. Canada-USA (CANUSA) Peritoneal Dialysis Study Group.

The objective of the study presented here was to evaluate the relationship of adequacy of dialysis and nutritional status to mortality, technique failure, and morbidity. This was a prospective cohort study of consecutive patients commencing continuous peritoneal dialysis in 14 centers in Canada and the United States. Between September 1, 1990 and December 31, 1992, 680 patients were enrolled. Follow-up was terminated December 31, 1993. There were 90 deaths, 137 transplants, and 118 technique failures. Fifteen withdrew from dialysis. Analysis of the patient and technique survival used the Cox proportional hazards model with adequacy of dialysis and nutritional status as time-dependent covariates. The relative risk (RR) of death increased with increased age, insulin-dependent diabetes mellitus, cardiovascular disease, decreased serum albumin concentration and worsened nutritional status (subjective global assessment and percentage lean body mass). A decrease of 0.1 unit Kt/V per week was associated with a 5% increase in the RR of death; a decrease of 5 L/1.73 m2 creatinine clearance (CCr) per week was associated with a 7% increase in the RR of death. The RR of technique failure was increased with decreased albumin concentration and decreased CCr. Hospitalization was increased with decreased serum albumin concentration, worsened nutrition according to subjective global assessment and decreased CCr. A weekly Kt/V of 2.1 and a weekly CCr of 70 L/1.73 m2 were each associated with an expected 2-yr survival of 78%.

Adolescent↗
PubMed1995

[How to use the peritoneum as a dialysis membrane. Methods of surveillance, criteria of efficacy and longevity as a dialysis membrane, consequences with respect to techniques of peritoneal dialysis].

The structure of the peritoneum is well known. However, the real surface of the membrane which participates to solute transports during dialysis is purely putative, depending on numerous factors as cardiac output and consequently mesenteric blood flow, mesothelial cell junctions, interstitial thickness, number of functional peritoneal capillaries and so on. In addition lymphatic absorbtion of peritoneal fluid interacts with transcapillary water shifts. These various factors vary from one moment to another in a same patient and from patient to patient. Eventually, mechanical problems related to peritoneal catheter may alter fluid and solute transfer evaluation when estimated from analysis of drained dialysate. Notwithstanding, solute peritoneal equilibration curves may be used as a guide to prescribe dialysis, provided they are repeated several times. They appear more reliable to detect, and therefore prevent peritoneal structure alterations. The APEX (Accelerated Peritoneal Examination) test is more convenient than Peritoneal Equilibration Test (PET), as it summarizes in a single number the peritoneal permeability both to glucose and urea: hence, it represents the time at which glucose and urea equilibration curves (using percentages as units) cross; the shorter is the APEX time, the higher is the peritoneal permeability and, reversely, the longer is this time, the lower is the peritoneal permeability. The peritoneal membrane may be used at least five years without concern with lactate buffered solutions if peritonitis are efficiently prevented. Some patients have been followed for more than ten years without detectable adverse effects, but further evaluations still have to be performed to evaluate the longterm consequences of peritoneal dialysis. Peritoneal dialysis and haemodialysis must be considered as complementary technics which must be both available to patients.

Humans↗
PubMed1998

[Adequate peritoneal dialysis: limitations of continuous ambulatory peritoneal dialysis (CAPD), place of automated peritoneal dialysis (APD)].

Recent epidemiological studies show a slowing down of the global growth of CAPD which is not compensated by the considerable development of APD. These modifications are the result of the arrival of technologies which allow new strategies as well as an improved knowledge of the adequate dialysis dose for PD. The re-evaluation of the adequate clearance targets show that CAPD does not deliver an adequate dialysis dose for anuric patients but it remains an excellent technique for patients with residual renal function. APD and mixed techniques (APD with automated diurnal exchange(s), CAPD with automated nocturnal exchange) can deliver an adequate dialysis dose if the peritoneal permeability is not too low and if the prescription is adapted to each patient. The growth of CAPD seems to be slowing down due to a better knowledge of its limitations. However the development of APD does not seem to be related to the increasing knowledge of its possibilities. The development of automated techniques, prescribed as substitute treatments, depends on a precise evaluation of the cost/efficiency/quality of life index, compared to the reference treatment which is iterative hemodialysis.

Humans↗
PubMed2002

A single-center review of the death notification form: discontinuing dialysis before death is not a surrogate for withdrawal from dialysis.

