[Accumulated experience in the analysis of quality indicators in a haemodialysis unit]. / Experiencia acumulada en el análisis de indicadores de calidad en una unidad de hemodiálisis.

INTRODUCTION: The object of this work was to review our use of various indicators of haemodialysis within the guidelines of good clinical practice. MATERIALS AND METHODS: The study includes all patients from our haemodialysis program from June 2005 to February 2008. The indicators we evaluated included various areas: anaemia, bone-mineral metabolism, dialysis dose, cardiovascular risk, vascular access and morbidity/ mortality. The measurement intervals varied according to the parameter being evaluated. RESULTS: We gathered those indicators in which we found a difference between our results and the targets set. It is possible to reach a haemoglobin of > or = 11 g/dl in more than 85% of the patients, although more than 20% of them showed > 13 g/dl. We were able to stay on target with phosphorous (> 85%) but not with calcium (72.7%) or PTH (38.8%) although average values were improved. The incorporation of new patients to the haemodialysis programme, some previously unknown, limited our possibilities of achieving > or = 85% with a Kt/V > or = 1.3. Only 62.2% of the patients had a systolic blood pressure of < or = 140 mmHg. The percentage of patients dialysed by catheter (objective < 10%) was only achieved in five out of the eleven measures. The hospitalisation rate was between 0.49 and 0.71 episodes/patient/year. The patient survival rates coincide with those of the Comunidad Valenciana Register. CONCLUSION: the use of clinical performance measures has improved our results, whilst in some cases it has raised doubts over their definition and established targets. In general we feel that they should be revised and redefined where necessary in an attempt to avoid variability, iatrogenia, and increased costs. The use of only those indicators in which a clear scientific basis is evident, should be considered.

Accumulated experience in the analysis of quality indicators in a haemodialysis unit

Introducction: The object of this work was to review our use of various indicators of haemodialysis within the guidelines of good clinical practice. Materials and Methods: The study includes all patients from our haemodialysis program from June 2005 to February 2008. The indicators we evaluated included various areas: anaemia, bone-mineral metabolism, dialysis dose, cardiovascular risk, vascular access and morbidity/ mortality. The measurement intervals varied according to the parameter being evaluated. Results: We gathered those indicators in which we found a difference between our results and the targets set. It is possible to reach a haemoglobin of >_ 11g/dl in more than 85% of the patients, although more than 20% of them showed > 13g/dl. We were able to stay on target with phosphorous (> 85%) but not with calcium (72.7%) or PTH (38.8%) although average values were improved. The incorporation of new patients to the haemodialysis programme, some previously unknown, limited our possibilities of achieving >_85% with a Kt/V >_ 1.3. Only 62.2%of the patients had a systolic blood pressure of <_ 140mmHg.The percentage of patients dialysed by catheter (objective< 10%) was only achieved in five out of the eleven measures. The hospitalisation rate was between 0.49 and 0.71episodes/patient/year. The patient survival rates coincide with those of the Comunidad Valenciana Register. Conclusion: the use of clinical performance measures has improved our results, whilst in some cases it has raised doubts over their definition and established targets. In general we feel that they should be revised and redefined where necessary in an attempt to avoid variability, iatrogenia, and increased costs. The use of only those indicators in which a clear scientific basis is evident, should be considered (AU)

Introducción: El objetivo de nuestro trabajo es analizar nuestra experiencia en el manejo de varios indicadores de calidad en Hemodiálisis (HD) basados en las guías de buena práctica clínica. Material y método: hemos estudiado a todos los pacientes prevalentes de nuestro programa de HD desde junio de 2005 a febrero de2008. Los indicadores evaluados abarcaban diferentes áreas: anemia, metabolismo óseo-mineral, adecuación, riesgo cardiovascular, accesos vasculares y morbimortalidad. Las mediciones se han realizado con diferente periodicidad en función de la definición de cada uno de ellos. Resultados: recogemos los de aquellos indicadores en los que hemos encontrado una controversia entre nuestros resultados y los objetivos pretendidos. Es posible alcanzar una hemoglobina >_11 g/dl en más del 85% de pacientes, pero con más del 20% con hemoglobina >13 g/dl. Logramos alcanzar el estándar con el fósforo (>85%), pero no con el calcio (72,7%) ni con la Hormona Paratiroidea (PTH) (38,8%), aunque con mejoría en los valores medios. La incorporación de nuevos pacientes al programa de HD, algunos no conocidos, nos impide alcanzar el estándar (>_85%) con Kt/V >_1,3 de forma constante. Sólo un62,2% de pacientes alcanzó cifras de Tensión Arterial Sistólica(TAS) <_140 mmHg. El porcentaje de pacientes dializados a través de catéter (objetivo <10%) sólo lo cumplimos en 5 de 11 mediciones. La tasa de hospitalización se situó entre 0,49 y 0,71 episodios/paciente/año. La supervivencia es superponible a los resultados del Registro de la Comunidad Valenciana. Conclusión: la medida de indicadores en nuestra (..)(AU)

