We reviewed a number of prospective randomized and multiple retrospective cohort studies of different dialysis prescriptions: longer dialysis time, at a frequency of at least three times a week, or a frequency of daily hemodialysis with a shorter dialysis time. Interestingly, the retrospective analyses have generally found significant survival benefits in the intensive dialysis groups, whereas more modest effects were observed in the prospective randomized controlled trials. The reason for this discrepancy may be related to the retrospective nature of the studies and possible selection bias; for example, the patients who were prescribed more frequent dialysis may have had more difficulties with volume control or high blood pressure. In contrast, the randomized controlled trials of increased dialysis frequency, which have shown indirect and modest benefits in complex coprimary end points, have small sample sizes and are plagued with difficulties in recruitment and compliance with the randomly allocated more frequent dialysis. This review, which attempts to balance the potential benefits of more frequent dialysis with the burden on the patient's lifestyle, an increased risk of access malfunction, as well as societal costs of such intensive dialysis prescriptions, concludes in favor of the conventional three times per week dialysis (at a minimum) but at longer dialysis times than is currently prescribed based on the Kt/Vurea metric alone.
A 59-year-old Laotian male with a past medical history of multiple myeloma on peritoneal dialysis (PD) presented with abdominal pain and peritoneal eosinophilia. He was treated empirically for bacterial peritonitis and discharged although his PD fluid did not isolate any pathogens. He soon developed a partial small bowel obstruction and his serum Strongyloides IgG was positive. After treatment with ivermectin, stool microscopic examination showed Strongyloides stercoralis larvae. This case illustrates that the differential diagnosis of peritoneal eosinophilia should include typical and atypical infections in addition to an allergic or hypersensitivity type reaction.
A lthough an in-center hemodialysis facility is primarily perceived as a provider of health care, it is also a business that requires a leader. Analogous to the "Triple Aim" of the health care system envisioned by the Centers for Medicare & Medicaid Services (CMS), each hemodialysis facility has its own triple aim: (1) providing each patient with a safe, high-quality, pleasing experience of care; (2) complying with CMS's certification requirements; and (3) ensuring that the facility remains financially viable. The common denominator for all 3 aims is quality of care, which is a focus for Medicare survey and certification activities, affects patient outcomes and perceptions, and affects payment through the Quality Incentive Program (QIP). The facility medical director is primarily responsible for the Quality Assessment and Performance Improvement (QAPI) program within the facility, but must partner with the facility administrator to ensure that resources are directed to address opportunities for improvement. The responsibilities of the medical director have been addressed in detail in a series of articles that appeared in the Clinical Journal of the American Society of Nephrology in 2015 and will not be extensively discussed in this article. Both the facility administrator and medical director report to the governing body of the facility and may be members of the governing body. It is ultimately the responsibility of the governing body to adopt and enforce rules and policies to allow for safe and effective care delivery in the hemodialysis unit (Box 1). The key responsibilities and qualifications of the facility administrator are summarized in Box 2. CERTIFICATION AND LICENSURE The initial End-Stage Renal Disease (ESRD) Conditions for Coverage (CfC) were established in 1976 and most recently revised in 2008. To participate in the Medicare or Medicaid programs, facilities must be in compliance with the federal rules and standards for dialysis facilities found in the CfC. CMS developed the standards to ensure safe care of the highest quality to dialysis patients. The revised CfC focus on using an interdisciplinary integrated care system that emphasizes patient assessment, care planning, care delivery, and quality assessment and performance improvement. These new standards also stress patient satisfaction, as well as involvement in the development of the care plan and treatment. Outcome measures were developed and validated with input from the nephrology community so that they are clinically meaningful and reflect current scientific knowledge. It should be noted that dialysis facilities must comply with the laws and regulations of other local and federal agencies in addition to the CfC. These are summarized in Box 3. To provide guidance in the application of these regulations, CMS developed the ESRD Interpretive Guidelines. The guidelines identify regulations with a "V tag" and include the regulation and a point-bypoint interpretation of each condition. There are more than 500 V tags, so this guidance is particularly...
SummaryBackground and objectives In living-donor kidney transplantation, various donor factors, including gender, age, and baseline kidney function, predict allograft function and recipient outcomes after transplantation. Because higher phosphorus is predictive of vascular injury in healthy adults, the effect of donor phosphorus levels on recipient renal function after transplantation was investigated.Design, setting, participants, and measurements Phosphorus levels in 241 living donors were analyzed from a 7-year period, and recipient renal function and acute rejection at 1 year posttransplantation were examined controlling for other influencing factors, including multiple donor variables, HLA matching, and acute rejection.Results Female and African-American donors had significantly higher phosphorus levels predonation. By multivariable analysis, higher donor phosphorus correlated with higher recipient serum creatinine (slope ϭ 0.087, 95% confidence interval [CI]: 0.004 to 0.169, P ϭ 0.041) and lower recipient estimated GFR (slope ϭ Ϫ4.321, 95% CI: Ϫ8.165 to Ϫ0.476, P ϭ 0.028) at 12 months. Higher donor phosphorus also displayed an independent correlation with biopsy-proven acute rejection and delayed or slow graft function after transplantation. ConclusionsIn a cohort of living kidney donors, higher donor phosphorus correlated with female gender and African-American ethnicity and was an independent risk factor for early allograft dysfunction after living-donor kidney transplantation.
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