Adopting on-line hemodiafiltration as standard therapy in EMEA NephroCare centers.

This paper describes the historical journey that led to the adoption of on-line hemodiafiltration (HDF) as a standard therapy for the patients in the Fresenius Medical Care (FME) NephroCare dialysis network. In 1998, FME faced the tremendous challenge of consolidating a series of heterogeneous clinics under one umbrella. In 2002, the European Best Practice Guidelines (EBPG) for hemodialysis (HD) were published by the European Renal Association which FME promptly adopted within its clinic network. On the basis of this document, the strategic decision was taken to apply high-flux, biocompatible membranes throughout the entire network. To cope with the effective implementation of this step, the clinics' technical infrastructure was updated. The widespread application of high-flux therapy, together with the implementation of the required infrastructure, especially concerning water quality, opened the way to the extensive use of on-line HDF. To fully realize this ambitious goal, two further technological steps were targeted and successfully reached: introduction of the Fresenius 5008 dialysis equipment and an even stricter control of the water quality. The combined pressure from the educational activities, which brought about a preliminary cultural change, and the creation of a target based on the percentage of treatments by this technique resulted in an increasing implementation of this modality by the individual clinics. After 2004, on-line HDF continuously increased its share among the dialysis techniques prescribed in the network and currently more than 50% of patients are on this modality.

Haemoglobin level and vascular access survival in haemodialysis patients.

BACKGROUND: A full correction of anaemia in haemodialysis (HD) patients may lead to an increased risk of vascular access (VA) failure. We studied the relationship between haemoglobin (Hb) level and VA survival. METHODS: Incident patients between January 2000 and December 2002 with <1 month on HD were considered. The relative risk (RR) of access failure was evaluated in four different groups of patients divided according to their Hb level (<10, 10-12, 12-13 and >13 g/dl). Other factors possibly influencing VA survival were also considered: age, gender, diabetes, vascular disease, intact parathyroid hormone (iPTH) and treatment with an angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker (ARB) or recombinant human erythropoeitin therapy. RESULTS: We studied 1254 patients (1057 with autologous fistulae, 75 grafts and 122 permanent catheters at admission). Based on Cox analysis, we found the next statistically significant RR of VA failure to be 2.3 times higher with grafts than with arterio-venous fistulae (AVFs) and 1.8 times higher in AVFs with Hb <10 g/dl than in AVFs of the next Hb group. There was no statistically significant difference in the RR of VA failure between patients with Hb 10-12 g/dl and those with Hb 12-13 g/dl or >13 g/dl. Diabetes (RR: 1.41, P = 0.06), age >65 years (RR: 1.32; P = 0.11) and iPTH (RR: 1.56; P = 0.01) were identified as predictive factors for VA failure; ACE inhibitors or ARB (RR: 0.69; P = 0.03) were found to be protective factors. CONCLUSIONS: In the studied population, the correction of Hb level to >12 g/dl was not associated with a higher incidence of VA thrombosis than in patients with Hb between 10 and 12 g/dl. ACE inhibitors or ARBs were found to be protective factors, and diabetes, age >65 years and iPTH >400 pg/ml were negative predictive factors for VA survival.