Decrease in the average duration of hemodialysis treatment time is a continuing phenomenon. We investigated the relationship of 3-year mortality to duration of dialysis in a 1984-1985 national random sample of 600 hemodialysis patients from 36 dialysis units. Mortality was negatively associated with duration of dialysis treatments, as shown by the Cox model, adjusted for other patient and dialysis unit covariates. With adjustment for other covariates, patients receiving an average dialysis treatment duration of less than 3.5 hours had relative mortality risks of 1.17 to 2.18 compared with those with treatments longer than 3.5 hours (mortality risk of 1.0). Reverse causation (the possibility that more seriously ill patients received dialysis for a shorter time) appears unlikely. We conclude that duration of the dialysis procedure is an important element in determining patient mortality as one of the factors determining the adequacy of dialysis.
In light of mounting federal government debt and levels of Medicare spending that are widely viewed as unsustainable, commentators have called for a transformation of the United States health care system to deliver better care at lower costs. This article presents the priorities of the Coalition for Supportive Care of Kidney Patients for how clinicians might achieve this transformation for patients with advanced CKD and their families. The authors suspect that much of the high-intensity, high-cost care currently delivered to patients with advanced kidney disease may be unwanted and that the "Three Aims" put forth by the National Quality Strategy of better care for the individual, better health for populations, and reduced health care costs may be within reach for patients with CKD and ESRD. This work describes the coalition's vision for a more patient-centered approach to the care of patients with kidney disease and argues for more concerted efforts to align their treatments with their goals, values, and preferences. Key priorities to achieve this vision include using improved prognostic models and decision science to help patients, their families, and their providers better understand what to expect in the future; engaging patients and their families in shared decision-making before the initiation of dialysis and during the course of dialysis treatment; and tailoring treatment strategies throughout the continuum of their care to address what matters most to individual patients.
Nephrotoxicity was evaluated in 37 patients receiving aminoglycosides by serial urinary measurements of the low-molecular weight protein β2-microglobulin (β2m), and the proximal tubular enzymes N-acetyl-glucosaminidase and β-glucuronidase. Clinical nephrotoxicity, with a rise in serum creatinine > 20% of the baseline value, was diagnosed in 15 of 30 evaluable patients. The laboratory diagnosis of nephrotoxicity, defined as a two-fold increase in β2m, N-acetyl-glucosaminidase and β-glucuronidase, was confirmed in 11/15 patients. Additionally, there were 3 patients in whom there was definitive laboratory nephrotoxicity in the absence of a rise in serum creatinine. The laboratory diagnosis of nephrotoxicity could be made 4.1–5.5 days prior to significant elevation in serum creatinine. The data suggest that β2m and enzyme studies are predictors of nephrotoxicity.
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