Current Technology for Dialysis and Multidisciplinary Care for patients with DKI (Diabetic Kidney Disease)

Current Technology for Dialysis and Multidisciplinary Care for patients with DKI (Diabetic Kidney Disease)
By: Blessilda S.

There are current health issues and updates related to hemodialysis and how this changes and affects the multidisciplinary approach to patient care. Healthcare professionals should be informed of these changes in order to provide quality health care.
Freestanding dialysis clinics are currently being prevalent treatment facilities for patients with acute kidney injury. These patients were known to gain access to dialysis at a hospital setting exclusively.
It is common for the medical and clinical field to constantly change and update, with ongoing revisions. This year, the Nephrology and Renal associations ensured during their annual gatherings to include more information on the transition of AKI patients from hospital treatments to outpatient dialysis centers.

Magnet Technology for Hemodialysis Patients
According to American Journal of Kidney Disease, there is a latest minimally invasive procedure utilizing radiofrequency energy instead of doing surgery for patients requiring hemodialysis access.
Mayo Clinic says “Hemodialysis prolongs life for many people, but life expectancy for people who need it is still less than that of the general population.”
Hemodialysis is a treatment for kidney disease wherein a machine is used to filter blood outside of the body. There are certain conditions or risks involved once a patient undergoes such treatment, although it varies from different patients. It is important to discuss these concerns to the dialysis team because they are experts in this subject.
Access site complication can be dangerous due to blockage, infection, or aneurysms like narrowing or ballooning of blood vessels.
The traditional method for creating surgical fistulas requires more procedures before the AV-fistula can be used. However, the new fistulas used by this magnet technology only needs limited procedures.
Information from Science Daily mentions the new study is entitled “Endovascular Proximal Forearm Arteriovenous Fistula for Hemodialysis Access: Results of the prospective, multicenter Novel Endovascular Access Trial (NEAT),” which is published by the American Journal of Kidney Disease, with Dr. Charmaine Lok as the primary researcher.
According to Dr. Lok, this new study can be a great option for patients who are looking for other methods wherein open surgery is not necessary, especially because this option is less invasive than the conventional one.
According to Science Daily, The NEAT clinical study uses a new practice of creating AV-fistula without open surgery. Flexible magnetic catheters are being inserted into an artery and vein of each patient. They also reported, “The vessels were drawn together by the magnets. A small burst of radiofrequency energy, given through the catheters, was then used to create a connection between the artery and vein, creating the AV-fistula. The catheters were then removed leaving no surgical scar. These study procedures were performed on outpatients who did not need general anesthesia.”
This new technology can provide beneficial results to AKI patients, providing a safe and quick solution to access veins and arteries for dialysis.

Diabetic Kidney Disease
Diabetic Kidney Disease is becoming a worldwide health issue, with high morbidity and mortality rate despite some pharmacologic managements and strategies being implemented. It is also associated with increased healthcare costs to patients diagnosed with it.
It has been discussed by researchers that multidisciplinary management programs includes participation of more than one allied healthcare practitioner such as nurses, pharmacists, dieticians and health educators in order to manage DKD. It is their goal to improve the quality of life of patients with DKD by preventing decline in kidney function, controlling progression of kidney diseases, and managing blood pressure.

American Journal of Kidney Diseases
National Institute of Diabetes and Digestive and Kidney Diseases
Mayo Clinic
Science Daily
Helou N, Dwyer A, Burnier M, Shaha M, Zanchi A. Multidisciplinary management of diabetic kidney disease: a systematic review protocol. JBI Database of Systematic Reviews & Implementation Reports 2014;12(7) 192 – 203

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Measuring Quality of Life with CKD Patients

Chronic kidney disease (CKD) stage 5 [also known as end-stage renal disease (ESRD)] can take a toll in the quality of life (QOL) an individual. As with any other chronic illnesses, the goal of the medical management is to ensure that CKD patients get quality life despite their condition.

For healthcare professionals in the dialysis industry, it is important to recognize the importance of keeping track of the QOL of clients under our care. While quantitative measurements such as an optimum laboratory test result or an efficient dialysis adequacy rate can provide a peek on the effectiveness of the medical management, it does not reflect the overall health, much less, the quality of life of an individual.

Defining quality of life

To better understand QOL in the context of patients undergoing dialysis, it is important to define what life means. Based on the American Heritage Dictionary, life is the physical, emotional, mental, and spiritual experiences that comprise the existence of an individual. Meanwhile, the World Health Organization defines QOL as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, personal beliefs and their relationship to salient features of their environment.”

Others terms that are often equated with QOL include sense of well-being, functional status, health status, and life satisfaction. These terms, however, are never synonymous with QOL but are just mere components of a quality life.

In the management of CKD, as well as other chronic illnesses, a multidisciplinary approach is undertaken to address all the various aspects of life. As a healthcare professional, you may be aware of the numerous and complex stressors that confront our patients. All these aspects have an effect in the global health of the person. It is difficult, even impossible, to measure an CKD patient’s global health based only on conventional health metrics such as protein catabolic rate (PCR) or Kt/V. Some may even consider health status based only on one primary endpoint, such as attaining normal blood pressure, which completely rejects and misses out on the other equally significant aspects of health.

Quality of life measurement

The WHO has advocated the use of HRQOL (Healthcare Related Quality of Life) tools especially in the treatment of chronic illnesses. It is one of the most important components in the care of patients but sadly this aspect is often overlooked in the management of CKD patients. As compared with other chronic illnesses, the use of these measurement tools in individuals with CKD is highly recommended, due to the numerous and complex comorbid conditions associated with CKD.

These measuring tools are either subjective or objective, and are used to evaluate the global health and well-being of an individual. Check with your dialysis facility if there is an established HRQOL measuring tools. Usually, these tools use scoring systems that are disease targeted, with appropriate control populations. Some HRQOL tools incorporate other aspects like the Beck depression inventory, Sickness Impact Profiles, Karnofsky index, Illness Effects Questionnaire, SF-36 health survey and others. These measuring tools may vary per facility.

Importance of HRQOL assessment

Apart from ensuring an optimum level of wellness, the HRQOL is closely related to the mortality and morbidity of patients with CKD. Evaluating HRQOL is also helpful in making crucial decisions in the medical management of an ESRD patient. It helps in assessing the impact of interventions, increasing patient satisfaction, and increasing patient’s compliance and participation to their medical management. For instance, when deciding whether an individual would benefit more by submitting into a new procedure or medication the effects on the quality of life must be a primordial concern. The clinician must weigh between decreasing mortality and possible effects on the life of the individual.

HRQOL is enhanced by addressing most common issues of ESRD patients such as malnutrition, pre-dialysis care, inactivity, anemia and social support systems. An optimum quality of life has been linked with improve survival rates. The nephrology healthcare team should focus their strategies aimed at these components and in preserving remaining renal function, controlling blood pressure, and ensuring dialysis adequacy. All these can help improve the outcome of the patient and the quality of his life. In the near future, more advanced medical technologies can help improve mechanisms and strategies for improving HRQOL.

At present, all members of the nephrology team must work with patients closely to better improve their quality of life. The use of validated measuring tools can better upgrade the holistic wellbeing of patients suffering from ESRD.

