Urgent-Start Peritoneal Dialysis: A Quality Improvement Report
Authors: Arshia Ghaffari
Journal Citation: Am J Kidney Dis. 201;59(3):400-408, doi:10.1053/j.ajkd.2011.08.034.

Summary

Peritoneal dialysis (PD) is a dialysis modality used relatively infrequently in the USA, but more frequently in other areas of the world.  A portion of patients with end-stage renal disease (ESRD), however, need to initiate dialysis before a treatment plan can be developed or before they are able to enter a nephrologist’s care.  The author describes a quality improvement report from a small single-center, nonrandomized study of the outcomes from a structured urgent-start PD program at the LA county and USC medical center between March 2010 and March 2011; this program involved a standardized process including access placement, nurse education, administrative support, and patient education.  Eligible patients had chronic kidney failure (or a transplant recipient whose transplant had failed), required dialysis within 2 weeks, and had no planned modality for long-term dialysis.  In all, 18 patients met these criteria; 9 patients who received non-urgent PD were included as control.  Assessed clinical outcomes within 90-days were measured and were found to be similar between the 2 groups, for all but uncorrected serum calcium levels (which were lower in the urgent-start group, P = 0.02).  Complications were generally similar, with the exception of slightly more frequent minor leaks in the urgent start group.  The authors suggest that, as PD can be a cost-effective form of dialysis, with outcomes similar to hemodialysis, further exploration of the use of PD through a structured program such as the one described here for such a late-referred population with chronic renal failure may be warranted

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Dialyzer Reuse and Mortality Risk in Patients with End-Stage Renal Disease: A Systematic Review
Authors:   Tais Freire Galvao, Marcus Tolentino Silva, Maria Elizete de Almeida Araujo, Wilson Seffair Bulbol, Angela Libia de Melo Pereira Cardoso
Journal Citation:   Am J Nephrol 2012;35:249–258. doi: 10.1159/000336532

Summary
Reuse of dialyzers can be economically beneficial and may prove less wasteful; however, the risks associated with reuse are less clear.  The authors assessed mortality associated with dialyzer reuse in patients with end-stage renal disease (ESRD).  They conducted a systematic review of the published evidence, both in indexed and non-indexed literature.  Of 1190 identified studies, 14 were included in the review, and these describe outcomes in 956,807 patients.  Most of these studies were conducted on retrospective data from the 1980s and 1990s in the USA, a period of time during which conventional dialyzers were commonly used The authors note that all of the studies were observational studies, and of low quality according to the GRADE criteria (ie, Grading of Recommendations Assessment, Development and Evaluation).  The inconsistencies amongst these studies prohibited the ability to do a statistical assessment across the studies.  In all, the authors conclude that reuse of dialyzers does not appear to affect mortality, based on the lack of consistent and significant findings, compared with single use.  The authors point out that these results may not be as translatable to modern dialyzers that use synthetic and more biocompatible membranes as these factors may confound the outcomes.  Finally, the authors argue that better studies, including randomized studies, are required to help inform this question.
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Myocardial microvascular disease and major adverse cardiovascular events in patients with end-stage renal disease: rationale and design of the MICROCARD study
Authors: Theodora Bejan-Angoulvant, Cyrille Bergerot, Laurent Juillard, Aline Mezergues, Emmanuel Morelon, Claire Pouteil-Noble, Xavier Andre-Fouet, and Denis Angoulvant
Journal Citation: Nephrol Dial Transplant (2012) Published online early. doi: 10.1093/ndt/gfs008

Summary
Mortality in patients with end-stage renal disease (ESRD) is often due to cardiovascular disease.  In this patient population, compared with those without ESRD, coronary artery disease appears to differ in its pathophysiology; for example, patients with ESRD tend to have a higher risk of myocardial microvascular disease (MMD) and other cardiovascular symptoms.  The authors describe MICROCARD, an ongoing observational prospective cohort study (Clinicaltrial.gov NCT01291771) investigating the prevalence of myocardial microvascular disease (MMD) and its association with major adverse cardiovascular events (MACE) in patients with ESRD who had a positive non-invasive test for myocardial ischemia (experimental group), compared to patients with ESRD who had a negative test (control group).  Patients in the experimental group will undergo further cardiac assessments.  All patients with ESRD scheduled for a kidney transplant at Lyon University Hospital Centre are referred for evaluation.  Enrolment in this study began in January of 2011, and was planned to end in January 2012. The primary endpoint follow-up will be completed in January 2014.  Patients in the experimental group will be examined in greater detail.  Results from this study, expected in 2014, should provide more insight into coronary artery disease and especially MMD in patients with ESRD.

