Patient-Reported Factors Associated With Poor Phosphorus Control in a Maintenance Hemodialysis Population.

OBJECTIVE: The purpose of this study was to determine the influence of patient-reported medication adherence and phosphorus-related knowledge on phosphorus control and pharmacy-reported adherence to phosphorus binding medication among patients on maintenance hemodialysis. DESIGN: Retrospective, cross-sectional cohort study. SUBJECTS: Seventy-nine hemodialysis patients (mean age 64.2 years, SD = 14 years; 46.8% female) in a stand-alone hemodialysis unit within an integrated learning healthcare system. Ten percent (10%) of subjects were Caucasian, 42% Latino, 19% African American, and 29% Asian. Forty-eight percent had diabetes; 72% had BMI ≥ 30. Inclusion criteria included the provision of survey data and having medication refill data available in the pharmacy system. 77.2% had mean phosphorus levels ≤ 5.5 mg/dL; 22.8% had mean phosphorus levels > 5.5 mg/dL. INTERVENTION: Subjects were administered the 8-item Morisky Medication Adherence Scale (MMAS-8) and also reported on their phosphorus-related knowledge. MAIN OUTCOME MEASURE: Phosphorus levels within an adequate range. RESULTS: The mean serum phosphorus level was 4.96 mg/dL (SD = 1.21). In the well-controlled group, mean phosphorus was 4.44 mg/dL (SD = 0.76). In the poorly controlled group, mean phosphorus was 6.69 mg/dL (SD = 0.74). A total of 61% of patients reported at least some unintentional medication nonadherence, and 48% reported intentional medication nonadherence. Phosphorus-specific knowledge was low, with just under half of patients reporting that they could not name two high-phosphorus foods or identify a phosphorus-related health risk. Phosphorus binder-related nonadherence was substantially higher in the uncontrolled than the controlled group. Adjusting for age, individuals with poorer self-reported binder adherence were less likely to have controlled phosphorus levels (odds ratio = 0.71, P = .06). CONCLUSION: Phosphorus-related non-adherence, but not low phosphorus-specific knowledge, was associated with poorer phosphorus control. Such findings provide important information for the development of evidence-based strategies for improving phosphorus control among patients on dialysis.

False estimates of elevated creatinine.

One of the most common reasons for a nephrology consult is an elevated creatinine. An elevation in the serum creatinine concentration usually reflects a reduction in the glomerular filtration rate (GFR). Given the association of elevated creatinine and risk of cardiovascular mortality, it is important to keep in mind that at times the elevation of the creatinine is not representative of a true reduction in GFR. There are various causes of factitious elevation of creatinine. They can be broadly grouped into increased production of creatinine, interference with the assay and decreased tubular secretion of creatinine.

Hyponatremia-what is cerebral salt wasting?

BACKGROUND: Hyponatremia is a common electrolyte imbalance in hospitalized patients. It is associated with significant morbidity and mortality, especially if the underlying cause is incorrectly diagnosed and not treated appropriately. Often, the hospitalist is faced with a clinical dilemma when a patient presents with hyponatremia of an unclear etiology and with uncertain volume status. Syndrome of inappropriate antidiuretic hormone (SIADH) is frequently diagnosed in this clinical setting, but cerebral salt wasting (CSW) is an important diagnosis to consider. OBJECTIVE: We wanted to describe the diagnosis, treatment, and history of CSW to provide clinicians with a better understanding of the differential diagnosis for hyponatremia. CONCLUSION: CSW is a process of extracellular volume depletion due to a tubular defect in sodium transport. Two postulated mechanisms for CSW are the excess secretion of natriuretic peptides and the loss of sympathetic stimulation to the kidney. Making the distinction between CSW and SIADH is important because the treatment for the two conditions is very different.

Comparison of outcomes of peritoneal dialysis catheters placed by the fluoroscopically guided percutaneous method versus directly visualized surgical method.

PURPOSE: To compare complications in catheters placed by the fluoroscopically guided percutaneous method versus directly visualized surgery. MATERIALS AND METHODS: A retrospective cohort analysis was performed. Mechanical complication rate data, including catheter leakage, malfunction, malposition, and bleeding, were compared between the two groups over a 1-year follow-up period. Additionally, exit site infection rates, tunnel infection rates, and peritonitis episodes were evaluated based on the incidence within 30 days of insertion and 30 days to 1 year after insertion. RESULTS: A total of 101 patients were analyzed (52 in the fluoroscopic guidance group, 49 in the direct visualization group). Prevalence of diabetes was similar: 56% in the directly visualized surgery group and 47% in the fluoroscopically guided treatment group (P = .37). Although the difference was not significant, complication rates tended to be higher in the directly visualized surgery group compared with the percutaneous placement group. These included catheter leakage (13% vs 4%; P = .093), malfunction (11% vs 9%; P = .73), malposition (13% vs 6%; P = .20), and bleeding (8% vs 2%; P = .21). There were no differences in early and late exit site infections and tunnel infections. Late peritonitis rates were lower in the percutaneous placement group (20%) than in the direct visualization group (42%) (P = .018). Diabetic patients had approximately six times greater risk of catheter malfunction than nondiabetic patients regardless of method of catheter insertion. CONCLUSIONS: Placement of peritoneal dialysis catheters percutaneously with fluoroscopic guidance is as safe as placement with direct visualization techniques.

Impact of predialysis care on clinical outcomes.

INTRODUCTION: A structured predialysis multidisciplinary team program is beneficial in improving quality of life in patients with end-stage renal disease (ESRD). Educating pre-ESRD patients about their disease is vital in their care. Patients who can identify signs and symptoms of impending problems can seek help and avoid complications that may lead to hospital admissions. Our dialysis center offers two predialysis classes in a structured format. The first class is for those patients with mild to moderate renal disease, whereas the second class is for those with advanced renal disease who are expected to need dialysis in 3 to 6 months. The patients are followed by a multidisciplinary team once they are enrolled in our chronic kidney disease program. METHODS: We retrospectively reviewed all the charts of patients who started dialysis at our center between 1997 and 2000. We identified 68 patients who participated in the predialysis education program and 35 patients who did not because of late referral or refusal to participate. We compared these two groups over a 100-day period (10 days before initial dialysis and 90 days after), for hospitalizations, emergency room (ER) visits, and dialysis access placement. Patients' comorbid conditions, complications, and length of hospitalizations were extracted from the medical records. RESULTS: The 68 patients who completed the predialysis program had an average age of 60.3 years, a total of 96 hospital days, and 39 ER visits. Average length of hospital stay for these patients was 1.4 days. Three patients (4.4%) required placement of temporary catheters for the initial dialysis. Fifty-one percent of these patients had diabetes mellitus. The 35 patients of average age of 54.9 years who did not go through the program had 347 total hospital days and 39 ER visits. Average length of hospitalization was 9.9 days. Thirteen patients (37%) required temporary catheters for initial dialysis. This group included 16 patients (45.7%) with diabetes. CONCLUSION: Patients who participated in a multidisciplinary predialysis education program had fewer complications, ER visits, and hospitalizations. They also had fewer temporary catheter placements, shorter hospital stays, and reduced costs associated with initial dialysis.