Joan D. Mayers

Pervasive Failed Rehabilitation in Center-Based Maintenance Hemodialysis Patients

At its inception in 1972, the end-stage renal disease (ESRD) program was conceived with a set of assumptions about cost, rate of growth, and treatment outcomes in its client population. Despite the potential to correct anemia with recombinant erythropoietin (EPO) introduced in 1987 and improved survival, the level of physical activity among some segments of the hemodialysis population remains suboptimal. This study was undertaken, among other reasons, to identify correlates of poor functional status as measured by a modified Karnofsky scale. Using a modified Karnofsky scale, we measured the functional status of 430 patients who had been treated by hemodialysis for at least 1 year and some of whom were also receiving concomitant treatment with EPO. Patients studied were randomly selected from eight dialysis units in urban New York and suburban New Jersey. A Karnofsky score of less than 70 indicated frank disability--the subject was unable to perform routine living chores without assistance. In addition, current vocational activity was ascertained, and comorbid conditions were quantified. The necessity for wheelchair dependence was noted for each patient. The mean age (+/- SD) of the study population was 56 +/- 14 years (range, 21 to 92 years). Subjects had been on maintenance hemodialysis for 4.09 +/- 3.8 years (range, 1 to 23 years). The study group included 215 men and 215 women, of whom 65% were black, 27% white, 6% Hispanic, and 2% Asian; 36.5% had diabetes mellitus. Although 376 members (87%) of the study group were under treatment with EPO, the mean hematocrit of the study population was only 29% +/- 4.5%.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlates of Vascular Access and Nonvascular Access-Related Hospitalizations in Hemodialysis Patients

Four hundred and thirty randomly selected hemodialysis patients, aged 20 years and over, were studied to identify risk factors for vascular access and nonvascular access-related hospitalizations in the immediately preceding 1 year. Risk estimates for hospitalization were assessed using a multinominal logistic analysis model. We measured functional status, utilizing a 14-point Karnofsky scale, and in a separate analysis of covariance, in which Karnofsky score was the outcome, we examined the relationships of age, gender, ethnicity, renal diagnosis, and hospitalization. Individual comparisons were adjusted for multiple comparison bias by Tukeys Honest Difference method. There were a total of 508 hospitalizations of which 322 (63%) lasted > or = 1 week. Two hundred and sixty (60%) patients were hospitalized at least once; 105 (24.4%) for access problems only, 115 (27%) for a nonaccess problem only, and 40 for access and nonaccess-related problems. Access-related problems, accounted for 48% of all hospitalizations. The risk of hemodialysis vascular access morbidity was increased in women (p < 0.028) and white (p < 0.048) hemodialysis patients. Neither diabetic nor elderly hemodialysis patients were at greater risk for access hospitalization than their respective counterparts, though a greater proportion of the access hospitalizations in the elderly (> or = 64 years) lasted > or = 1 week (p < 0.0006). More access-related hospitalizations in blacks (64.5%), lasted for > or = 1 week than in whites (40.6%) (p < 0.001). Hispanics (p < 0.043), whites (p < 0.002), and the older patients (p < 0.054) were at greater risk for nonaccess hospitalization than blacks and younger patients, respectively. Even after adjusting for age, race, and diabetes, each decrease of one unit in the modified Karnofsky score was associated with a 3-4% increased risk for all types of hospitalization (p < 0.001)--poor functional status is associated with increased risk for all hospitalizations. We conclude that the risk for hemodialysis vascular access morbidity is increased in women and white hemodialysis patients. Poor functional status is associated with increased risk for all hospitalizations.

Vascular access surgery for maintenance hemodialysis. Variables in hospital stay.

Access surgery in support of maintenance hemodialysis is a major factor contributing to prolonged hospitalization in the hemodialysis patient population. In surveying 140 consecutive patients admitted for access surgery, average length of stay was 14 days, independent of race or underlying cause of renal disease. Extended length of stay was most commonly encountered in older patients admitted for thrombosed fistulae or grafts. Postoperative fever, the need for repeated femoral catheterization, delay in access revision or placement due to infection, and the need for adequate social service support resulted in prolonged hospitalization. Understanding and preventing factors that prolong hospitalization may allow the minimization of length of stay in the future and improve quality of life for the end-stage renal disease patient, while also decreasing the cost of care.