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Focus on Malnutrition in ESRD Patients

Nutrition is a critical component in the care of patients with ESRD. Recent studies reveal that around 50% of all patients diagnosed with ESRD and undergoing maintenance dialysis are malnourished.
Malnutrition and the disease process
Malnutrition among ESRD patients is caused by a number of factors, particularly increased nutritional needs and improperly met nutritional requirements. Kidney failure results in metabolic abnormalities such as impaired glucose tolerance, altered lipid and amino acid metabolism, uremia, metabolic acidosis, increased leptin and cytokine activity, and carnitine depletion.
Most ESRD patients also have concomitant diseases, particularly sepsis, inflammation and cardiovascular disease, that further add up to their nutritional requirements. Moreover, the disease process results in symptoms, such as anorexia and gastrointestinal disturbances, which lead to decreased food intake.
Socioeconomic and psychosocial factors also contribute in malnutrition of ESRD patients. Depression, loneliness, lack of knowledge, ignorance, and alcohol or drug abuse can take toll on a patient’s nutritional state. These psychosocial factors can set in at any stage of the disease process. Some patients may have difficulty complying with recommended dietary changes due to economic issues.
Malnutrition is associated with muscle wasting, poor wound healing, increased risk of infection, and increased mortality. Moreover, the risk of mortality doubles in patients with poor nutritional status at initiation of maintenance dialysis. Low serum albumin levels, considered as indicator of an ESRD patient’s nutritional status, are often associated with increased risk of mortality.
Achieving nutritional goals
Nutritional assessment and evaluation is critical in helping ESRD patients cope up with the disease process. While it is the role of the in-house nutritionist to ensure that patients get proper nutrition, collaboration among the healthcare team members – nephrologists, dialysis nurses, dialysis technicians, social worker and nutritionist – is critical in achieving the nutritional goal of each patient.
Each patient requires a carefully planned diet that is based on his or her nutritional state, disease process, and level of activity. Primarily, the goal of dietary adjustment is to keep the build-up wastes in the body in between dialysis sessions to a minimum while meeting the nutritional needs of ESRD patients. The nephrologists and
Levels of calories, protein, potassium, sodium, fluid, phosphorus, calcium, and vitamins may vary depending on the needs of the patient. Balancing these nutritional components can help improve the patient’s well-being and have better outcomes. Compared to patients on hemodialysis, patients on CAPD or daily dialysis have fewer dietary restrictions and fluid limits.
Helping patients achieve better nutrition status
Patients undergoing in-center HD undergo regular dietary and nutritional counseling. Dialysis nurses and technicians can reinforce dietary instructions provided by the nutritionist through the following measures:
– At every session, talk with your patient about their eating patterns. Tell the dietitian or charge nurse any reported changes in taste, appetite, gastrointestinal symptoms (nausea or vomiting, diarrhea, heartburn and bloating, constipation, feeling of fullness after ingesting very little food), or problems maintaining desired blood sugar levels.
– Discuss with the social worker and dietitian if a patient is unable to meet recommended dietary intake due to dialysis treatment times or economic problems.
– In case a patient consistently arrives below dry weight, notify the charge nurse and dietitian. Low energy level or any unplanned weight loss may signal problems with nutrition.
– For patients with diabetes, inform the dietitian if there is trouble maintaining blood sugar levels.
– Encourage patient compliance in the prescribed sodium and fluid limits. Discuss with the dietitian and nephrologists if the patient gains a lot of fluid during off-days.
– Discuss with the patient the prescribed meal plan. Reassure patients that they can still enjoy foods that they love as long as they are within the recommended nutritional plan.
– Remind patients to take their prescribed nutritional supplements, particularly binders.
Malnutrition in ESRD is a preventable disease complication. Patient education and a collaborative approach can help patients overcome this prevalent problem. Each healthcare team member play a role in achieving better nutrition status for patients.

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Dialysis Quality Water: Why Is It An Issue Today?

Water is a vital component of dialysis. Compared to a healthy person who consumes around 2 liters of water daily, a hemodialysis patient is exposed to around 200 liters of water for every four-hour dialysis treatment. Water is also the major component of dialysate. Because of the huge volumes of water patients are exposed to, it is essential that dialysis water is maintained free of bacteria and contaminant.
Dialysis nurses and dialysis technicians play a central role in ensuring safe and quality water for dialysis. Policies and procedures for the maintenance and monitoring of water must be taken seriously to avoid patient complications, and to some extent, possible problems with the machines.
Why bacterial contamination of water and dialysate is a serious issue?
During the early years of dialysis, system-wide contamination of water resulted in wide-spread infections that often affected all patients within the center. Dialysis water-related infections were among the leading causes of morbidity and mortality among dialysis patients. Over the last 20 years, quality of dialysis water has improved significantly, particularly with the introduction of reverse osmosis (RO), ultrafiltation, UV filtration, and other sophisticated water purification methods.
While the bacteriological quality of dialysis water has considerably improved, the almost universal use of sodium bicarbonate instead of sodium acetate as buffer dialysate has also increased the risk of bacterial contamination of dialysate.
Compared to acetate, bicarbonate promotes the growth of specific microorganisms known to cause pyrogenic reactions among dialysis patients. Some of the commonly detected water-born microorganisms include the Pseudomonas species, including P. versicularis, P. maltophilia, and P. aeruginosa. There are also gram-negative bacteria that the dialysis water could harbor such as Moraxella, Alcaligenes species, and Corynebacteria. Likewise, dialysate has a nutrient-rich environment conducive for the growth of yeast and fungi. Severe contamination of dialysate can lead to pyrogenic reactions usually presenting as fever and cardiovascular instability.
Considering the favorable environment of dialysate, it is primordial to ensure that the dialysis water used for preparation of dialysate is free of any microorganism. Dialysis quality water is important now more than ever.
Focus on water treatment system
Due to the critical role of dialysis nurses and technicians in ensuring dialysis quality water, it is imperative that they understand what happens throughout the water treatment system.

Municipal water contains unwanted contaminants and bacteria that pose risk to patients and machines. So, before they are fed to the machines or used for preparing dialysate and reprocessing dialyzers, raw water passes through a systematic purification system – a series of devices, which filters out bacteria and contaminants.
The system is composed of three processes: the pre-treatment, water purification, and distribution. Through each process, monitors are in place to check water quality, water temperature, flow rates, and pressures. These monitors provide alarms if the condition does not meet the accepted limits. In addition, water sampling and testing is done periodically at each process.
The pre-filter process is composed of a series of devices that ensure adequate pressure, flow rate, and temperature is achieved. Blending valve mixes hot and cold water for an optimal temperature (77º F). Backflow preventer ensures water does not back up into the city water supply. A booster pump keeps the incoming water flow within the desired levels and prevents unwanted fluctuations. Components of the pre-filter and RO system require certain water pressure and flow rate to run efficiently.
The pre-treatment process comes with four filtration methods intended to remove specific contaminants. The multimedia or depth filter removes sand and silt in the water, as well as other solutes and substances. Once the water is free of micro-debris, it then passes through the water softener which removes magnesium and calcium. The softener works together with the brine tank to prevent scaling (accumulation of hard mineral deposits) in the RO membranes, which could potentially damage it. Carbon tanks (usually come in pairs) filter out chloramines/chlorine that is abundant in municipal water. Sample ports are located at the end of each tank to check the adequacy of removal of chloramines/chlorine. The carbon tanks also remove the finest debris and are the last process before the water enters the RO unit.
After the pre-treatment, water then passes through the RO membranes followed by an ultrafilter. The RO unit is contains a pump, semi-permeable membranes and quality monitors. It is a powerful purification method that removes bacteria, endotoxin, viruses, fine particles, and other solutes. It works by reversing the transport mechanism osmosis. The semi-permeable membrane allows water but not chemicals, microorganisms, and other un-dissolved substances. Product or treated water is then passes through the ultrafilter while the waste water is disposed to the drain. The ultrafilter is capable of removing bacteria, viruses and most endotoxin. It is also the last and final step before water is used for the machines, dialysate preparation and dialyzer reprocessing.
AAMI Dialysis Quality Water
The AAMI has set standards for maintaining dialysis quality water in all dialysis facilities. The recommended total viable microbial count should be lower than 200 CFU/mL and endotoxin concentration lower than 2 EU/mL. Action level for total microbial count is 50 CFU/mL and for endotoxin concentration, 1 EU/mL. Actions and corrective measures must be taken promptly in case treated water falls in the action level.
Periodic monitoring of the water bacteriology is essential to ensure patient safety. As dialysis nurse or dialysis technician, expect to check the water quality regularly.

