Edwin B. Toffelmire

Quantity of Dialysis: Quality of Life—what is the Relationship?

Health related quality of life (HRQOL) is increasingly being used to evaluate physical and psychosocial parameters in patients receiving dialysis. In patients with chronic illness, these indices are important adjuncts to biochemical measurements. Inadequate dialysis with low urea clearance (Kt/Vurea) has been linked to adverse outcomes in dialysis patients. Little is known about the relationship between dialysis adequacy and patient reported HRQOL. We evaluated HRQOL in 55 hemodialysis and 60 peritoneal dialysis patients using the RAND 36 Item Health Survey 1.0, measuring the following: physical functioning; role limitations (physical); role limitations (emotional); social functioning; emotional well being; pain; energy; and general health perceptions. Kt/V was also calculated for each patient. Mean HD Kt/V was 1.44 +/- 0.31 (range, 0.5-2.0); mean weekly PD Kt/V was 2.28 +/- 0.90 (range, 1.13-6.02). The relationship between Kt/V and HRQOL was tested using Pearsons correlation. No significant association was found for either treatment group between Kt/V and any of the domains of HRQOL. Thus, HRQOL seems to be influenced by factors other than dialysis adequacy, enhancing its role as an independent measure of patient problems otherwise undetected by traditional objective parameters.

Self-delivery of hemodialysis care: A therapy in itself

Patient autonomy, sense of control, and well-being are thought to be enhanced by self-care hemodialysis as a therapy for end-stage renal disease. Dialysis in a satellite setting reduces travel time and can diminish therapy intrusiveness. Health-related quality of life (HRQOL), in terms of functional status and well-being, was measured in a group of patients trained for self-care, and then measured again after these patients were transferred to a satellite unit. Comparison was made with an age- and comorbidity-matched cohort of full-care patients. Patients trained for self-care tended to score higher than the full-care patients in the psychosocial domains of HRQOL, such as role function, social function, and emotional well-being, before and after transfer to the satellite unit. Physiological measurements did not differ significantly between groups at any time during the study, indicating that differences in HRQOL were not attributable to differences in metabolic stability. We conclude that patients trained for self-care hemodialysis experience better subjective quality of life than their full-care counterparts. This study highlights both the usefulness of measuring HRQOL as an outcome of hemodialysis therapy and the potential benefits of therapies such as self-care and satellite dialysis.

Prevention of catheter lumen occlusion with rT-PA versus heparin (Pre-CLOT): study protocol of a randomized trial [ISRCTN35253449].

BackgroundMany patients with end-stage renal disease use a central venous catheter for hemodialysis access. A large majority of these catheters malfunction within one year of insertion, with up to two-thirds due to thrombosis. The optimal solution for locking the catheter between hemodialysis sessions, to decrease the risk of thrombosis and catheter malfunction, is unknown. The Prevention of Catheter Lumen Occlusion with rt-PA versus Heparin (PreCLOT) study will determine if use of weekly rt-PA, compared to regular heparin, as a catheter locking solution, will decrease the risk of catheter malfunction.Methods/DesignThe study population will consist of patients requiring chronic hemodialysis thrice weekly who are dialyzed with a newly inserted permanent dual-lumen central venous catheter. Patients randomized to the treatment arm will receive rt-PA 1 mg per lumen once per week, with heparin 5,000 units per ml as a catheter locking solution for the remaining two sessions. Patients randomized to the control arm will receive heparin 5,000 units per ml as a catheter locking solution after each dialysis session. The study treatment period will be six months, with 340 patients to be recruited from 14 sites across Canada. The primary outcome will be catheter malfunction, based on mean blood flow parameters while on hemodialysis, with a secondary outcome of catheter-related bacteremia. A cost-effectiveness analysis will be undertaken to assess the cost of maintaining a catheter using rt-PA as a locking solution, compared to the use of heparin.DiscussionResults from this study will determine if use of weekly rt-PA, compared to heparin, will decrease catheter malfunction, as well as assess the cost-effectiveness of these locking solutions.

Changes in waist circumference following haemodialysis: a brief report.

BACKGROUND Waist circumference (WC) is a known indicator of cardiovascular disease in the haemodialysis (HD) population. However it is not known if HD results in clinically significant changes in WC. OBJECTIVE The study purpose was to quantify the degree of change in WC induced by HD. METHODS This was a prospective cohort study with 27 patients on HD. Height, body weight, WC, hip circumference (HC), body mass index (BMI) and waist to hip ratio (WHR) were measured immediately prior to and following HD over three consecutive treatments. Differences between three-day average pre- and post-HD weight, BMI, WC, HC and WHR were assessed. RESULTS Post-HD WC was significantly lower than that measured pre-HD. Differences in pre-post HD body weight, BMI, HC and WHR were also observed. CONCLUSIONS All of the traditional clinical indicators of body composition (WC, HC, WHR, body weight and BMI) were lower following HD.

Effect of intravenous iron on insulin sensitivity in dialysis patients

This is a prospective study of 14 consecutive, prevalent HD patients. Exclusions were diabetes, hospitalization within the past month, dialysis for o3 months, hemoglobin o90 g/L or above 130 g/L, and a change in erythropoietin (EPO) dose concurrent with the initiation of IV iron. The exposure was 1 g iron dextran (MW 200 kd) IV over 10 HD treatments (100 mg/treatment) given in routine care. The outcome was the change in homeostasis model IS (homeostasis model assessment [HOMA]–IS) measured in duplicate in 2 predialysis blood samples (5 min apart) before and after the course of IV iron (HOMA–IS=fasting glucose [mmol/L] fasting insulin [U/mL]/22.5). The insulin levels were measured using a radioimmunoassay kit (Intermedico, Toronto, ON, Canada) as reported previously. The other variables were: age, race, gender, time on dialysis, abdominal circumference, hemoglobin (g/L), serum ferritin (g/L), and transferrin saturation (%). The analysis was performed using statistical software SAS System for Windows release 8.1 (SAS Institute Inc., Cary, NC, U.S.A.). Hemoglobin, serum ferritin, transferrin saturation, and HOMA-IS before and after the administration of IV iron were compared using the paired Student’s t test or nonparametric tests as appropriate. The level of significance was a=0.05 for all comparisons. The Queen’s University Research Ethics Board approved the protocol.