Home run-results of a chronic kidney disease Telemedicine Patient Education Study.

BACKGROUND: Chronic kidney disease (CKD) incidence is increasing and associated mortality and morbidity are high. Educating patients is effective in delaying progression and establishing optimal renal replacement therapy (RRT). Tele-education/telemedicine (TM) can be an effective tool to provide such education, but there are no available data quantifying its effectiveness. We attempted to establish such evidence correlating the effect of education in patient choices and with the start of actual RRT. We present results from a 3-year pilot study evaluating the effectiveness of comprehensive predialysis education (CPE) through TM for CKD patients compared with a standard care group [face to face (FTF)]. The patient's ability to choose RRT was the primary endpoint. METHODS: This was a randomized controlled study providing CPE over three classes at nine sites (one FTF and eight TM). Three assessment tools were utilized to compare groups: CKD knowledge, literacy and quality of life. RESULTS: A total of 47.1% of FTF and 52.2% of TM patients reported not having enough information to choose a modality. This decreased by the third visit (FTF 7.4%, TM 13.2%). Home modality choices more than doubled in both groups (FTF 25.8-67.7%, TM 22.2-50.1%). In patients that completed one visit and needed to start RRT, 47% started on a home modality or received a pre-emptive transplant (home hemodialysis 6%, peritoneal dialysis 38%, transplant 3%). CONCLUSIONS: Results show almost 90% (TM 87%, FTF 95%) of the attendees could choose a modality after education. Home modality choices doubled. Patients were able to make an informed choice regardless of the modality of education.

Recommended Clinical Trial End Points for Dialysis Catheters.

Central venous catheters are used frequently in patients on hemodialysis as a bridge to a permanent vascular access. They are prone to frequent complications, including catheter-related bloodstream infection, catheter dysfunction, and central vein obstruction. There is a compelling need to develop new drugs or devices to prevent central venous catheter complications. We convened a multidisciplinary panel of experts to propose standardized definitions of catheter end points to guide the design of future clinical trials seeking approval from the Food and Drug Administration. Our workgroup suggests diagnosing catheter-related bloodstream infection in catheter-dependent patients on hemodialysis with a clinical suspicion of infection (fever, rigors, altered mental status, or unexplained hypotension), blood cultures growing the same organism from the catheter hub and a peripheral vein (or the dialysis bloodline), and absence of evidence for an alternative source of infection. Catheter dysfunction is defined as the inability of a central venous catheter to (1) complete a single dialysis session without triggering recurrent pressure alarms or (2) reproducibly deliver a mean dialysis blood flow of >300 ml/min (with arterial and venous pressures being within the hemodialysis unit parameters) on two consecutive dialysis sessions or provide a Kt/V≥1.2 in 4 hours or less. Catheter dysfunction is defined only if it persists, despite attempts to reposition the patient, reverse the arterial and venous lines, or forcefully flush the catheter. Central vein obstruction is suspected in patients with >70% stenosis of a central vein by contrast venography or the equivalent, ipsilateral upper extremity edema, and an existing or prior history of a central venous catheter. There is some uncertainty about the specific criteria for these diagnoses, and the workgroup has also proposed future high-priority studies to resolve these questions.

Effects of a Comprehensive Predialysis Education Program on the Home Dialysis Therapies: A Retrospective Cohort Study.

BACKGROUND: Improvement in the rates of home dialysis has been a desirable but difficult-to-achieve target for United States nephrology. Provision of comprehensive predialysis education (CPE) in institutes with established home dialysis programs has been shown to facilitate a higher home dialysis choice amongst chronic kidney disease (CKD) patients. Unfortunately, limited data have shown the efficacy of such programs in the United States or in institutes with small home dialysis (HoD) programs. METHODS: We report the retrospective findings examining the efficacy of a CPE program in the early period after its establishment, with reference to its impact on the choice and growth of a small HoD program. RESULTS: Over the initial 22 months since its inception, 108 patients were enrolled in the CPE clinic. Seventy percent of patients receiving CPE chose HoD, of which 55% chose peritoneal dialysis (PD) and 15% chose home hemodialysis (HHD). Rates of HoD choice were similar across the spectrum of socio-economic variables. Of just over half (54.6%) of those choosing to return for more than 1 session, 25.3%, changed their modality preference after the first education session, and nearly all reached a final modality selection by the end of the third visit. Initiation of the CPE program resulted in a 216% growth in HoD census over the same period and resulted in near doubling of HoD prevalence to 38% of all dialysis patients. CONCLUSIONS: Comprehensive patient education improves the choice and prevalence of HoD therapies. We further find that 3 sessions of CPE may provide needed resources for the large majority of subjects for adequate decision-making.