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Focus on Catheter-Related Bloodstream Infections

Infection is the second leading cause of hospitalization and mortality in hemodialysis patients. Compared to patients on peritoneal dialysis, patients undergoing hemodialysis are twice likely to be hospitalized due to infection. In addition, about one in four deaths among hemodialysis patients are associated to infections. Notably, infections are associated with excessive financial burden for patients and healthcare facilities.
Although hemodialysis patients are continually exposed to a variety of infections, catheter-related bloodstream (CRB) infections are particularly more severe and can even possibly result in fatal outcomes. Around 37,000 patients with central catheters develop bloodstream infection each year, with an estimated cost of $23,000 per hospitalization.
Incidence of CRB Infections
Two of the most common causes of catheter-related infection are Staphylococcus aureus and Staphylococcal epidermidis. These microorganisms can lead to considerable morbidity, even possible death. The catheter insertion site serves as the portal of entry for these bacteria. Bacteria migrate to the insertion site from the skin and follow through the outer surface of the catheter. Repeated use of catheter lumen during hemodialysis sessions increases the risk of contamination.
CRB infections are rarely caused by infusion of contaminated solutions. Studies show that the duration of catheterization increases the risk of infection. Moreover, the infection rate is higher with non-tunneled catheters compared to tunneled catheters. Incidence of infection among patients with non-tunneled catheters is between 3.8 to 12.8 events per 1,000 catheter days and 2.9 per 1,000 catheter days for tunneled catheters. The possibility of adverse outcome steadily increases over time. The risk of infection for nontunneled catheters in the IJ location is five times higher than the tunneled catheters, and seven times for femoral catheters in the femoral site.
Preventing CRB Infections
While the incidence of infections is high, it is considered a preventable complication. Dialysis nurses and dialysis technicians are at the forefront in the prevention of CRB infections.
Dialysis nurses must alert the nephrologist of any evidence of exit-site infection, even if there are no systemic symptoms present. Usually, exit site infection preludes bacteremia thus prompt catheter removal is often recommended. Bacteria are thought to migrate much faster along the outer surface and tunnel of the catheter due to the absence of a cuff.
Dialysis nurses and dialysis technicians must strictly follow infection prevention protocols. Below are preventive measures:
• Use of 2% aqueous chlorhexidine for skin disinfection before insetion
• Proper insertion technique
• Practice aseptic technique during access handling
• Thorough skin disinfection using povidone-iodine solution at every HD session
• Application of mupirocin ointment or povidone-iodine ointment at insertion site every change of dressing
• Use of dry gauze dressing
• Use of surgical mask and face shield by healthcare providers and patients during cannulation and de-cannulation procedures
• Shortened/limited duration of catheters
Many healthcare facilities now use 2% aqueous chlorhexidine for skin disinfection prior to insertion. Chlorhexidine is more preferred over isopropyl alcohol and povidone-iodine. During catheter insertion or guidewire exchange, maximal sterile barrier precautions must be carefully followed.
Dialysis nurses and all other healthcare providers must be aware that hemodialysis access, especially central lines, should not be used to draw blood samples or used for infusions. After each HD session, disinfect the surrounding skin using povidone-iodine or chlorhexidine solution. Apply antimicrobial ointment (such as polysporin or mupirocin) to the catheter exit site, then, apply dry gauze (not occlusive dressing) over the exit site. Make sure the exit site is secured with plaster.
In 2009, the Centers for Disease Control and Prevention (CDC) has established 9 core interventions in the prevention of bloodstream infections among the dialysis community. Among others, hand hygiene has been pointed out as among the most important procedures that can help reduce infections associated to hemodialysis. The CDC noted a poor adherence with aseptic techniques in both acute and chronic hemodialysis facilities. Other core interventions recommended by CDC include: surveillance and feedback, catheter/vascular access care observations, continuous staff training and education, patient education, catheter reduction, catheter hub disinfection, use of chlorhexidine for skin disinfection, and use of antimicrobial ointment. Participants in the study have shown a decrease in the incidence of bloodstream infection.
Finally, realizing the burden and fatality of bloodstream infections, healthcare providers including doctors, dialysis nurses, and dialysis technicians must understand their pivotal role in preventing infection. Each facility has its own infection prevention and tracking protocols, which every healthcare provider is expected to know and practice.
Do you know your facilities infection prevention protocols? Do you practice them? As healthcare practitioners, let us show our care to our patients by diligently practicing recommended infection control interventions.

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A Team Approach in the Effective Management of Anemia of CKD

reposted from July 2015

Anemia is considered the most prevalent hematologic complication of chronic kidney disease (CKD). It affects twice as many CKD patients as in the general population. As condition progresses through stages of CKD, anemia prevalence also increases (from 8.4% at Stage 1 to 53.4% at Stage 5.)

What is anemia?

