Compliance with subcutaneous erythropoietin in peritoneal dialysis patients.

The use of erythropoietin in dialysis patients is associated with improved quality of life and may lead to improved outcomes. Peritoneal dialysis patients are generally taught to give subcutaneous erythropoietin at home. The purpose of this study was to determine compliance with erythropoietin use in peritoneal dialysis patients. Records of patient prescriptions, refills of erythropoietin, the person administering the injection, and average hematocrit were retrospectively examined. Demographic and comorbidity data were collected prospectively on all peritoneal dialysis patients. The use of more than 90% of the prescribed dose was considered compliant. Data were available for 55 patients. The mean follow-up time was 12 months. Thirty patients (55%) were noncompliant with erythropoietin. Compliant patients were older (65.4 years vs 50 years, p = 0.01), had higher comorbidity (p = 0.01), higher average hematocrit (34% vs 31.5%, p < 0.003) and were less likely to self-administer the injection. Sex, diabetes, and compliance with dialysis exchanges were not associated with erythropoietin compliance. Using logistic regression, the only significant variable was the person administering the erythropoietin (r = 0.46, p = 0.005). Noncompliance with subcutaneous erythropoietin is a significant problem. Compliance may improve if someone other than the patient is trained to administer it.

A survey of home visits at peritoneal dialysis centers in the United States.

OBJECTIVE: To determine the frequency and characteristics of home visits in centers that provide training for peritoneal dialysis (PD). DESIGN: Mail survey sent to all dialysis centers in the United States providing home PD, using the Health Care Federal Administration (HCFA) Renal Provider list. RESULTS: Surveys were mailed to 1247 centers; 13 were undeliverable, resulting in 1234 surveys successfully delivered; 670 (54%) of those surveyed responded. Of those responding, 525 (78.4%) reported home visits were part of the care of home PD patients: 11% made a single home visit, 52% made an initial home visit with at least one follow-up visit, and 16% made visits only as needed. No home visits were made by 21% of responding centers. A registered nurse (RN) alone made the home visit in 61% of the centers, while a multidisciplinary team accompanied the RN in 35% of centers; 3% of visits were made by a licensed practical nurse, and 1% by the physician. Half of the visits required 0.5-1 hour, while 41% required 1-2 hours. Travel time was most often an hour or less one way. Staff were reimbursed for travel expenses by 90% of the centers. The 525 centers making home visits were not different than the 145 centers not making home visits in number of patients per center, number of RNs, rural or urban location, or affiliation with a university. Interpretation of the HCFA regulations concerning home visits was the most important factor influencing centers making home visits. CONCLUSIONS: Home visits to continuous ambulatory PD and continuous cycling PD patients in the United States are common. Nearly 80% of centers responding to the survey include home visits in the care of their home peritoneal dialysis patients.

Factors influencing dialysis patients' completion of advance directives.

Although chronic dialysis patients support the use of advance directives, they rarely complete them. We asked 80 chronic dialysis patients (60 receiving in-center hemodialysis and 20 receiving peritoneal dialysis) why they had not completed an advance directive, and gave them the opportunity to complete a dialysis-specific living will and to designate a health care proxy. Questionnaires containing the dialysis-specific living will, patient demographic information, and questions about advance directives were distributed during a routine hemodialysis session or peritoneal dialysis clinic visit by a nurse working in the unit. Forty-one hemodialysis patients and 14 peritoneal dialysis patients completed the questionnaires (69% response rate). The mean age was 53 +/- 15 years and the mean time on dialysis was 5 +/- 5 years. Fifty-eight percent of the patients were women, 57% were white, 67% were hospitalized in the past year, 23% were employed, 70% had children, and 21% lived alone (43% lived with a partner and 11% lived with parents). All patients thought advance directives were a good idea, but only 35% had completed one and only seven (14%) had discussed wishes for life-sustaining therapy with their nephrologist; 34 patients (67%) had discussed their wishes with their family. Most said they had not completed an advance directive because their family knew what they would want (12 of 32 patients [38%]). Thirty-nine patients who completed the questionnaire also completed the dialysis-specific living will (71%). Those who did not complete the dialysis-specific living will chose not to because they were not sure what they would want done (12 of 16 patients [75%]). The only demographic factor that influenced completion of the dialysis-specific living will was having children: more patients with children did not complete the will (12 of 37 patients [32%] with children v two of 16 patients [13%] without children; P = 0.02). The dialysis-specific living will asks about choices for life-sustaining treatment (cardiopulmonary resuscitation and dialysis) based on one's health state (current health; permanent coma; terminal illness; mild, moderate, or severe stroke; dementia). Using patient-specific advance directives that focus on health states rather than life-sustaining interventions (eg, the dialysis-specific living will) and repeated discussion of advance directives and advance care planning initiated by dialysis unit staff may improve the completion of advance directives by chronic dialysis patients. The appropriate focus of such issues should include family involvement and health states rather than treatment interventions.

