John P. Capelli

Effect of Intradialytic Parenteral Nutrition on Mortality Rates in End-Stage Renal Disease Care

Several studies have now demonstrated that low serum albumin and/or low protein catabolic rates correlate with increased risk of death in the chronic hemodialysis patient. A study involving 81 patients receiving thrice-weekly hemodialysis treatments and who had either a low serum albumin and/or protein catabolic rate was conducted to compare the effect of intradialytic parenteral nutrition (IDPN) on mortality rates. Fifty patients received IDPN and 31 patients did not. Thirty-eight of the patients were black (47%), 34 were white (42%), and 9 were Hispanic (11%). The study included 33 diabetic patients (41%), 20 of whom received IDPN. Nondiabetic patients received an average of 725 kcal/hemodialysis treatment and diabetic patients received an average of 670 kcal/hemodialysis treatment. The average length of treatment was 9 months. The results of the study revealed a better survival rate (64% v 52%) for patients treated with IDPN. Using Cox analysis, the IDPN-treated group had a significantly better survival rate (P < 0.01). Serum albumin increased by 12% in the survivors. There was no difference in survival when considered separately for diabetic and nondiabetic patients who received IDPN (mortality rate for diabetics: 50% for treated patients and 54% for untreated patients; mortality rate for nondiabetics: 26% for treated patients and 44% for untreated patients). However, the nondiabetic treated patients had the lowest mortality rates. In conclusion, correction of hypoalbuminemia by IDPN significantly reduced mortality rates overall.

Factors Affecting Survival of Hemodialysis Patients Utilizing Urea Kinetic Modeling

The objective of this study was to analyze risk factors affecting mortality rates (MR) in hemodialysis patients undergoing shortened dialysis time who were regularly kinetically modeled. Over a 14-month period, 180 in-center hemodialysis patients, 54% male, 46% female, 57% Black, 39% Caucasian, and 4% Hispanic, treated with rapid high efficiency dialysis (RHED = 2-3 h, 3 times/week) and conventional dialysis (3-4 h, 3 times/week) were studied. Median patient age was 56.7 years (16-84 years) and dialysis care ranged from 6 months to 18 years (mean +/- SD = 4.0 +/- 4.2 years). The patients underwent monthly urea kinetic modeling. The dialysis prescription was based upon normalizing Kt/V between 0.8 and 1.2 and the protein catabolic rate (PCRn) between 0.9 and 1.1. Thirty-three percent of the patients received recombinant human erythropoietin (r-HuEPO). The effects of various covariates, including primary diagnosis, post/predialysis BUN ratios, creatinine, albumin, calcium, phosphate, cholesterol, hemoglobin, r-HuEPO, Kt/V, and PCRn were analyzed using analysis of variance, chi 2 and linear discriminant function (DF) statistical methods. Several significant factors emerged as influencing outcome. The DF analysis produced a highly statistically significant (p < 0.0001) model to predict mortality based upon certain laboratory and dialysis parameters. Further, the linear DF correctly predicted mortality rate in 86% of cases. The results of the analysis revealed an overall mortality rate of 15.6%; hospitalization rates (HR) were 1.4 +/- 1.8 times/year. Length of dialysis time, i.e., dialysis times between 2 and 4 h, when adjusted for Kt/V has no correlation with MR or HR. Variables associated with survival were higher post/predialysis BUN ratios, normal Kt/V (0.8-1.2), normal albumin levels (> 3.5 g/dl), higher postdialysis BUN, creatinine, and cholesterol levels, and use of r-HuEPO. The use of r-HuEPO when analyzed by DF significantly improved MR, 8.3% as opposed to 19.2%. It is concluded that urea kinetic modeling permits shortening dialysis times without affecting mortality or hospitalization rates, and that low postdialysis BUN, post/predialysis BUN ratios, creatinine, and albumin values are correlated with a lower chance of survival.

Case-Mix and Treatment in End-Stage Renal Disease: Hemodialysis v Peritoneal Dialysis

The University of Southern California School of Medicine conducted a nationwide survey of 336 nephrologists to obtain demographic and clinical data on 6,411 patients with end-stage renal disease (ESRD). Patient demographic data, along with ESRD etiology and comorbid conditions noted by the physician, were compared across various modalities of dialysis. Characteristics of the treatment provided were differentiated by the mode of dialysis and the location of the patient encounter. Results of the analysis show that patients on peritoneal dialysis are more likely to be female and have higher rates of diabetes compared with hemodialysis (HD) patients. Statistically, patients on intermittent peritoneal dialysis are older, more likely to be black, and have a higher incidence of cardiovascular conditions. Continuous ambulatory peritoneal dialysis patients have greatest problem severity and require more physician time and more complex services, whereas home HD patients require the greatest number of diagnostic tests and therapeutic procedures. Hospital inpatient care shows greater case-mix severity and more intensive treatment, but this does not differ by the mode of dialysis. Finally, patients of freestanding dialysis facilities are more likely to have hypertensive renal disease, whereas patients at hospital-based facilities are older, more likely to be seen in the hospital, have more urgent and severe problems during dialysis rounds, and require more physician time, more complex services, and more diagnostic tests and therapeutic procedures.

