 |
| dialysis - session 4 (Photo credit: wj gibson (Archie Goodwin)) |
Hemodialysis is a life saving therapy for patients with severe kidney disease. The therapy is well established and is the most readily available form of renal replacement therapy in the United States. Improving survival on dialysis is the aim of several ongoing studies. The largest of these studies is the Dialysis Outcomes and Practice Patterns study or (DOPPS). The investigators sought to determine detailed information about the association of various co-morbid and clinical characteristics of patients which may shed light on the causes of death and ultimately how to increase length and quality of life on dialysis.
Data from the DOPPS study suggests that patients are at the highest risk of death within 120 days after starting dialysis. This increased risk of death is believed to be based on patient specific factors such as age, race and the presence of various co-morbidities. Previous studies that have attempted to isolate the predictors of early death in patients starting dialysis have revealed death rates as high as 12% for the first 90 days.
The DOPPS study has revealed that death within 120 days was more likely in patients that were.
- Elderly
- White
- Diagnosed with heart failure.
- Utilized a catheter for first dialysis.
- Diagnosed with cancer
- Diagnosed with lung disease
- Diagnosed with neurologic disease
- Diagnosed with psychiatric disorder
- Were referred late to a specialist.
 |
| Simplified hemodialysis circuit. (Photo credit: Wikipedia) |
Although some of these risk factors are admittedly unchangeable and expected. Two risk factors are particularly note worthy. Late referrals and the use of a catheter at first dialysis session. These two factors are a more direct index of the degree of health care that the patients received during their follow up prior to needing dialysis. Any death due to these two factors within the first 120 days of starting dialysis are directly preventable by simply following the established protocols. Patients should be referred to a specialist in a timely manner such that interventions are possibly that will improve the prognosis of the patient.
Catheters are a form of dialysis access that are grossly inferior to other methods of accessing the blood stream for the purposes of dialysis. The use of catheters at first dialysis are associated with increased risk of life threatening infection and decreased dialysis adequacy and thus decreased survival and quality of life. The choice to place a catheter as a form of first access should only be made when no other access is possible. However discussing the types of possible access and the pros and cons in a manner that allows the patient an educated choice will take time hence the need for early referral.
Late referral to a nephrologist almost always results in the use of a catheter. The quality of life of patients may therefore be significantly improved by referring patients to a nephrologist in a timely manner to allow for a more appropriate choice of access such as a natural AV fistula.
In summary while some factors are unmodifiable such as age and race, we must strive to maximize the benefit of other factors that are well within our ability to modify by simply improving basic patient care in the pre dialysis period.
No comments:
Post a Comment