Anemia is characterized by a decrease in hemoglobin level (<13 g/dL in men and <12 g/dL for women). Hemoglobin (Hgb) is a protein found in the red blood cells (RBC) and supplies oxygen to all the body cells. Production of red blood cells is dependent on the body’s oxygenation. What causes anemia of CKD? In healthy adults, the kidneys produce a hormone called erythropoietin (EPO), which stimulates the bone marrow to make erythropoietin or red blood cells (RBC). However, for patients with CKD, the kidneys are unable to provide sufficient amounts of EPO, resulting in anemia. With fewer Hgb, body cells and tissues are not adequately oxygenated thus resulting in anemia. Additionally, the uremic environment due to CKD significantly shortens the life span of red blood cells, from 120 to 70 days. RBCs die much faster than normal resulting in low oxygen levels in the blood. Significant blood loss from dialysis, particularly frequent blood sampling, dialyzer leaks, and incomplete blood recovery after dialysis, also contributes to the progress of anemia. Other factors associated to anemia of renal failure include impaired iron intake, bleeding problems, elevated parathyroid hormone (PTH), and poor diet and nutrition. What are the symptoms of anemia? Symptoms of anemia include pallor, fatigue, chest pain, and shortness of breath. Other symptoms attributable to anemia include weakness, poor appetite, dyspnea, poor exercise tolerance, irritability, and sexual dysfunction. With proper nutrition, sufficient iron intake, and adequate dialysis, most patients adjust well to anemia and even feel better. Despite having significantly low hemoglobin levels for weeks or even months, hematocrit level will usually stabilize by up to 30%. The difficulty of diagnosing and monitoring the progress of anemia in CKD patients makes it very important for healthcare providers to conduct thorough assessment and laboratory tests to properly manage this condition. Poorly managed anemia in CKD can lead to a host of morbidities, often serious and life-threatening. Left ventricular hypertrophy (LVH), one of the leading causes of mortality among CKD sufferers, has long been associated to anemia. How is anemia of CKD managed? Prior to erythropoiesis-stimulating agents (ESA) and intravenous iron, majority of CKD patients on dialysis suffered severe anemia. Frequent blood transfusions were the only treatment options available. Unfortunately, transfusions have a number of potential adverse effects that include increased risk of hepatitis, transfusion reactions, and iron overload. They also reduced the patient’s chances of getting a kidney transplant and were costly. Today, there are various treatment options used by healthcare practitioners in the management of CKD. Intravenous iron, ESAs (such as recombinant EPO and darbepoeitin) and other agents, and red cell transfusion are the mainstays. Following the KDIGO guidelines for the management of anemia in CKD, the physician orders the best treatment course. Majority of renal failure patients are given twice to thrice a week injections of ESAs or scheduled intravenous iron administration. Patients’ hemoglobin and hematocrit levels are continuously monitored. How important is anemia management of CKD? The importance of anemia management cannot be overstated, as it significantly affects the quality and quantity of life of our patients. To ensure effective management of anemia, most dialysis facilities follow an anemia management protocol. This protocol delegates anemia management to a non-physician staff (also called the Anemia Manager; usually a nurse or dietitian), thus allowing the healthcare team to properly monitor and manage this hematologic complication. However, this protocol should be used only as a guide and must not replace clinical judgement. The individual health concerns of the patient must be considered at all times. Why effective anemia management is a team effort? Effective management of anemia in renal failure patients requires a team approach. Every member of the healthcare team (dialysis technician, nurses, dietitian, and nephrologist) plays a crucial role in achieving and maintaining the target hemoglobin levels. • The nephrologist conducts a thorough clinical assessment and prescribes the treatment course. • The renal nurse, usually the Anemia Manager, prepares and oversees the care plan, adjusts medical management depending on patient’s response, coordinates with other team members, and conducts patient education. • The dialysis technician ensures complete blood recovery after each treatment, reports unusual bleeding and other symptoms, minimizes blood loss from frequent blood extraction, and reinforces patient education. • The renal dietitian evaluates the patient’s nutritional status, prepares and oversees the nutritional plan, and provides dietary counseling. In some dialysis facilities, a renal dietitian may also be the Anemia Manager. The patient, being the focus of care and the most important member of the healthcare team, should fully cooperate with the anemia management care plan. Full cooperation by the healthcare team helps achieve target anemia outcomes and, ultimately, quality life of patients.

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Meet the Renal Care Team

Experiencing a kidney disease is a way of life in itself. People with renal disease, whether on dialysis or after a kidney transplant, become detached from their routine life and are forced to adjust to a new world. The renal healthcare team plays a crucial role in helping patients and their caretakers adapt to their new life. While each team members has unique roles and responsibilities, they all work together to achieve one goal – the highest quality of life for the patient.

Members of the dialysis care team include the nephrologist, dialysis nurses, social worker, dialysis technician, dietitian, and the patient.


A nephrologist is a licensed medical doctor who specializes in renal disease. The nephrologist establishes the care plan alongside other members of the renal healthcare team. He or she prescribes medications and treatment, orders diagnostics, and makes necessary adjustments to the overall treatment plan based on the patient’s condition.

Dialysis Nurse

The dialysis nurse oversees the implementation of the plan of care. He or she coordinates with other team members to ensure treatment plan is carried out. The nurse is also responsible for crafting and implementing patient education plan, providing direct patient care, assessing patient prior and post dialysis treatment, and training other team members.

Social Worker

Renal disease, especially chronic kidney disease, is life-changing. That is why a nephrology social worker is essential in the management of patients. The social worker assists patients and their loved ones adapt to the changes in their lives – and this includes helping them with the emotional and financial issues that are a part of kidney disease. They provide counseling to the patient and family members.

Social workers also address issues with patient’s healthcare coverage, patient resources, rehabilitation, and community services. They help rebuild the patient’s life.

Dialysis Technician

There are different types of technicians in some centers. Patient care technicians are those who are directly handling the patients and are under the supervision of a nephrology nurse. Biomedical equipment technicians maintain and troubleshoot dialysis equipment. They ensure that the machines are in perfect shape for every use. There are also reuse technicians who reprocess the dialyzers.

Renal Dietitian
Diet has a significant impact in the overall treatment of the patient. The renal dietitian makes sure that the patient’s nutritional needs are met while keeping dietary restrictions. He or she also assist the patients in coming up with a meal plan that will maintain health at the same time enjoyable and easy for them to follow. The dietitian also provides education for the patient, family members and caretakers on how to meet nutrition needs.


Last and the most important member of the health care team – the patient. As the person with renal ailment, the patient must learn about his condition and its treatment. They should also know their patient’s rights and responsibilities.

Patients should notify his care team about any problems or symptoms as they develop. Patients know themselves best so they are the ones who can more accurately gauge the progress of their treatment, whether they feel better or not. They also spend most of their time outside the center and are in control of their lives.

Healthcare providers must encourage patients to have input into their care plan. Being involved in their care increases their compliance to the treatment regimen, including dialysis, medications, diet and fluid limits. The rest of the team assists the patient towards a quality life. In some cases, it is family members or caretakers who will speak in behalf of patients.

Whether you are a dialysis nurse or a renal dietitian or a social worker, you should dutifully fulfill your roles and responsibilities. You are a member of one team and the patients are your goal!

The word TEAM actually means Together Everyone Achieves More!

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Keeping Patients Safe: A Fundamental Requirement to Move Up the Clinical Quality Pyramid

By Allen Nissenson, MD posted in Nephrology, Patient Education

I was having a conversation with my mother-in-law, Doris, recently at her assisted-living facility. She had moved from her own apartment to the memory-care unit two years prior and had adjusted well to the smaller space and more institutional structure of the care she was receiving. At 92 years old she was fortunate to be physically frail but otherwise healthy—on only Synthroid for long-standing hypothyroidism. Slowly progressive dementia is apparent, but she is still able to carry out activities of daily living and recognize and enjoy visitors. I had recently completed Atul Gawande’s newest book, “Being Mortal: Medicine and What Matters in the End,” and decided to ask Doris what mattered most to her at this stage in her life. She wanted to be treated compassionately, with dignity, and she wanted to feel safe as her external environment contracted around her.

She wanted to feel safe. How many of us as physicians have asked our patients what is important to them? How many of our patients would say they want to feel safe when undergoing a complex technical medical treatment 156 times per year, year after year? My guess is many of them would express this as a concern. Years ago the Renal Physicians Association took on this issue and surveyed dialysis facilities about common safety issues, and then developed the Keeping Kidney Patients Safe website to help educate professionals and patients about this topic. Key areas of focus are proper dialyzer and dialysate use, proper administration of medications, avoiding falls in the dialysis facility and at home, proper hand hygiene, avoiding needle dislodgements and following all policies and procedures as written.

This list of very specific areas of patient safety in the dialysis setting is consistent with the national movement in health care in this area. On July 29, 2005, President Bush signed the Patient Safety and Quality Improvement Act to encourage voluntary and confidential reporting of adverse health care events. Toward that goal, the act authorized the creation of Patient Safety Organizations to collect related data and maintain appropriate confidentiality. Both DaVita Kidney Care and Fresenius Medical Care have such organizations focused on improving quality and safety of care. In addition, the Joint Commission accreditation process for various health care settings includes evaluation of efforts to improve patient safety. Although the specifics vary somewhat depending on the site of care, key areas include proper identification of patients and matching treatments/medications to the right patient, appropriate medication administration, prevention of infection, prevention of falls and identification of other safety risks.