BACKGROUND: Form 2746, the death notification form, is the primary source of data on cause of death for patients with end-stage renal disease in the United States. Since the revised form was introduced in May 1990, withdrawal from dialysis is no longer a specific cause of death code. A separate section of form 2746 asks whether dialysis was discontinued before death. Based on US Renal Data System data from form 2746, more than 20% of dialysis patients discontinue dialysis before death. It is not known whether stopping dialysis is a proximate cause of death in these patients. METHODS: Two hundred twelve death notification forms completed between January 1, 1993, and December 31, 2000, from a single dialysis center were reviewed for location of death, primary and secondary causes of death, and whether dialysis therapy was discontinued before death. Dialysis unit and hospital billing records of patients who discontinued dialysis before death were reviewed to obtain the dates of hospitalization and last dialysis treatment before death. RESULTS: Fifty-six patients (26%) discontinued dialysis therapy before death. In only 8 of those patients' deaths (8 of 212 deaths; 4% of all patient deaths), nephrologists used form 2746 to attribute the death to uremia from stopping dialysis therapy. Time in days from the last dialysis treatment to death in these 8 patients was longer than in the remaining 48 patients who stopped dialysis therapy before death, but in whom cause of death was not coded as uremia (median, 12.5 versus 5 days, respectively; P = 0.01). Patients who stopped dialysis therapy before death were more likely to have malignancy and less likely to have cardiovascular disease coded as cause of death. Most patients died in the hospital; only 2 patients died in hospice. CONCLUSION: There is physician variability in interpretation of discontinuation of dialysis before death. Thirty percent of patients who discontinued dialysis therapy before death died 3 or fewer days from their last dialysis treatment, making uremia an unlikely cause of death, but suggesting that nephrologists wanted to note that a decision not to continue dialysis therapy had been made before the patient died. Discontinuing dialysis therapy as noted on the death notification form is not a surrogate for withdrawal from dialysis as a cause of death. Providing criteria for reporting discontinuing dialysis therapy would allow us to clarify the incidence of withdrawal from dialysis as a cause of death.

Adult↗
PubMed2004

Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis.

CONTEXT: In light of conflicting evidence of differential effects of dialysis modality on survival, patient experience becomes a more important consideration in choosing between hemodialysis and peritoneal dialysis. OBJECTIVE: To compare patient satisfaction with hemodialysis and peritoneal dialysis in a cohort of patients who have recently begun dialysis. DESIGN AND SETTING: Cross-sectional survey at enrollment in a prospective inception cohort study of patients who recently started dialysis at 37 dialysis centers participating in the Choices for Healthy Outcomes in Caring for End-stage Renal Disease (CHOICE) study, a national multicenter study of dialysis outcomes, from October 1995 to June 1998. PATIENTS: Of 736 enrolled incident dialysis patients, 656 (89%) returned a satisfaction questionnaire after an average of 7 weeks of dialysis. MAIN OUTCOME MEASURE: Data collected from a patient-administered questionnaire including 3 overall ratings and 20 items rating specific aspects of dialysis care. RESULTS: Patients receiving peritoneal dialysis were much more likely than those receiving hemodialysis to give excellent ratings of dialysis care overall (85% vs 56%, respectively; relative probability, 1.46 [95% confidence interval, 1.31-1.57]) and significantly more likely to give excellent ratings for each specific aspect of care rated. The 3 items with the greatest differences were in the domain of information provided (average of information items: peritoneal dialysis [69% excellent] vs hemodialysis [30% excellent]). The smallest differences were in ratings of accuracy of information from the nephrologist, response to pain, amount of fluid removed, and staff availability in an emergency. Adjustment for patient age, race, education, health status, marital status, employment status, distance from the center, and time since starting dialysis did not reduce the differences between peritoneal dialysis and hemodialysis patients. CONCLUSIONS: After several weeks of initiating dialysis, patients receiving peritoneal dialysis rated their care higher than those receiving hemodialysis. These findings indicate that clinicians should give patients more information about the option of peritoneal dialysis.

Adult↗
PubMed2003

Effect of starting with hemodialysis compared with peritoneal dialysis in patients new on dialysis treatment: a randomized controlled trial.

BACKGROUND: Up-until-now, the survival and health-related quality of life of hemodialysis and peritoneal dialysis patients has only been compared in observational studies. These studies have reported small and opposing differences between both modalities. The aim of this study was to compare the outcome of hemodialysis as initial chronic dialysis treatment with that of peritoneal dialysis in a randomized controlled trial. METHODS: All new dialysis patients from 38 dialysis centers in The Netherlands without indications against either modality were invited to participate. Patients were assigned to start with hemodialysis or peritoneal dialysis. The primary outcome was mean quality-adjusted life year (QALY) score. Secondary outcome was survival. RESULTS: Due to the low inclusion rate, the trial was prematurely stopped after which 38 patients had been randomized: 18 patients to hemodialysis and 20 to peritoneal dialysis. The mean QALY score in the first 2 years was 59.1 (SD 12) for hemodialysis patients versus 54.0 (SD 19) for peritoneal dialysis patients, which constitutes a small difference in favor of hemodialysis of 5.1 (95%CI -7.3 to 17.6) After 5 years of follow-up, nine hemodialysis and five peritoneal dialysis patients had died, a significant difference in survival; hazard ration of hemodialysis versus peritoneal dialysis of 3.8 (95%CI 1.1 to 12.6). After adjustment for age, comorbidity, and primary kidney disease the hazard ratio was 3.6 (0.8 to 15.4). CONCLUSION: Only a small difference in QALY score was observed between patients who started with hemodialysis compared to patients who started with peritoneal dialysis, lending support for the equivalence hypothesis. The significant difference in longer-term survival, which favored peritoneal dialysis in this small group of patients, could be used to posit that incident dialysis patients might benefit from starting on peritoneal dialysis.

