RESUMEN
In 1999, the End-Stage Renal Disease Network of Texas, Inc, #14 (NW14) initiated a quality improvement project in support of the Health Care Finance Administration's End-Stage Renal Disease Health Care Quality Improvement Program. The project, titled "Mission Possible: Vascular Access: Decreasing the Utilization of Catheters in the Texas Hemodialysis Community," aims to assist the Texas dialysis community decrease the use of hemodialysis catheters. This report reviews the goal of the project, baseline vascular access survey results, and quality improvement activities initiated to help dialysis professionals implement quality management processes that will improve the quality of care for Texas dialysis patients.
Asunto(s)
Catéteres de Permanencia/estadística & datos numéricos , Garantía de la Calidad de Atención de Salud , Diálisis Renal/instrumentación , Centers for Medicare and Medicaid Services, U.S. , Humanos , Fallo Renal Crónico/terapia , Diálisis Renal/métodos , Texas , Gestión de la Calidad Total , Estados UnidosRESUMEN
Several studies have shown that patients who have been dialyzed with high-flux biocompatible membranes have a lower plasma level of beta 2-microglobulin and a lower incidence of amyloid disease compared with patients who have been dialyzed with low-flux bioincompatible membranes. However, because high-flux membranes are associated with significant dialytic removal of beta 2-microglobulin, the specific role of membrane biocompatibility in influencing the rate of increase of beta 2-microglobulin has not been previously determined. This study investigated the effect of biocompatibility on the rate of increase of plasma levels of beta 2-microglobulin in 159 new hemodialysis patients from 13 dialysis centers (ten centers affiliated with Dallas Nephrology Associates and three with Vanderbilt University Medical Center) by using two low-flux membranes with widely different biocompatibilities. These patients were prospectively randomized to be dialyzed with either a low-flux biocompatible membrane or a low-flux bioincompatible membrane. Plasma beta 2-microglobulin levels were measured at 0, 3, 6, 9, 12, and 18 months. Sixty-six patients completed the 18-month study. Plasma beta 2-microglobulin increased in all patients; however, the increase was not significantly different from baseline at any time point in the group that used the biocompatible membrane. In this group, beta 2-microglobulin increased from (mean +/- SD) 27.8 +/- 14.8 mg/L to 34.0 +/- 10.0 mg/L at 18 months (P = not significant), and the mean increase at 18 months was 2.6 +/- 14.7 mg/L. In contrast, the increase in plasma beta 2-microglobulin level in the bioincompatible membrane group became significant in Month 6 when the levels had increased from a baseline of 24.8 +/- 9.6 mg/L to 29.5 +/- 12.2 mg/L (P < 0.001); these increases continued to be significant until Month 18, when serum beta 2-microglobulin reached 36.8 +/- 13.9 mg/L with an average increase of 11.8 +/- 11.2 mg/L (P < 0.0001). The higher rate of plasma B2-microglobulin increase in the group that had been dialyzed with the bioincompatible membrane was also evident when only patients who had completed the study were analyzed. There were no significant differences in the actual level of beta 2-microglobulin or in residual renal function between the two groups during the 18 months of the study. It was concluded that over a period of 18 months, the use of biocompatible membranes, even in the low-flux configuration, is associated with a significantly slower increase in plasma beta 2-microglobulin, independent of the influence of residual renal function.
Asunto(s)
Materiales Biocompatibles , Membranas Artificiales , Diálisis Renal , Insuficiencia Renal/sangre , Microglobulina beta-2/metabolismo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Análisis de Regresión , Diálisis Renal/instrumentación , Insuficiencia Renal/terapia , Estudios Retrospectivos , Resultado del Tratamiento , Urea/metabolismoRESUMEN
Malnutrition is highly prevalent in chronic hemodialysis patients and is an important determinant of their morbidity and mortality. Several recent studies have suggested that the inflammatory response associated with the biocompatibility of the dialysis membranes is a potential contributing factor. In a prospective study of 159 new hemodialysis patients from two centers randomized to either a low-flux biocompatible (BCM) membrane or a low-flux bioincompatible (BICM) membrane, we measured the long-term effects of biocompatibility on several nutritional parameters, including estimated dry weight, serum albumin, insulin-like growth factor-1 (IGF-1), and prealbumin over 18 months. Our results show that the BCM group had a mean (+/- SD) increase in their dry weight of 2.96 +/- 6.88 kg at month 12 and 4.36 +/- 8.57 kg at month 18 (P < 0.05 vs. baseline for both), whereas no change in mean weight was observed in BICM group. Following initiation of hemodialysis, a significant increase was observed in serum albumin levels in both groups of patients. However, the biocompatible group had an earlier and more marked increase in serum albumin levels compared to the BICM group. The average increase in serum albumin compared to baseline was consistently greater than 0.25 g/dl after seven months in the BCM group, but did not reach this level until 12 months after initiation of dialysis in the BICM group. The difference between the groups was statistically significant at months 7, 8, and 10 (P < 0.05, higher in the BCM group). Furthermore, the overall difference in serum albumin concentration between the two groups was larger in the center where the dose of dialysis was equivalent (P < 0.001). A consistently higher value was also observed in IGF-1 levels for BCM patients compared to BICM group (P = NS). In a further analysis, changes in IGF-1 levels, but not prealbumin, predicted the subsequent changes in serum albumin. We conclude that biocompatible hemodialysis membranes favorably impact on the nutritional status of chronic hemodialysis patients, independently of the flux characteristics of the membranes, and that IGF-1 may be an early marker of nutritional status.