Implementing Organizational Systems to Measure Outcome-Related Processes of End-Stage Renal Disease Care

The process to implement a continuous quality improvement program for the patient with end-stage renal disease requires a basic understanding of the complex medical and often psychological circumstances that affect these patients. The organizational elements require, therefore, a recognition and integration of functions from all those involved in delivering care. This includes the medical, nursing, social work, dietary, and technical staff. In the development and establishment of the quality assessment and improvement program at Our Lady of Lourdes Medical Center, experience has identified certain basic elements to use in the organizational and functional aspects of the system to achieve a measurable level of success. The primary element in establishing such a program begins with the commitment at the highest level of the organizational structure. Selection of leadership whose responsibility is to provide education and direction of staff participants should follow. Through leadership, education, and early staff involvement, physician support is gained that provides the operational elements for a successful program. A multidisciplinary team, representative of the various aspects of care, can then develop a quality assessment and improvement plan that establishes clinical indicators used to measure various quality components. A data collection and review process is the next phase of implementation of the organizational system to measure the various types of outcome and/or processes of care. The process is one of continued education based on outcome data for all staff members involved in care.

End-Stage Renal Disease and the Practice of Nephrology

Data from a national survey of 336 nephrologists who provide dialysis care on capitation reimbursement show differences in practice activity associated with the proportion of patients with end-stage renal disease (ESRD). On the average, ESRD patients account for 53% of patients seen by these physicians. Nephrologists who have the majority of their visits with ESRD patients average more than 120 patient encounters per week, approximating the practice workloads of primary care physicians. Nephrologists spend comparable amounts of time providing treatment for ESRD and non-ESRD patients in the same settings, schedule additional office visits for facility dialysis patients, and provide treatment and advice for problems not related to dialysis. Whereas care for acute renal failure patients is primarily based on consultations and involves a narrow focus, treatment for ESRD involves the provision of comprehensive primary medical care by nephrologists to their patients being treated with dialysis.

Correlates affecting survival in chronic hemodialysis patients: The combined impact of albumin and high hemoglobin levels on improving outcomes, local and national results

While national mortality rates for end‐stage renal disease (ESRD) patients remain high, for the past 4 years, lower than expected local mortality rates have been consistently seen in our facilities. Because of these progressive improvements in mortality rates, a study of 687 hemodialysis patients over a 4‐year period, 2003 through 2006, was undertaken to analyze which factors may be contributing to the enhanced survival rates. We also examined the partially overlapping United States Renal Data System clinical performance measures national data sets of hemodialysis patients for 2001 to 2004. Proportional hazards and logistic regression models were used to determine significant predictors of short‐term survival. Variables tested included hemoglobin (Hb), albumin, calcium, phosphorus, infections, hospitalizations, URR, Kt/V, erythropoietic stimulating agents (epoetin‐α) use, and comorbid conditions. The local and national models identified albumin, Hgb, and hospitalization as statistically significant predictors of survival. Local models also found years of dialysis as a significant predictor. Locally, there was a 69‐fold increase from 16.1 deaths/1000 patient years for albumin ≥4.0 with Hgb≥14.0 to 1115.9 deaths/1000 patient‐years for albumin <3.5 with Hgb<11.0. The increase nationally is a 4‐fold increase from 96 deaths/1000 patient‐years for albumin ≥4.0 with Hgb≥14.0 to 406 deaths/1000 patient‐years for albumin <3.5 with Hgb<11.0. There was no evidence that higher erythropoietic stimulating agents dose levels were associated with higher mortality rates, independent of the other significant factors. In conclusion, the findings indicate that individually higher Hgb and albumin levels are associated with increased survival, and when higher Hgb levels are in association with high albumin levels, the survival rates and hospitalizations are synergistically improved.

When Should Chronic Peritoneal Dialysis Be Recommended Over Hemodialysis

As with any therapeutic modality, the selection process is usually the result of an integration of the patient’s clinical picture and psychosocial needs, with the physician’s judgment, and to some extent, clinical bias. Thus, if one eliminates the one critical element in the end-stage renal disease (ESRD) patient’s clinical picture, i.e., lack of vascular access, there is no single ovemding issue which would compel the physician to recommend CAPD/CCPD over hemodialysis. However, if one looks at trends in current nephrologic practice and clinical studies, there does emerge a pattern into which certain patients should be considered for CAPD/CCPD rather than chronic hemodialysis, and therefore recommendation of this modality is preferred. As one looks at these trends, one notes that chronic peritoneal dialysis has grown from less than 1,OOO cases nationally in 1979, to over 13,000 cases currently, accounting for about 17% of all patients undergoing chronic dialysis and the majority of patients on home dialysis (1). In our own program, there have been a total of 375 patients treated on some form of chronic peritoneal dialysis from 1979 through 1988, representing an average annual caseload of 40%. The advantages of CAPD are listed in Table 1, and serve to offer certain clinical parameters which should be presented to the patient for consideration in determining which mode of therapy may be best suited to the patient’s need. In a recent study by Radecki and co-workers (2), physician practice patterns were analyzed for the selection of patients in various modes of therapy. While primary hypertensive disease (nephrosclerosis, benign and malignant), glomerulonephritis, and diabetic nephropathy account for 70% of all patients on dialysis, 20% to 40% of chronic peritoneal dialysis patients are diabetic as opposed to less than 10% of home hernodialysis patients. Older patients (ie., greater than 65 years), and patients with various cardiac problems (heart failure, arrhythmia, myocarditis, hypotension, and other) were also more likely to be on chronic peritoneal dialysis. Thus, the diabetic geriatric, and symptomatic cardiovascular patient pose recognizable and difficult management problems for therapy with hemodialysis while constituting a large, and growing, proportion of the ESRD caseload. While there have not been any prospective controlled trials, there has a been a general sense among larger centers that the avoidance of anticoagulation and steady-state control of blood pressure and blood chemistries are beneficial factors in the prevention of progressive retinopathy in the diabetic undergoing CAPD as opposed to hemodialysis (1, 3). Another