Comentarios a la propuesta de indicadores del grupo de gestión de calidad de la SEN / No disponible

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Resultados del acceso vascular en mayores de 75 años / Vascular access outcome in patients aged over 75 years

Estudio retrospectivo de 30 meses sobre las fístulas autólogas (n = 132), prótesis vasculares (n = 12) y catéteres tunelizados (n = 27) de los 144 pacientes tratados en nuestra unidad en dicho periodo, comparando los resultados en función de la edad: mayores de 75 años (n = 58, 80,3 ± 3,5 años) vs menores de 75 años (n = 86, 59,5 ± 13,3 años) e incluyendo en el análisis las variables sexo, presencia de diabetes mellitus y tipo de fístula. Resultados: No hubo diferencias en las necesidades de uso de catéteres tunelizados o prótesis vasculares como acceso vascular definitivo entre mayores y menores de 75 años (8,6% vs 5,8% y 5,2% vs 10,5% respectivamente), tampoco en el fallo primario de fístulas autólogas (7,1% vs 25,5%), tasa de trombosis (0,03 vs 0,09/paciente y año) ni en los procedimientos percutáneos o quirúrgicos para mantener la permeabilidad de la fístula (0,11 vs 0,16/paciente y año). No hubo diferencias en función de la edad en las permeabilidades primaria, primaria asistida y secundaria de las fístulas autólogas. La edad media de realización de una fístula humerocefálica como primer acceso fue mayor que en las radiocefálicas (74,9 ± 9,3 vs 64,9 ± 16,2 años, p < 0,005). La diabetes fue un factor desfavorable en las permeabilidades primaria (RR Cox 2,08, p < 0,05) y secundaria (Log Rank p = 0,05). Conclusiones: Los accesos vasculares para hemodiálisis de los pacientes ancianos presentan una evolución similar a los de los más jóvenes si su realización se basa en un estudio exhaustivo, incluyendo el ecodoppler, de su árbol vascular y utilizando vasos más proximales si es preciso. Por lo tanto, no está justificado el uso de prótesis vasculares o catéteres con mayor frecuencia que en otros pacientes

We report a retrospective study on the results of 132 native fistulas, 12 grafts and 27 tunneled catheters followed during 30 months in 144 patients on hemodialysis. The results were compared according to patient age: 75 years or over (n = 58, 80.3 ± 3.5) vs below 75 years (n = 86, 59.5 ± 13.3). Gender, presence of diabetes and type of fistula were also included in the analysis. Results: There were no statistically significant differences between both groups in the use of tunneled catheters or grafts (8.6% vs 5.8% y 5.2% vs 10.5% respectively), primary failure of native fistulas (7.1% in those aged 75 years or over vs 25.5% in patients below 75 years), rate of thrombosis (0.03 vs 0.09/patient year at risk respectively) or number of percutaneous or surgical procedures in order to maintain the fistula patency (0.11 vs 0.16/patient year at risk respectively). At the same time no differences were seen in the primary, primary assisted and secondary patency of the native fistulas. The mean age of the patients when the first access fistula was created was different according to the area of surgery (74.9 ± 9.3 for the elbow vs 64.9 ± 16.2 years for the forearm, p < 0.005). Diabetes was an unfavourable factor for primary (HR Cox 2.08, p < 0.05) or secondary (Log Rank, p < 0.05) patency. Conclusion: The vascular access for hemodialysis in elderly patients presents a similar evolution to that seen in younger populations if the access creation is based on an exhaustive study, including ecodoppler of the vascular map and the use of more proximal fistulas if necessary. Therefore the more frequent use of grafts or catheters in elderly patients is not justified

Fracaso renal agudo anúrico secundario a tratamiento con acetazolamida / Anuric acute renal failure due to acetazolamide

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[Vascular access outcome in patients aged over 75 years]. / Resultados del acceso vascular en mayores de 75 anos.