A quality improvement project: Strategies to reduce intradialytic hypotension in hemodialysis patients.

Intradialytic hypotension is defined as a decrease in systolic blood pressure by ≥ 20 mm Hg or a decrease in mean arterial pressure by 10 mm Hg, and is associated with symptoms that include abdominal discomfort, yawning, sighing, nausea, vomiting, muscle cramps, restlessness, dizziness or fainting, and anxiety. The incidence of a symptomatic reduction in blood pressure during (or immediately following) dialysis ranges from 15-50% of dialysis sessions. It is a major cause for morbidity in elderly hemodialysis patients and those with cardiovascular compromise. It impairs patient well-being, limits ultrafiltration, and increases the risk for coronary and cerebral ischemic events as well as vascular access thrombosis. Several studies have shown a poorer survival in dialysis patients who experience frequent hypotensive episodes on dialysis as opposed to those who do not. In our outpatient dialysis unit, we identified that 9% of our dialysis patients experienced a decrease in their systolic blood pressure to below 80 during dialysis. The purpose of this quality improvement project was to study the factors associated with intradialytic hypotension in these patients and institute appropriate measures to mitigate this issue. Another aim was to educate the dialysis staff on how to manage these patients. Patients were selected using data from weekly rounding reports and orders were written for interventions including ultrafiltration profiling, cool (36 degrees C) dialysate, weight-based ultrafiltration, etc. Outcomes were studied over a period of 3 months. We found that up to 40% of patients experienced an improvement in their blood pressure profile over the period of the study, suggesting that simple changes to dialysis prescription can result in a significant reduction in the incidence of intradialytic hypotension.

Correcting iron-restricted erythropoiesis and improving anemia in patients on hemodialysis: practical tips that can make a difference.

In healthy individuals, the body remains in an iron-balanced state. Iron intake and loss on a daily basis is minimal, and the majority of iron in the body is recycled. However, patients on hemodialysis may have an insufficient supply of iron available to the bone marrow for erythropoiesis, a condition known as iron-restricted erythropoiesis or inflammation-mediated reticuloendothelial blockade. This state may occur as a result of an inflammatory process and can limit the patient's ability to respond to erythropoiesis-stimulating agents (ESAs). Intravenous (IV) iron supplementation may be needed to overcome iron-restricted erythropoiesis and improve ESA response. This article focuses on the complex relationship among the three I's in anemia management: inflammation, iron-restricted erythropoiesis, and IV iron treatment.

Updating practices in an evolving IV iron and anemia environment: practical solutions.

The latest considerations in the management of iron-deficiency anemia in patients on hemodialysis have centered on the updated guidelines and recommendations issued by the National Kidney Foundation, with interest on appropriate hemoglobin and serum ferritin targets. With practices evolving in the anemia environment, it is necessary for nurses to stay informed of new evidence-based data and practical solutions to improve patient outcomes. This underscores the importance of a team approach to managing anemia and balanced therapy with intravenous iron and erythropoiesis-stimulating agents. A symposium held during the 2007 annual meeting of the American Nephrology Nurses' Association addressed these issues. This article is based on the presentations and discussions from that symposium.

The challenges of using serum ferritin to guide i.v. iron treatment practices in patients on hemodialysis with anemia.

Expert guidelines recommend routine administration of intravenous iron therapy and frequent monitoring of iron status for patients on hemodialysis who are being treated for anemia with erythropoiesis-stimulating agents. However, monitoring iron status using conventional markers, such as serum ferritin, may be complicated by acute and chronic inflammation and malnutrition, which are common in this patient population. Therefore, nephrology nurses must be knowledgeable of the limitations of using serum ferritin to assess iron status and how to interpret high serum ferritin values to effectively treat patients on hemodialysis with anemia.