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Effects of thrice weekly nocturnal hemodialysis on arterial stiffness

Authors: Meltem Sezis Demirci, Gulperi Celik, Mehmet Ozkahya, Murat Tumuklu, Huseyin Toz, Gulay Asci, Soner Duman, Ali Basci, Fatih Kircelli, Oner Ozdogan, Cenk Demirci, Levent Can, Ismet Onder Isik, Ercan Ok, On behalf of the ‘Long Dialysis Group’

Journal Citation:  Atherosclerosis 2012. 220(2): 477-485.
Link to Article    http://www.atherosclerosis-journal.com/article/S0021-9150(11)01084-7/abstract

Summary

Patients with chronic kidney disease, eg, end-stage renal disease, are particularly susceptible to developing serious cardiovascular complications.  These complications may arise from multiple factors such as increased arterial stiffness, possibly resulting from increased fluid overload, increased localized calcium ion levels, hypertension, and arterial calcification.  Altering the frequency and/or length of dialysis sessions may provide better control of these factors.
These investigators describe a prospective, nonrandomized substudy of patients enrolled in the “Long Dialysis Study” (Clinicaltrials.gov ID NCT00413803), a prospective, controlled study of 494 prevalent HD patients receiving thrice weekly 8-hour nocturnal HD (NHD) or thrice weekly 4-hour conventional HD (CHD).  This substudy measured arterial stiffness outcomes in 60 NHD and 60 CHD patients over the 12-month study period.  These patients (mean age, 49 years) had a mean dialysis vintage of 57 months (SD, 47 months).  The two groups were similar in their baseline demographics.
In this study, longer hemodialysis sessions with NHD, compared to CHD, appeared to improve control of both phosphorus and extracellular fluid, resulting in less arterial stiffness, reduced requirements for antihypertensive treatments, and lower calcium-phosphorus product. Based on these results, the authors recommend a randomized controlled study to assess the impact of NHD on hospitalization and death rates.

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Medication Reminder Systems: An Adjunct Technique in Improving Phosphate Binder Adherence

Authors:  Thessaa Obrero Churillo

Journal Citation:   J Ren Nutr 2012; 22(1): e3-e9,. doi:10.1053/j.jrn.2011.10.002

Summary
Poor adherence to prescribed treatment is a common issue across medicine and has been identified as resulting in increased risk of hospitalization and other poor outcomes.  In nephrology, management of hyperphosphatemia is critical to help mitigate the risk of cardiovascular disease among patients with chronic kidney disease (CKD) as directed by KDOQI and KDIGO guidelines.  Typically a regimen of phosphate binders is prescribed.  However, reported compliance with phosphate binder treatment has been poor due to issues including the pill burden in this population, patient ignorance, forgetfulness, and discomfort with the treatment.  Various approaches have been taken in nephrology and other areas of medicine, including improving education, communication, and ease of treatment regimens.
The authors review various electronic approaches that can be employed to help improve patient compliance.  These attempts include prescription reminder services, medication devices with electronic reminders, and mobile applications.  Each approach to help improve patient compliance has different implications for patients, their needs and their resources.  Patient factors need to be considered when deciding what approach to employ.  In the case of management of hyperphosphatemia with phosphate binder treatment, the need to coordinate treatment and meal schedule is an additional complication likely resulting in the need for a multifactorial approach to help ensure patient compliance with treatment.  The ability of these and other approaches to help improve patient compliance in this setting remains to be confirm in a prospective controlled study.

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