UNLABELLED: We report a retrospective study on the results of 132 native fistulas, 12 grafts and 27 tunneled catheters followed during 30 months in 144 patients on hemodialysis. The results were compared according to patient age: 75 years or over (n = 58, 80.3 +/- 3.5) vs below 75 years (n = 86, 59.5 +/- 13.3). Gender, presence of diabetes and type of fistula were also included in the analysis. RESULTS: There were no statistically significant differences between both groups in the use of tunneled catheters or grafts (8.6% vs 5.8% y 5.2% vs 10.5% respectively), primary failure of native fistulas (7.1% in those aged 75 years or over vs 25.5% in patients below 75 years), rate of thrombosis (0.03 vs 0.09/patient year at risk respectively) or number of percutaneous or surgical procedures in order to maintain the fistula patency (0.11 vs 0.16/patient year at risk respectively). At the same time no differences were seen in the primary, primary assisted and secondary patency of the native fistulas. The mean age of the patients when the first access fistula was created was different according to the area of surgery (74.9 +/- 9.3 for the elbow vs 64.9 +/- 16.2 years for the forearm, p < 0.005). Diabetes was an unfavourable factor for primary (HR Cox 2.08, p < 0.05) or secondary (Log Rank, p <0.05) patency. CONCLUSION: The vascular access for hemodialysis in elderly patients presents a similar evolution to that seen in younger populations if the access creation is based on an exhaustive study, including ecodoppler of the vascular map and the use of more proximal fistulas if necessary. Therefore the more frequent use of grafts or catheters in elderly patients is not justified.

[Enzyme replacement therapy in Fabry's disease]. / Terapia de sustitución enzimática en la enfermedad de Fabry: evaluación clínico-histológica tras 18 meses de terapia.

We report a 56-year-old man with history of chronic renal failure, who was diagnosed to have Fabry's disease after performing a percutaneous kidney biopsy. The diagnosis was confirmed by the deficient level of activity of alpha-galactosidase A and by the identification of the mutation. A enzime replacement therapy with alpha-galactosidase A was administered. After 18 months of treatment, a second kidney biopsy was performed showing renal deposits of globotriaosylceramide (we did not evaluate the percentage of histologic clearance of the deposits). Six months after the end of the therapy, a reduction in the impairment of renal function is observed, and the classic manifestations of the disease are absent.

Terapia de sustitución enzimática en la enfermedad de Fabry: evaluación clínico-histológica tras 18 meses de terapia / Enzyme replacement therapy in fabary's disease

Presentamos el caso de un varón de 56 años, con enfermedad de Fabry diagnosticadatras la realización de biopsia renal por cuadro de insuficiencia renal crónica.La determinación de niveles de actividad enzimática disminuidos de la a-galactosidasaA leucocitaria y la identificación de la mutación, confirmaron eldiagnóstico. Se administra tratamiento de remplazamiento enzimático con alfa-galactosidasa. Tras 18 meses de terapia se ha objetivado un enlentecimiento en elritmo de progresión de la insuficiencia renal crónica, sin aparición de nuevas manifestacionesatribuibles a la enfermedad. Se practicó una segunda biopsia renalobservando que los depósitos de globotriasilceramida persistían tras la terapia

We report a 56-year-old man with history of chronic renal failure, who wasdiagnosed to have Fabry’s disease after performing a percutaneous kidney biopsy.The diagnosis was confirmed by the deficient level of activity of a-galactosidaseA and by the identification of the mutation. A enzime replacement therapy with alfa-galactosidase A was administered. After 18 months of treatment, a second kidneybiopsy was performed showing renal deposits of globotriaosylceramide (wedid not evaluate the percentage of histologic clearance of the deposits). Six monthsafter the end of the therapy, a reduction in the impairment of renal function isobserved, and the classic manifestations of the disease are absent

[Vascular access guidelines for hemodialysis]. / Guías de acceso vascular en hemodiálisis.

Quality of vascular access (VA) has a remarkable influence in hemodialysis patients outcomes. Dysfunction of VA represents a capital cause of morbi-mortality of these patients as well an increase in economical. Spanish Society of Neprhology, aware of the problem, has decided to carry out a revision of the issue with the aim of providing help in comprehensión and treatment related with VA problems, and achieving an homogenization of practices in three mayor aspects: to increase arteriovenous fistula utilization as first vascular access, to increment vascular access monitoring practice and rationalise central catheters use. We present a consensus document elaborated by a multidisciplinar group composed by nephrologists, vascular surgeons, interventional radiologysts, infectious diseases specialists and nephrological nurses. Along six chapters that cover patient education, creation of VA, care, monitoring, complications and central catheters, we present the state of the art and propose guidelines for the best practice, according different evidence based degrees, with the intention to provide help at the professionals in order to make aproppiate decissions. Several quality standars are also included.

[Successful pregnancy in a patient with systemic lupus erythematosus on hemodialysis]. / Gestación con éxito en una paciente con lupus eritematoso sistémico en hemodiálisis.

