Developing an anemia management protocol. Case study of the anemic patient.

Anemia is best managed with an effective protocol that provides standardized guidance for clinical interventions while maintaining the flexibility to respond to the needs of individual patients. An anemia management protocol can help nurses and other clinicians: (a) monitor and manage erythropoietic parameters, (b) successfully achieve the higher hematocrit (33% to 36%) and hemoglobin (11 g/dL to 12 g/dL) target levels recommended by the Dialysis Outcomes Quality Initiative (DOQI) guidelines, and (c) maintain a stable Hct to help manage the new Medicare Hematocrit Measurement Audit policy. Maintaining a stable hematocrit higher in the target range has been associated with improved patient outcomes. This article describes how to use a continuous quality improvement (CQI) approach to develop an anemia management protocol. The potential benefits of coordinating protocol implementation through an anemia management nurse are also discussed.

Peritoneal membrane transport function in children receiving long-term dialysis.

Accurate characterization of peritoneal solute transport capacity in children has been hampered by a lack of standardized test mechanics and small patient numbers. A standardized peritoneal equilibration test was used to study 95 pediatric patients (mean age, 9.9 +/- 5.6 yr) receiving chronic peritoneal dialysis at 14 centers. Patients were divided into four age groups (< 1, 1 to 3, 4 to 11, 12 to 19 yr) for analysis. Each patient received a 4-h peritoneal equilibration test with an exchange volume of 1100 mL/m2 per body surface area. Dialysate to plasma (D/P) ratios for creatinine (C) and urea (U) and the ratio of dialysate glucose (G) to initial dialysate glucose concentration (D/D0) were determined. Mass transfer area coefficients (MTAC) were calculated for the three solutes and potassium (P). The mean (+/- SD) 4-h D/P ratios for C and U were 0.64 +/- 0.13 and 0.82 +/- 0.09, respectively. The mean 4-h D/D0 for G was 0.33 +/- 0.10. D/P and D/D0 ratio results were similar across age groups. Normalized (for body surface area) mean MTAC (+/- SD) values were as follows: C, 10.66 +/- 3.74; G, 12.93 +/- 5.02; U, 18.43 +/- 4.02; and P, 14.02 +/- 3.94. Whereas a comparison of the normalized MTAC values across age groups with an analysis of variance showed significant age group differences only for glucose (P = 0.001) and potassium (P = 0.036), analysis by quadratic regression demonstrated a nonlinear decrease with age for C (P = 0.016), G (P < 0.001), and P (P = 0.034). In summary, evaluation of D/P and D/D0 ratios obtained from a large group of children in a standardized manner reveals values that are similar across the pediatric age range and not unlike the results obtained in adults. In contrast, normalized MTAC values of young children are greater than the values of older children, possibly as a result of maturational changes in the peritoneal membrane or differences in the effective peritoneal membrane surface area.

The relationship between intraperitoneal volume and solute transport in pediatric patients. Pediatric Peritoneal Dialysis Study Consortium.

A multicenter study was conducted to determine the relationship between intraperitoneal volume and solute (e.g., urea, creatinine) transport as determined by the dialysate to plasma (D/P) ratio and mass transfer area coefficient (MTAC). Two 4-h peritoneal equilibration tests were conducted on each of 12 pediatric peritoneal dialysis patients (mean age, 10.8 yr; range, 0.2 to 19.2 yr). One test exchange volume was 900 mL/m2 body surface area (BSA), and the other was 1,100 mL/m2 BSA. Dialysate samples were collected at 0, 30, 60, 120, 180, and 240 min. Blood samples were drawn at 0 and 240 min. Solute equilibration was significantly more rapid with the 900 mL/m2 BSA exchange volume than with the 1,100 mL/m2 exchange volume when evaluated by the D/P ratio. In contrast, no differences in solute transport were noted with either exchange volume when assessed with the MTAC. In conclusion, solute D/P ratios vary with changes in the intraperitoneal volume, necessitating the use of a standardized exchange volume for the reliable interpretation of evaluations such as the peritoneal equilibration tests. In contrast, the use of the MTAC allows for an accurate assessment of solute transport over a wide range of exchange volumes.