Asunto(s)
Materiales Biocompatibles , Membranas Artificiales , Evaluación Nutricional , Diálisis Renal/instrumentación , Adulto , Anciano , Peso Corporal , Enfermedad Crónica , Activación de Complemento , Interpretación Estadística de Datos , Femenino , Humanos , Factor I del Crecimiento Similar a la Insulina/metabolismo , Masculino , Persona de Mediana Edad , Prealbúmina/metabolismo , Proteínas/metabolismo , Albúmina Sérica , UltrafiltraciónRESUMEN
The mortality rate for hemodialysis patients in the United States is higher than in other industrialized countries. Some attribute this to insufficient quantities of prescribed and delivered dialysis. A multicenter study in Dallas dialysis centers (Dallas Nephrology Associates) was begun in 1989 to assess the impact of increasing the delivered quantity of dialysis on mortality in subsequent years. Dialysis dose was measured by urea kinetic modeling. Kt/V, reflecting the fractional volume of body water clearance of urea during a dialysis treatment, was purposefully increased from 1.18 starting in 1989 to 1.46 in 1992. Additionally, the dialysis dose measured by the urea reduction ratio, the fractional reduction of blood urea nitrogen concentration caused by a dialysis treatment, increased from 63.0% to 69.6% between 1990 and 1992. Outcome analytical methods included both crude and standardized mortality rates and mortality ratios standardized to large end-stage renal disease databases at the United States Renal Data System and at National Medical Care, Inc. Crude mortality rates at Dallas Nephrology Associates decreased from 22.5% in 1989 to 18.1% in 1992. In comparison, between 1990 and 1992 the urea reduction ration in National Medical Care facilities increased from 57.1% to 62.5%. During that time crude mortality rates decreased from 21.8% to 19.5%. Crude mortality in the United States remained essentially unchanged in the same time period. By 1992, Dallas Nephrology Associates and National Medical Care had standardized mortality ratios of 0.77 and 0.74, respectively, compared with the US dialysis population, indicating almost 30% fewer observed deaths than expected. Monitoring dialysis dose by urea kinetic modeling or urea reduction ratio are equally effective in predicting improvement in patient survival. Improved survival is possible in the US end-stage renal disease program with greater amounts of dialysis. This strategy can save an estimated 8,000 to 16,000 lives per year.
Asunto(s)
Fallo Renal Crónico/mortalidad , Diálisis Renal/métodos , Factores de Edad , Femenino , Humanos , Fallo Renal Crónico/metabolismo , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana Edad , Diálisis Renal/tendencias , Factores Sexuales , Tasa de Supervivencia , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
Glutaraldehyde has been proposed to be as effective as formaldehyde as a disinfectant for reprocessing capillary hemodialyzers. Formaldehyde has become the standard to which all disinfectants are compared. The two products are compared for microbiological efficacy, reuse, membrane integrity, biocompatibility, performance, residual binding and ease of removal, environmental hazards, and immunogenicity. Glutaraldehyde (0.8%) is as effective as 4% formaldehyde in its microbiocidal effect. The disinfectants are comparable except in the following areas: the use of glutaraldehyde leads to lower reuse rates than formaldehyde, significantly less glutaraldehyde than formaldehyde remains in the dialyzer following standard predialysis rinse procedures, and less glutaraldehyde than formaldehyde is found in environmental air.