We report a twenty-nine-year-old patient, on renal replacement treatment (including 2 kidney transplants) since she was 11 years old, because of systemic lupus erythematosus. The patient became pregnant on hemodialysis, concluding the pregnancy successfully. The evolution and management of pregnancy were described and the related literature was revised. We concluded that, although pregnancy on hemodialysis and/or systemic lupus erythematosus patients involves a high risk for the mother and the fetus that makes advisable contraception, an increase in success in pregnancies in systemic lupus erythematosus patients on remission during the previous months, has been recently observed. Moreover, the increase of frequency and duration of hemodialysis sessions, has improved the neonatal survival around the 50% in pregnancies on dialysis. We emphasize the difficulty to maintain the mother's hemoglobin at an adequate target, as well as the high frequency of fetal prematury.

Utilidad de la vía laparoscópica en la resolución de problemas de los catéteres de diálisis peritoneal / Utility of laparoscopic surgery in resolving problems with peritoneal dialysis catheters

Objetivo. Describir la técnica y los resultados de la vía laparoscópica en la resolución de los problemas de los catéteres de diálisis peritoneal. Pacientes y método. En 13 pacientes se efectuaron 15 laparoscopias. En 6 pacientes se indicó la vía laparoscópica por una función inadecuada del catéter y en los 7 restantes como vía de implantación por presentar en 6 casos antecedentes de cirugía abdominal y en un caso peritonitis de repetición. Se utilizó un trocar de Hasson infraumbilical y, si eran necesarios otros actos quirúrgicos, una puerta accesoria de 5 mm. Resultados. Se detectaron 3 migraciones simples del catéter y 3 atrapamientos por epiplón. La recolocación en la pelvis del catéter migrado fracasó en los 3 casos, optándose por la retirada y nueva implantación (dos por técnica convencional y uno por vía laparoscópica). Se realizaron 3 omentectomías, una simple y en 2 casos con sustitución del catéter. Se consiguió la implantación en los 6 pacientes con cirugía abdominal previa y en el paciente con peritonitis de repetición, efectuándose en 3 de ellos lisis de adherencias. No hubo morbilidad de la técnica y todos los catéteres funcionan correctamente. Conclusión. La vía laparoscópica es útil en la resolución de los problemas de los catéteres de diálisis peritoneal malfuncionantes debido a que permite detectar la causa del obstáculo al flujo y realizar el acto quirúrgico necesario. Así mismo, facilita la implantación de catéteres peritoneales a pacientes con cirugía abdominal previa (AU)

Importance of residual renal function in continuous ambulatory peritoneal dialysis: its influence on different parameters of renal replacement treatment.

OBJECTIVE: To study the influence of residual renal function (RRF) on different parameters of the renal substitutive treatment offered by peritoneal dialysis. METHODS: We analyzed the impact of RRF on dialysis dose, nutrition parameters, anemia and phosphocalcic metabolism in 37 patients with end-stage renal disease (ESRD) treated by continuous ambulatory peritoneal dialysis (CAPD). Analytical controls were done every 6 months after an initial assessment at the end of the first month of treatment. Multiple lineal regression models were used as the statistical method to analyze the influence of RRF on different theoretically dependent factors. RRF was calculated as a mean of creatinine and urea clearances. Three observations per patient were used: one at the end of the first month of treatment; a final one at the end of follow-up (mean time 24.2 +/- 11.4 months), and at a mean time between them (13.4 +/- 6.7 months), with a final number of 111 observations. RESULTS: Dialysis dose: RRF was the most important factor in terms of creatinine clearance (r(2) = 0.94; beta = 0.999), KT/V (r(2) = 0. 68; beta = 0.819) and beta(2)-microglobulin levels (r(2) = 0.46; beta = -0.489). Nutrition parameters: RRF was a determinant factor for normalized protein catabolic rate (r(2) = 0.53; beta = 0.471), percent lean body mass (r(2) = 0.45; beta = 0.446) and albumin levels (r(2) = 0.25; beta = 0.229). Anemia: RRF was the most important factor when studying hemoglobin levels (r(2) = 0.28; beta = 0.407). Phosphocalcic metabolism: Between the analyzed factors, RRF was the only one which reached significance on serum phosphate levels (r(2) = 0.19; beta = -0.594). RRF did not show any relationship with either calcium or PTH levels. CONCLUSIONS: Independent of other factors, RRF in CAPD is positively and directly related to dialysis dose, beta(2)-microglobulin levels, nutrition parameters (albumin, normalized protein catabolic rate and percent lean body mass, hemoglobin and serum phosphate levels.