Anemia severity and missed dialysis treatments in erythropoietin-treated hemodialysis patients.

&NA; Neither the sociodemographic correlates nor the biochemical/clinical consequences of missed dialysis treatments have been well defined. During a 10 week period, the authors enumerated missed dialysis treatments among 430 patients randomly selected from a pool of 1,395 hemodialysis patients. A forward logistic regression model was used to determine whether a relationship existed between missed dialysis treatments and the following independent variables: age, gender, race, renal diagnosis, length of time on maintenance hemodialysis, co‐morbidity index, modified Karnofsky score, employment status, household residents, and laboratory indices. Forty‐three (10%) of 430 patients missed a total of 96 treatments. Despite equivalent treatment with erythropoietin, patients who missed dialysis treatment(s) had a lower mean hematocrit (27 ± 4.3%) at the end of the study than those patients who underwent all treatments (29 ± 4.5%) (p = 0.0287). Mean serum albumin and creatinine levels were equivalent in compliant and noncompliant patients. Recent starts (p = 0.0048), and younger patients (p = 0.0424) were most likely to miss dialysis treatment(s). One of the major consequences of missed dialysis treatment(s) is exacerbation of anemia, and younger patients and freshly started patients are more likely to miss scheduled dialysis treatments than their respective counterparts. ASAIO Journal 1996;42:146‐149.

Cardiovascular disease in elderly hemodialysis patients

Cardiovascular disease (CD) is the most common cause of death in all dialysis patients. We studied 104 stable elderly (≥ 65 years) hemodialysis patients to determine the prevalence of cardiovascular disease as evidenced by congestive heart failure or symptomatic coronary artery disease, by race and by coincidence of diabetes and to assess the impact of cardiovascular morbidity on physical activity. CD was judged to be present if a patient had clinical and laboratory confirmed congestive heart failure or coronary artery disease. Physical activity assessed by a modified Karnofsky scale was compared in subjects with and without CD. We inventoried co-morbid conditions and compared the extent of co-morbidity in elderly patients with and without CD. We determined the effect of advancing age and increasing duration of ESRD on the prevalence of CD.

Rehabilitation of elderly patients on hemodialysis

Hemodialysis is the most broadly applied form of renal replacement therapy. For a growing number of older patients with end-stage renal disease (ESRD), hemodialysis is the only practical option in dialytic therapy because most cannot learn to perform ambulatory peritoneal dialysis (CAPD), and many are too old for kidney transplantation. Recent demographic data reveal that those over 65 are the fastest growing segment of the population; a reality that is reflected in the dialysis population. It has been projected that, by the year 2010, patients 65 and over will represent about 60% of the total hemodialysis population [1]. Current studies assessing the efficacy of maintenance hemodialysis emphasize survival, adequacy of dialysis, and other technical indices, while giving less attention to morbidity, quality of life, and functional status, although less pragmatic and admittedly difficult to quantify.

Functional and vocational rehabilitation of hemodialysis patients

End-stage renal disease, is unique in being the only major chronic illness whose cost of care is funded by the government with the criteria solely based on diagnosis [1]. At its inception in 1971 few demographers or policy makers anticipated that the program would grow to its current level in terms of cost [2–4]. In the seventies and eighties, a series of studies on the rehabilitation of hemodialysis patients was done, the results of which showed both suboptimal physical activity and low employment rate [5,6]. Then employment was used as a major index of rehabilitation, primarily because the policy makers who passed the bill were convinced that a great number of hemodialysis patients would be vocationally rehabilitated thereby contributing to the tax base [1]. While several studies have found that the latter objective has not been achieved, other investigators have found improved ‘quality of life’ especially with the controlled use of erythropoietin in study settings [7,8]. In the current atmosphere of health care reform and fiscal austerity we revisit the issue of functional and vocational rehabilitation of maintenance hemodialysis patients, by a multicenter survey of a large number of patients but this time under real life conditions of erythropoietin use.