How a multidisciplinary vascular access care program enables implementation of the DOQI guidelines. Part I.

This comprehensive, proactive, multidisciplinary team approach to access management has enabled the achievement of center-specific best-demonstrated clinical practiCes for vascular access care. It has also resulted in significant cost savings to the health care delivery process. It has not been an easy task; if it were, access care outcomes would be better nationally than they are today. The VACP approach to vascular access care improvement employs four key implementation principles that ensure the success of Gambro's program and form the infrastructure supporting any successful team approach to care. These core processes, known as the four "C's, include: 1. Commitment, 2. Continuous Quality Improvement, 3. Core Competency, and 4. Communication.

Lessons learned. Implementing a vascular access quality improvement program. Part II.

Implementing a CQI program for vascular access can seem an overwhelming task. It encompasses many areas that are not in the nephrologists' or dialysis facilities' control. However, involving the right multidisciplinary team members in the process and aligning the goals and objectives creates an environment conducive to success. Ongoing communication is critical. Everyone needs to be a part of the change process.

Tuberculous peritonitis in patients undergoing chronic home peritoneal dialysis.

Peritonitis is a well-recognized complication of chronic peritoneal dialysis. However, in many instances the etiology of the peritonitis remains obscure despite intensive evaluation. Recent reports have suggested that pulmonary and extrapulmonary tuberculosis occurs with increased incidence in chronic hemodialysis patients. We report the first three cases of tuberculous peritonitis occurring in patients being treated with chronic intermittent peritoneal dialysis. The lack of active tuberculosis elsewhere and the predominance of polymorphonuclear leukocytes in peritoneal fluid made the diagnosis particularly difficult in this setting. The characteristics of the peritoneal fluid are quite similar to that seen in bacterial peritonitis, and unlike that found in peritonitis due to tuberculosis in nondialyzed patients. Tuberculous peritonitis should be suspected in peritoneal dialysis patients with chronic or relapsing peritonitis in whom the diagnosis of bacterial or fungal peritonitis cannot be confirmed.

Methods for assessing nutritional status of patients with renal failure.

Since wasting and malnutrition are common problems in patients with renal failure, it is important to develop techniques for the longitudinal assessment of nutritional status. This paper reviews available methods for assessing the nutritional status; their possible limitations when applied to uremic patients are discussed. If carefully done, dietary intake can be estimated by recall interviews augmented with dietary diaries. Also, in a stable patient with chronic renal failure, the serum urea nitrogen (N)/creatinine ratio and the rate of urea N appearance reflect dietary protein intake. A comparison of N intake and urea N appearance will give an estimate of N balance. Anthropometric parameters such as the relationship between height and weight, thickness of subcutaneous skinfolds, and midarm muscle circumference are simple methods for evaluating body composition. Other methods for assessing body composition, such as densitometry and total body potassium, may not be readily applicable in patients with renal failure. More traditional biochemical estimates of nutritional status such as serum protein, albumin, transferrin, and selected serum complement determinations show that abnormalities are common among uremic patients. Certain anthropometric and biochemical measurements of nutritional status are abnormal in chronically uremic patients who appear to be particularly robust; thus, factors other than altered nutritional intake may lead to abnormal parameters in such patients. Serial monitoring of selected nutritional parameters in the same individual may improve the sensitivity of these measurements to detect changes. Standards for measuring nutritional status are needed for patients with renal failure so that realistic goals can be established optimal body nutriture.