At the end of the day, however, optimal patient safety will be achieved only if organizations, including dialysis facilities, are successful in creating a culture of safety. This concept began outside of health care in industries such as commercial airlines, characterized (like dialysis) as ones where the work is complex and potentially hazardous. The key components of establishing the culture of safety according to the AHRQ Patient Safety Network include the following:
◾Acknowledgement of the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations
◾A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
◾Encouragement of collaboration across ranks and disciplines to seek solutions to patient-safety problems
◾Organizational commitment of resources to address safety concerns

To successfully develop a culture of safety in any organization requires focused commitment at all levels. In dialysis this includes corporate facility owners or independent owners/operators, medical directors and all members of the interdisciplinary care team. As articulated by the Institute for Healthcare Improvement, “In a culture of safety, people are not merely encouraged to work toward change; they take action when it is needed. Inaction in the face of safety problems is taboo.… There is no room in a culture of safety for those who uselessly point fingers or say, ‘Safety is not my responsibility, so I’ll file a report…’. Even so, an organization can improve upon safety only when leaders are visibly committed to change and when they enable staff to openly share safety information.”

So in this National Kidney Month of 2015 let us all commit to creating a culture of safety in our organizations. It is the right thing to do for our patients, as it is for all of the vulnerable, the frail, the chronically ill, and those like my mother-in-law, who deserve compassionate, safe care.

We could all learn from Sir Liam Donaldson, a British physician, chancellor of Newcastle University and former chief medical officer for England, who said,

“To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.… You wouldn’t just decide to forget about recovering the black box after an air crash. So why should it be thought so strange to want to learn from every accident in health care?”

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Will Incremental Hemodialysis Preserve Residual Function and Improve Patient Survival?

Most patients embark on hemodialysis with some degree of residual renal function. Its preservation is strongly associated with patient and technique survival for peritoneal dialysis patients. Comparative studies have suggested that initiating treatment with peritoneal dialysis offers patients a survival advantage over hemodialysis in the short term [1]. In most centers, patients treated by hemodialysis loose residual renal function more rapidly than those on peritoneal dialysis, and as such there has been renewed interest in how patients initiate hemodialysis and whether practice techniques influence loss of residual renal function.

In the United States, payment for chronic hemodialysis treatments are linked to achieving a defined dose of dialysis, in terms of urea clearance (Kt/V), and this has led to the practice of starting patients on thrice weekly treatments designed to achieve the target Kt/V, irrespective of residual renal function. It has been questioned as to whether this approach might lead to a more rapid loss of residual renal function by reducing the drive to hyperfiltration of the remaining functioning nephrons [2]. As such there has been renewed interest in initiating hemodialysis as an adjuvant to residual renal function, akin to incremental peritoneal dialysis.

Although a practioner of incremental hemodialysis, I believe there are a number of factors that need some consideration. Firstly, the greatest risk for death for hemodialysis patients is in the first 90 days after transition from nondialysis dependent chronic kidney disease (CKD) to dialysis [3]. Indeed, mortality in this period can be much greater for those initiating hemodialysis compared to stage 5 CKD patients opting for conservative nondialysis care [4]. The majority of studies which have investigated transitioning to dialysis have shown that mortality is predominantly associated with underlying patient co-morbidity and lack of predialysis specialist nephrological care [3]. This would suggest that the patient trajectory is an important determinant of outcome, as patients starting hemodialysis precipitously following an acute deterioration in renal function on a background of CKD—(such as following an acute coronary syndrome or development of cast nephropathy) have much higher mortality rates than those with slower progressive trajectories [5]. The alternative scenario, CKD patients attending specialist nephrology clinics, shows no benefit from earlier compared to later initiation of dialysis [6].

On the other hand, earlier initiation of dialysis in the IDEAL trial did not disadvantage patients, suggesting that a planned start of dialysis in patients benefiting from prior specialist nephrology care did not have increased mortality during the transition phase. As such the introduction of thrice weekly HD in this group of patients with a lower CKD trajectory did not result in excessive mortality, suggesting that hemodialysis per se may not carry a major mortality risk. However, these patients predominantly dialyzed using arterio-venous fistulae, rather than catheter access, whereas CKD patients who have a sudden rapid deterioration in renal function requiring dialysis, invariably dialyze using catheters with increased risk for systemic bacteremia and mortality [7].

Although there are many reported benefits for preserving residual renal function in hemodialysis patients [8], it is unclear whether its loss is a major driver for the increased mortality observed during the dialysis transition phase. Indeed, the Tassin center approach, associated with one of the highest reported survival rates for hemodialysis patients, renders more than 90% of patients initiating dialysis anuric within the first 90 days [9].There are no prospective trials reporting that preservation of residual renal function improves survival for hemodialysis patients.

Preserving Residual Function in Hemodialysis Patients

  1. Top of page
  2. Abstract
  3. Preserving Residual Function in Hemodialysis Patients
  4. Measurement of Residual Renal Function
  5. Summary
  6. Funding
  7. References

The majority of hemodialysis patients are volume overloaded prior to their dialysis session, and loose both extracellular and intracellular fluid during treatment [10]. Bioimpedance devices have been recently introduced into dialysis centers to aid clinical decision making assessing fluid status in dialysis patients [11]. Cross-sectional and longitudinal observational studies have reported that overhydrated dialysis patients do not have greater or better preservation of residual renal function [12, 13]. So, simply keeping patients overhydrated does not appear to preserve residual function, but risks hypertension and left ventricular hypertrophy.

On the other hand too rapid a removal of fluid during hemodialysis risks hypotension [14], and repetitive hypotensive episodes may potentially lead to renal ischemia and premature loss of residual renal function. Intradialytic hypotension is more common in centers which target lower pre and postdialysis blood pressures [15], and patients attending for dialysis at, or close to their target weight [16, 17]. Although this approach risks anuria, blood pressure is lowered and left ventricular hypertrophy regresses.

As most dialysis centers do not regularly measure residual function, it remains to be established whether preventing intradialytic hypotension by using bioimpedance and dialysis machine technology [18], can preserve residual renal function. However, observational studies have shown that patients with more intradialytic hypotensive episodes [19], and those deliberately dialyzed to achieve lower biompedance targets [20] lost residual renal function quicker. The more frequent nocturnal hemodialysis trial reported faster loss of residual renal function with more frequent and longer dialysis sessions [21]. Whether this was due to achieving greater clearances or more hypotensive episodes remains unclear.

In contrast, a Spanish study reported better preservation of residual renal function in patients hemodialyzed twice weekly compared to thrice weekly, with a similar loss of residual renal function to peritoneal dialysis patients [22]. However, this study was confounded by lead time bias, as patients with greater residual renal function initiating dialysis were dialyzed twice weekly, whereas those with lower residual renal function were dialyzed thrice weekly. Similarly other studies advocating twice weekly hemodialysis are also confounded by retrospective analysis, no propensity matching with differences in lead time and patient co-morbidity [23, 24].

If twice a week hemodialysis were to offer an advantage in terms of preserving residual renal function, then it may do so by keeping patients volume expanded and reducing episodes of intradialytic hypotension [25]. However, this practice risks worsening blood pressure control and left ventricular hypertrophy [25]. Supplemental thrice weekly hemodialysis would potentially control over-hydration better than twice weekly treatments, and also, by reducing the amount of fluid to be removed during any one session, would potentially reduce the risk of intradialytic hypotension. This is supported by recent prospective trial using incremental dialysis which reported very few intradialytic hypotensive episodes and observed that residual renal function was better preserved than that reported from historic series but this study [26].