Aged↗
PubMed2002

Cost-quality trade-offs in dialysis care: a national survey of dialysis facility administrators.

Dialysis facilities face important trade-offs between cost and quality under constrained capitated reimbursement. How management at dialysis facilities makes decisions affecting cost and quality of care and views opportunities and threats is unknown. We conducted a national survey of dialysis facility administrators. We asked administrators what changes they would make in response to increases or decreases in reimbursement, their views on linking dialysis care payment to quality-of-care measures, and their views on providing patients with treatment options and outcomes information. One hundred fifty-seven of 280 dialysis facility administrators (56%) responded. If dialysis reimbursement were to increase by 20%, the five most common responses were to: improve patient education programs (62% of respondents), improve facility amenities (42%), purchase new equipment (30%), provide more money for staff salaries (28%), and increase number of nursing staff (21%). Conversely, if dialysis reimbursement were to decrease by 20%, the most common responses were to: limit staff salary (45% of respondents), decrease nursing staff (41%), not replace dialysis equipment (43%), increase dialyzer reuse (37%), and return less to investors (36%). Differences in rank order of responses were observed according to professional training of the administrator and profit status of the facility. Administrators uniformly believe that it is very acceptable to provide facility-specific outcomes data to the public, as well as information on modalities of treatment provided by facilities. However, administrators varied in their views regarding whether reimbursement should be based on quality by using a process-of-care measure, such as the average dose of dialysis, or an outcome-of-care measure, such as case-mix-adjusted mortality rates. We conclude that increases in facility reimbursement generally would be used by dialysis facility administrators for the benefit of patients, whereas decreases (or inflation erosion) in payment rates might compromise staffing. US dialysis administrators support sharing treatment options and outcomes information with patients, but appear to be ambivalent with regard to linking reimbursement to adequacy of dialysis or patient outcomes. These results have important implications regarding proposed changes in the US capitated dialysis payment rate and current efforts to empower consumers of dialysis care.

Adult↗
PubMed1999

Dialysis adequacy and homocyst(e)ine concentrations in peritoneal dialysis patients.

INTRODUCTION: Determinants of hyperhomocysteinaemia in peritoneal dialysis patients have been recently reported but there is still conflicting data on the influence of dialysis adequacy on homocysteine (Hcy). METHODS: We studied 46 consecutive new continuous ambulatory peritoneal dialysis (CAPD) patients to determine the variation of Hcy before and 1 and 6 months after dialysis. The variation in Hcy was analysed with respect to dialysis adequacy, factors known to influence its metabolism, and Hcy peritoneal clearance. RESULTS: Hcy was 31.9+/-9 micromol/l before dialysis. It was significantly higher before dialysis than 1 month after the onset of PD (31.9+/-9 micromol/l vs 23.2+/-6.9 micromol/l, P < 0.0005). Weekly PD Hcy clearance was 14.3+/-5.4 1. There was no relationship between pre-dialysis Hcy and 1 month post-dialysis Hcy (r=0.176, P=0.15). There was a strong relationship between PD Hcy clearance and both PD creatinine clearance (r=0.502, P<0.005) and Kt/V (r=0.42, P<0.005). There was no relationship between Hcy and PD creatinine clearance (r= -0.221, P=0.11). In contrast, the decrease in tHcy at 1 month was related to PD Hcy clearance (r=0.487, P<0.01), to PD creatinine clearance (r= 0.349, P<0.02) and to Kt/V (r=0.32, P<0.02). Multivariate analysis confirmed the relationship between the decrease in Hcy and dialysis adequacy. Eleven patients (24%) experienced arteriosclerotic complications. Fasting Hcy concentrations in this population were significantly higher before and 1 month-post-dialysis than in patients without cardiovascular complications. CONCLUSIONS: We observed a significant and prolonged reduction in Hcy concentrations by peritoneal dialysis in end-stage renal disease patients. The decrease in Hcy concentration was positively related to dialysis adequacy. This study suggests the possibility that dialysis adequacy may influence arteriosclerotic outcomes through an Hcy-lowering effect.

Adult↗