The influence of nutritional status, dialysis adequacy, and residual renal function on the response to hepatitis B vaccination in peritoneal dialysis patients.

Little is known about the factors contributing to the reduced antibody response to hepatitis B vaccination in peritoneal dialysis patients. The influence of nutritional status [as assessed by serum albumin and nitrogen protein appearance (nPNA)], residual renal function, and dialysis adequacy (weekly Kt/V(urea)) on the development of hepatitis B antibodies was examined in 32 continuous ambulatory peritoneal dialysis/continuous cycling peritoneal dialysis patients. Vaccination with Engerix 40 micrograms given intramuscularly at 0, 1, 2, and 6 months resulted in a 63% response with 20 converters and 12 nonconverters. Patient age, sex, months on peritoneal dialysis, and race were not different among converters and nonconverters. Median serum albumin (3.75 vs 3.8 g/dL), nPNA (0.96 vs 0.94 g/kg/day initial and 0.78 vs 0.84 g/kg/day final), residual renal function (5.4 vs 4.0 mL/min), and final weekly Kt/V (2.12 vs 1.96) were not different among converters and nonconverters, respectively. Initial Kt/V was higher in converters (2.37 vs 2.01, p = 0.02). Nutritional status, residual renal function, and weekly Kt/V in nutritionally replete and well-dialyzed peritoneal dialysis patients do not predict response to hepatitis B vaccine. Patients with higher weekly Kt/V early in the course of peritoneal dialysis may be more likely to respond to hepatitis B vaccination.

Managing Staphylococcus aureus catheter infection in continuous ambulatory peritoneal dialysis patients.

A case of Staphylococcus aureus catheter infection in a patient on peritoneal dialysis is presented and discussed by nephrologists, a social worker, a nurse specializing in the care of peritoneal dialysis patients, and the patient involved. The focus of the multidisciplinary case discussion concerns the management of S aureus catheter infections, including catheter removal, psychosocial issues and the patient's response to the need for catheter removal, the risk factors and prevention of S aureus catheter infections in peritoneal dialysis patients, and exit site care practices.

Identifying elderly patients for early discharge after hospitalization for hip fracture.

BACKGROUND: Some elderly patients can be successfully treated in hospitals with lengths of stay (LOS) shorter than the norms developed by the diagnosis-related groups. This study was designed to test the hypothesis that elderly patients with short LOS after hip fracture have characteristics that can be identified shortly after hospital admission. METHODS: A retrospective chart review was performed of 216 patients over age 55 discharged alive from a university hospital after hip fracture. Demographic, medical, and functional data available within 48 hours of admission were used to develop an algorithm to identify patients eligible for early discharge. A prospective study of an additional 33 patients was undertaken to test this algorithm and to examine the predictive value of additional functional and psychosocial information not routinely recorded in the chart. RESULTS: Retrospective chart review identified 4 predictors of short LOS in multivariate analysis: age less than 75, admission from a nursing home, normality of admission laboratory results, and "no surgery or surgery by day three." These variables explain 25% of the total variation of LOS. In our prospective study the variable "day of surgery" had the greatest variance explanation (30.5%) in multivariate analysis. A model including day of surgery and the presence of dementia explained 42.5% of the variance of LOS. CONCLUSION: Short LOS can be predicted within 48 hours of admission utilizing data that measure severity of illness, functional status, and available support. The development of algorithms to identify patients eligible for early discharge would be beneficial to care managers.

Decreased tetanic contracture of rat skeletal muscle induced by pyridostigmine.

The purpose of this study was to compare the effects of various regimens of pyridostigmine administration on the contractile strength of skeletal muscle. Rats were exposed to pyridostigmine according to 3 dosing schedules: 2 mg/kg ip daily, 5 mg/kg X d by sc infusion, and 25 mg/kg X d by sc infusion. After 1, 4, 10, and 20 d of exposure, measurements were made of muscle tension during tetanic stimulation, and of muscle mass, erythrocyte acetylcholinesterase activity, and body weight. Pyridostigmine produced a dose-dependent decrement in the contracture generated during tetanic stimulation. Peak effect was observed after 4 d of exposure but remained depressed after 20 d. The magnitude of the decrement correlated with the frequency of the tetanic stimulation (from 20 to 100 Hz). Muscle tension at the end of the tetanic stimulus was affected to a greater extent than the initial tension. The 25-mg/kg infusion of pyridostigmine significantly depressed erythrocyte acetylcholinesterase activity throughout the study and also decreased body weight on d 1-4. No change in muscle mass was observed in any treatment group. These results show that pyridostigmine exposure results in decrements in skeletal muscle contracture that are dose-dependent, frequency-dependent, and time-dependent. The effect is probably not the result of muscle wasting and does not correlate well with erythrocyte acetylcholinesterase inhibition. The results are consistent with effects of pyridostigmine, both presynaptically and postsynaptically, at the neuromuscular junction that affect neurotransmitter release and receptor responsiveness.