However, it must be recognized that factors other than hypovolemia and episodes of intradialytic hypotension determine the loss of residual renal function. Due to the paucity of prospective studies in hemodialysis patients, most of the information on residual renal function emanates from peritoneal dialysis patients. These studies have consistently reported that the loss or residual renal function depends upon the original renal disease, typically faster loss for cystic and diabetic kidney disease compared to glomerulonephritis [27]. Similarly, those with proteinuric renal diseases are more likely to have a faster loss of RRF [28], as are those with peripheral and cardio-vascular disease [29]. Residual renal function tends to be lost earlier in those patients initiating dialysis with lower residual renal function, but this could be confounded by lead time bias. Although angiotensin enzyme converting enzyme inhibitors and angiotensin receptor blockers have been associated with preservation of residual renal function, they have not been shown to have any protective effect in hemodialysis patients [26, 30].

Measurement of Residual Renal Function

  1. Top of page
  2. Abstract
  3. Preserving Residual Function in Hemodialysis Patients
  4. Measurement of Residual Renal Function
  5. Summary
  6. Funding
  7. References

Incremental dialysis depends on the ability to measure residual renal function and then adjusting the dose of dialysis accordingly. Unfortunately there is no simple blood test to readily assess residual renal function; the obvious measure, urine volume, is an inaccurate assessment. The “gold” standards of inulin, 51chromium ethylenediaminetetra-acetic acid (EDTA), and iothalamate radiocontrast clearance are more accurate for determining residual renal function in dialysis patients than urine collections but are impractical in clinical practice. As such, 24 hour urine collections remain the standard method, with clinical guidelines recommending calculating the mean of both creatinine and urea clearance, as urea underestimates and creatinine overestimates inulin clearance, and then adjusting clearance to a body surface area of 1.73 m2 [31].

Putting aside the problems of reliably collecting 24 hour urine collections, both serum urea and creatinine are affected by dietary protein intake, and creatinine also depends upon muscle mass and physical activity, and changes in intestinal bacteria flora alter urea and creatinine gastrointestinal losses. In addition, there is the effect of chromagens which accumulate in CKD and interfere with the standard laboratory colorimetric Jaffe reaction [32]. Another confounder is the timing of the urine collection in relation to dialysis sessions, especially when patients are dialyzed twice or thrice weekly. The composite urea and creatinine clearance then has to be adjusted to body size. It is many years since the original equations linking anthropomorphic measurements to body surface area were made, and over time populations have changed, with increasing body fat [33]. As such the original link between body surface area and muscle mass, particularly in the dialysis population, with an increased risk of sarcopenia may no longer hold [34, 35].

As such, although 24 hour urine collections underpin measuring residual renal function in dialysis patients, one has to appreciate the limitations of the measurements and confounding errors. The final difficulty is then equating this measured residual renal clearance with a dialysis derived urea clearance, based on an estimate of total body water [36, 37].


  1. Top of page
  2. Abstract
  3. Preserving Residual Function in Hemodialysis Patients
  4. Measurement of Residual Renal Function
  5. Summary
  6. Funding
  7. References

Although there is a marked increased risk of mortality as CKD5 patients transition to hemodialysis, it is most likely that this is due to patient co-morbidity and unplanned dialysis starts, rather than simply the loss of residual renal function. Maintaining residual renal function potentially allows the patient a better quality of life with more liberal diet and fluid intake. However, there is no definitive evidence that preserving residual renal improves patient survival. Loss of residual renal function is predominantly determined by the primary renal disease and patient co-morbidity. However, hypovolemia, and repetitive episodes of hypotension are associated with faster loss of residual renal function, and as such incremental dialysis may help to preserve residual renal function. As dialysis dosing is not simply a matter of small solute clearance, and dialysis should also be prescribed to achieve volume control and maintain electrolyte and acid base balance. Although there are financial and patient benefits for twice weekly incremental dialysis, it is more likely that a thrice weekly approach will better preserve residual renal function.


  1. Top of page
  2. Abstract
  3. Preserving Residual Function in Hemodialysis Patients
  4. Measurement of Residual Renal Function
  5. Summary
  6. Funding
  7. References
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    Booth J, Pinney J, Davenport A: Do changes in relative blood volume monitoring correlate to hemodialysis-associated hypotension? Nephron Clin Pract 117(3):c179c183, 2011

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    Lin X, Yan Y, Ni Z, Gu L, Zhu M, Dai H, Zhang W, Qian J: Clinical outcome of twice-weekly hemodialysis patients in Shanghai. Blood Purif 33(1–3):6672, 2012

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  • 28
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  • 29
    Palomo-Piñón S, Mora-Villalpando CJ, Del Carmen Prado-Uribe M, Ceballos-Reyes GM, De Jesús Ventura-García M, Avila-Díaz M, Rodríguez OO, Paniagua-Sierra JR: Inflammation and myocardial damage markers influence loss of residual renal function in peritoneal dialysis patients. Arch Med Res 45(6):484488, 2014

  • 30
    Davenport A: Maintaining residual kidney function in dialysis patients –is there a role for angiotensin converting enzyme inhibitors or receptor blockers? Am J Kidney Dis 2014 (in press)

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  • 32
    Davenport A, Cholongitas E, Xirouchakis E, Burroughs AK: Pitfalls in assessing renal function in patients with cirrhosis–potential inequity for access to treatment of hepatorenal failure and liver transplantation. Nephrol Dial Transplant 26(9):27352742, 2011

  • 33
    Davenport A, Hussain Sayed R, Fan S: The effect of racial origin on total body water volume in peritoneal dialysis patients. Clin J Am Soc Nephrol 6(10):24922498, 2011

  • 34
    Fürstenberg A, Davenport A: Assessment of body composition in peritoneal dialysis patients using bioelectrical impedance and dual-energy x-ray absorptiometry. Am J Nephrol 33(2):150156, 2011

  • 35
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  • 36
    Davenport A: Differences in prescribed Kt/V and delivered haemodialysis dose–why obesity makes a difference to survival for haemodialysis patients when using a ‘one size fits all’ Kt/V target. Nephrol Dial Transplant 28(Suppl. 4):iv219iv223, 2013

  • 37
    Kumar S, Khosravi M, Massart A, Potluri M, Davenport A: The effects of racial differences on body composition and total body water measured by multifrequency bioelectrical impedance analysis influence delivered Kt/V dialysis dosing. Nephron Clin Pract 124(1–2):6066, 2013

Davenport, A. (2015), Will Incremental Hemodialysis Preserve Residual Function and Improve Patient Survival?. Seminars in Dialysis, 28: 16–19. doi: 10.1111/sdi.12320

Author Information

  1. University College London Center for Nephrology, Royal Free Hospital, University College London Medical School, London, United Kingdom

*Address correspondence to: Andrew Davenport, UCL Centre for Nephrology, Royal Free Hospital, London NW3 2QG, UK, Tel.: +44-2074726457, Fax: 44-2073178591, or e-mail:

Davenport, A. (2015), Will Incremental Hemodialysis Preserve Residual Function and Improve Patient Survival?. Seminars in Dialysis, 28: 16–19. doi: 10.1111/sdi.12320

  1. Conflict of interest: The author has no conflict of interest.

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Long-Term Survival Benefits of Combined Hemodialysis and Peritoneal Dialysis

Advances in Peritoneal Dialysis, Vol. 30, 2014

Hiromichi Suzuki,1 Hitosi Hoshi,1* Tsutomu Inoue,1 Tomohiro Kikuta,1 Hiroshi Takane,1 Tsuneo Takenaka,1 Yusuke Watanabe,1 Hirokazu Okada,1 Yumi Kimura2

Long-Term Survival Benefits of Combined Hemodialysis and Peritoneal Dialysis


Recently, it was reported that concomitant hemodi- alysis (HD) in peritoneal dialysis (PD) patients facili- tated continuation of PD treatment and mitigated the deterioration of peritoneal function in patients with uremic symptoms and excess body fluid associated with loss of residual renal function.

To determine the effect of combined HD and PD on patient and technique survival, we undertook a retrospective cohort study of patients who underwent PD at Saitama Medical University Hospital between 1995 and 2010. We compared patients who started PD during 1995 – 2002 with those who started during 2003 – 2010. Because our center started a new strategy of supplementing PD with once-weekly HD in 2000, the effects of combination therapy could be determined by comparing the data obtained during the two periods. The 440 patients (274 men, 166 women) who started  PD during the study period had a mean age of  60.2

± 7.3 years. The mean age was significantly higher in the 2003 – 2010 group than in the 1995 – 2002 group. Using a Kaplan–Meier plot, we observed a significant difference in technique survival (p < 0.001). The tech- nique survival rate at 3 and 5 years was, respectively, 89% and 74% in the 2003 – 2010 group and 68% and

35% in the 1995 – 2002 group (p < 0.05). Cumulative patient survival at 3 and 5 years was, respectively, 87% and 72% in the 2003 – 2010 group and 69% and

51% in the 1995 – 2003 group (p < 0.01).

Patient and technique survival were significantly improved in PD patients receiving the combination of HD and PD.


Key                                            words                                             Hemodialysis, combination therapy, technique survival, patient survival


It is well known that few peritoneal dialysis (PD) patients stay on PD more than 5 years from initiation of therapy. It is also known that a large proportion of dialysis patients transfer from PD to hemodialysis (HD) every year (1,2). Peritonitis recurrence and inadequate dialysis are considered the two major causes of transfer. Jaar et al. (3) reported that, of 292 PD patients followed prospectively, 40% switched within 1 year and 70% within 2 years of starting PD. In their series, the most common reasons for the switch were infection (36.9%) and volume overload (18.5%). In Japan, Kawaguchi et al. (4) reported that, in 224 patients, overall survival was 50% at a mean of 5.5 years, and ultrafiltration failure was the most frequent reason for withdrawal from PD.

Several methods have been proposed for the prevention of ultrafiltration failure, including use of icodextrin and inhibition of the renin–angiotensin system (5). Recently, Moriishi et al. (6) suggested that concomitant HD facilitates continuation of PD treat- ment and retention of peritoneal function in patients with uremic symptoms and excess body fluid associ- ated with a loss of residual renal function. Because our center started a new strategy of supplementing PD with once-weekly HD in 2000 (7,8), we evaluated the effects of combination therapy by comparing the patient data obtained during the periods before and after that change.



We recruited 440 patients attending the Kidney Dis- ease Center in Saitama Medical University Hospital, Saitama, Japan, who started PD from 1995 to 2010. Patients with less than 6 months of follow-up and


those who had been on HD or who had received a

From: 1Department of Nephrology, Saitama Medical Univer- sity, and 2Nursing Department, Saitama Medical University

Hospital, Saitama, Japan.                                                     * Deceased.




kidney graft before PD were excluded from the analy- sis. The criterion for introducing HD in combination therapy was a weekly creatinine clearance of less than 45 L [calculated using PD Adequest (Baxter Health- care, Tokyo, Japan)] or fluid overload (8).

To analyze patient and technique survival dur- ing the 14-year period, we collected such patient data as age at the start of PD, sex, underlying renal disease, comorbidities, follow-up duration, cause of death, and the occurrence of insufficiency or technique failure (that is, inadequate dialysis, peri- tonitis, ultrafiltration failure, exit-site infection, tunnel infection, and mechanical or operational problems). Causes of death were categorized as cardiovascular, stroke, malignancy, infection, and others. Technique failure resulted in transfer to HD or renal transplantation.

Informed consent was obtained from the patients before PD start. The present study was performed in accordance with the principles of the Declaration of Helsinki.


Regular treatment modality

More than 60% of the patients were treated with a standard PD regimen of 3 – 4 daily exchanges of

1.5 L or 2 L of dialysate. Other patients used 1 – 2 daily exchanges. The solution concentration was individualized to maintain the desired weight. Dwell times were also individualized to maximize overall ultrafiltration volumes. Mean daily dietary intake was recorded from individual 24-hour food records during a 3-day period at the start of the study. All subjects consumed between 0.8 g and 1.0 g of pro- tein per kilogram body weight daily, and their daily energy intake exceeded 25 kcal per kilogram body weight. Salt intake was restricted to less than 9 g daily throughout the study.


Combination of PD and HD

A 4-hour HD session was added once weekly after 6 consecutive days of PD. On the morning of HD, the PD dialysate was drained before the HD session. Bi- carbonate dialysate and a dialyzer with a polysulfone dialysis membrane was used for HD.


Patient monitoring

Patients were followed every month during the study period. At each clinic visit, serum creatinine, elec- trolyte concentrations, complete  blood  count,  and

other serum chemistries (uric acid, glucose, liver enzymes) were measured. Indices of the adequacy of dialysis, including weekly creatinine clearance, were calculated using the PD Adequest software for Win- dows (version 2.0). Chest radiographs were obtained regularly, and cardiothoracic index was calculated using established methods.

During the study, target home blood pressure was 130/80 mmHg or lower, and home blood pres- sure measurements were encouraged. The selection of antihypertensive agents depended on physician preference. Subjects were treated with recombinant human erythropoietin as necessary, and hemoglobin levels were maintained in the range 10 – 11 g/dL. Subjects were given oral iron supplementation if they were diagnosed with iron deficiency.

Subjects with parathyroid hormone levels greater than 500 pg/mL were treated with 1,25(OH)2D3 and

CaCO3  supplements, and patients with levels  lower

than 70 pg/mL were treated with CaCO3 to reduce the degree of hyperphosphatemia. Doses were  adjusted

based on serum levels of calcium and phosphate. Lipid-lowering drugs, primarily statin derivatives, were administered if serum cholesterol exceeded 240 mg/dL.


Statistical analysis

Results are expressed as mean ± standard error of the mean. Statistical analyses used the Student t-test for unpaired samples and  the  Mann–Whitney test to compare means. Statistical significance was  set at p < 0.05. The analyses were performed using the JMP software application (version 9: SAS Institute, Cary, NC, U.S.A.).

Patient and technique survival rates were deter- mined using the Kaplan–Meier method. A log-rank test was used to compare patient and technique sur- vival between groups.




Baseline characteristics of the study subjects

Table I shows baseline characteristics for all patients at the start of PD. The 440 patients analyzed in the study had a mean age of 60.2 years, and 62.6% were men. Chronic glomerulonephritis, diabetes mellitus, and hypertension were the three most common causes of end-stage renal disease. Mean age was significantly higher in the 2003 – 2010 group than in the 1995 – 2002




group (p < 0.05). Diabetic patients constituted a larger proportion of the 1995 – 2002 group than of the 2003 – 2010 group, but that difference was nonsignificant.

Table II shows the ages of the patients by underly- ing disease. The mean age of patients with glomeru- lonephritis was greater in the 2003 – 2010 group than in the 1995 – 2002 group, but nonsignificantly so. Differences in age for patients with the other two

table  i          Characteristics of the study subjects


Variable                                   Treatment group


Overall      1995–2002  2003–2010

Patients (n)                                    440                219                221

Sex (n men/women)                274/166      136/83             138/83 Mean age (years)          60.2±7.3    58.0±13.5   63.7±12.8a

underlying diseases were also nonsignificant. Glomerulonephritis 308 (70) 130 (59) 178 (80)
Diabetes mellitus 83 (19) 59 (27) 24 (11)
Causes of death Hypertension 38 (8) 25 (11) 13 (6)
Table  III  shows  the  cause-of-death  classifications Others and unknown 11 (3) 5 (3) 6 (3)


Underlying disease [n (%)]






for the patients. In a nationwide survey of Japanese patients on HD, cardiac and infectious disease were the two major causes of death. In the present study, the two groups showed no significant difference in the proportion of infectious disease, but more patients in the 2003 – 2010 group had cardiovascular diseases. That finding might reflect the aging process, because the patients in the 2003 – 2010 group were also older than those in the 1995 – 2002 group.


Transfers directly to HD or to combination HD and PD

All patients started PD as their initial dialysis therapy. Thereafter, some patients switched directly from PD to HD; others needed HD as a complementary therapy (Table IV). In the 2003 – 2010 group, 44% of




p < 0.05.



table ii         Mean age of patients by underlying disease


Underlying disease                      Treatment group (%)



Overall 1995–2002 2003–2010
Glomerulonephritis 59.3±9.4 55.7±13.9 63.3±12.1
Diabetes mellitus 63.5±10.6 62.6±11.0 65.9±12.1
Hypertension 65.3±12.2 64.9±11.0 68.1±14.8


table iii    Causes of death in the study subjects


Causes                                     Treatment group


                                          Overall               1995–2002        2003–2010



the patients used combination therapy as their second

dialysis modality, a proportion that was significantly

Deaths overall (n) Deaths from [n (%)] 203 141 62
higher than the 14%  of patients in the 1995 –   2002 CVD 41 (20) 23 (16) 18 (29)
group who used combined PD and HD. Infection 25 (12) 17 (12) 8 (13)
Stroke 16 (8) 11 (8) 5 (8)
Outcomes Malignancy 12 (6) 7 (5) 5 (8)
technique survival Unknown 109 (54) 83 (59) 26 (42)


Figure 1  shows  Kaplan–Meier technique survival

curves for the patients. Technique survival was sig- nificantly different between the groups (p < 0.001). The technique survival rate at 3 and 5 years was 89%

CVD = cardiovascular disease.


table  iv       Number of peritoneal dialysis (PD) patients transferred directly to hemodialysis (HD) or to combination HD and PD


and 74% in the 2003 – 2010 group and 68% and 35%

in the 1995 – 2002 group.


patient survival

Transfer modality                            Treatment group


Overall   1995–2002 2003–2010


Figure 2 shows that the duration of patient survival was significantly shorter in the 1995 – 2003 group than in the 2003 – 2010 group (Kaplan–Meier analy- sis, p < 0.01). The cumulative patient survival rates at 3 and 5 years were 87% and 72% in the 2003 – 2010

group and 69% and 51% in the 1995 – 2003 group.

All patients (n)                                  440             219               221

Patients transferring to [n (%)]

Hemodialysis                        124 (28)     120 (55)       63 (29)a

Combination PD+HD         129 (29)      31 (14)        98 (44)b


a   p < 0.05.

p < 0.01.









figure 1 Kaplan–Meier technique survival curves for patients treated during 1995 – 2002 (dotted line) and 2003 – 2010 (solid line). The difference in technique survival was significant ( p < 0.001). At 3 and 5 years, the technique survival rate was 89% and

74% respectively in patients treated during 2003 – 2010, and 68%

and 35% in patients treated during 1995 – 2002.

figure 2 Kaplan–Meier patient survival curves for patients treated during 1995 – 2002 (dotted line) and 2003 – 2010 (solid line). Patient survival was significantly shorter during 1995 – 2003 than during 2003 – 2010 (p < 0.01). At 3 and 5 years, the cumulative proportional patient survival was 87% and 72% respectively in patients treated during 2003 – 2010, and 69% and 51% in patients

treated during 1995 – 2003.





In this longitudinal cohort study, 440 incident PD patients were recruited from a single center. The results showed that the mean age of patients treated during 2003 – 2010 was significantly higher than that of patients treated during 1995 – 2002. In spite of advancing age, patient and technique survival were both significantly higher in patients who started PD after 2003 than in those who started before 2002.

Patient survival has been reported to be low in PD patients (9). However, compared with reports from Europe (2) and the United States, some reports from Korea (10), Hong Kong (11), and Japan (12) have dem- onstrated a relatively higher survival rate. In the pres- ent study, the survival rate for the 1995 – 2002 group was equivalent to that seen in data from Japan (12). However, the survival rate was significantly higher for the 2003 – 2010 group than for the 1995 – 2002 group. Previously, Han et al. (10) reported a better than 70% technique survival at 5 years in the period since 1993 for patients whose average age was 56 (younger than the mean of 60 years in the present study). How- ever, in our study, the proportion of patients with diabetes was lower than that reported from Asian countries, where diabetic patients typically constitute more than 30% of the PD population. That difference might negate the favorable findings in our study, be- cause it has been reported that diabetic patients    on

PD experience shorter survival (11).

The foregoing factors aside, the chief difference between the reports from Korea and Hong Kong and the present study is the method for continua- tion of PD therapy. In general, compensation for the declining ultrafiltration ability of the peritoneal membrane is attained by increasing the frequency of exchanges or the volume of dialysate; however, PD failure still typically occurs within 10 years. In the present study, instead of applying those methods, once-weekly HD was added to try to compensate for inadequate dialysis and volume removal. When weekly ultrafiltration began to decline below 45 L as calculated by PD  Adequest, once-weekly HD in combination with PD was recommended to the patients  (7,8).  Recently,  Kawanishi and McIntyre

  • and Kawanishi and Moriishi (14) reported that, compared with PD alone, complementary dialysis therapy provided higher weekly clearances and longer patient Our earlier studies also reached similar findings, in that weekly clearance increased after addition of once-weekly HD (7,8). The results of the present study extend the data presented by Kawanishi and colleagues, providing further validation of adding combination therapy with HD to prolong PD.

Statistics on causes of death in Japanese HD patients in 2004 show that the leading cause was cardiac failure (27.7%), followed by infectious disease (18.5%). In the present study,  significantly




more deaths from cardiovascular disease were observed in the 2003 – 2010 group (30.0%) than in the 1995 – 2002 group, but no difference in deaths from infectious disease was observed. That finding is probably attributable to the effects of advancing age. Also, despite there being no difference between the groups in the proportion of deaths from infection, the number of patients increased—possibly reflect- ing an increase in the number of patients undergoing combination therapy.


Limitations of the study

The present study has some limitations. First, it was a single-center study, and consequently, center- specific effects cannot be excluded. Second, selection bias resulting from the choice to switch from PD to HD or to add HD to PD might have influenced the results. Third, there was no definition for withdrawal from combination therapy with HD and PD. Fourth, the study compares data obtained during different time periods, which means that staff, methods, and procedures would have been different. Despite those limitations, our study proposes a new strategy for “PD First” therapy (15,16)



The present study demonstrates that, compared with PD alone, the combination of PD and HD resulted in longer patient and technique survival.



The authors have no financial conflicts of interest.



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Corresponding author:

Hiromichi Suzuki, md phd, Department of Nephrol- ogy, Saitama Medical University, 38 Moroyama- machi, Iruma-gun, Saitama  350-0495 Japan.


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