A year-long quality improvement project on fluid management using blood volume monitoring during hemodialysis.

Background: Inadequate removal of extracellular volume markedly increases blood pressure and contributes to high morbidity and mortality in hemodialysis patients. Advances in fluid management are needed to improve clinical outcomes. The aim of this quality improvement project was to examine the advantages of using a hematocrit-based, blood volume monitor (Crit-Line * ) for 12 months, as part of a clinic-wide, fluid management program in one dialysis facility.

Methods and challenges for the practical application of Crit-Line™ monitor utilization in patients on hemodialysis.

The Crit-Line™ monitor measures relative changes in intravascular blood volume during hemodialysis. The device is also used to monitor hematocrit and oxygen saturation. Using this device to decrease fluid volume has yielded inconsistent results on outcome measures such as hospitalization rates, erythropoietin utilization, and blood pressure reduction.

Intradialytic hypotension: frequency, sources of variation and correlation with clinical outcome.

Intradialytic hypotension (IH) is a frequent complication of hemodialysis (HD) and is associated with increased patient mortality and cardiovascular events. We studied IH to determine its variability, correlates, and clinical impact in 13 outpatient HD facilities. Blood pressure was captured by machine download.

Seasonal variations in mortality, clinical, and laboratory parameters in hemodialysis patients: a 5-year cohort study.

Background And Objectives: Mortality varies seasonally in the general population, but it is unknown whether this phenomenon is also present in hemodialysis patients with known higher background mortality and emphasis on cardiovascular causes of death. This study aimed to assess seasonal variations in mortality, in relation to clinical and laboratory variables in a large cohort of chronic hemodialysis patients over a 5-year period.

Design, Setting, Participants, & Measurements: This study included 15,056 patients of 51 Renal Research Institute clinics from six states of varying climates in the United States.

In vitro evaluation of the air separation ability of four cardiovascular manufacturer extracorporeal circuit designs.

Neurologic impairment is a common complication of adult cardiac surgery. Cerebral gaseous microemboli (GME) detected during cardiopulmonary bypass has been associated with cognitive impairment after adult cardiac surgery. Several previous studies have shown that components comprising the extracorporeal circuit (ECC) can affect the ability of the ECC to eliminate air.

External validation of compliance to perfusion quality indicators.

Purpose: There exists a significant gap between the expected and delivered level of quality received in America's hospitals. As a result, clinical outcomes of critical services such as coronary artery bypass graft (CABG) surgery have received unparalleled scrutiny. Medical information technology companies like Solucient and insurance carriers such as Blue Cross of California have identified and published a list of hospitals that demonstrate superior quality and patient outcomes for CABG procedures.

Observations from a national multiple institution autotransfusion (ATS) quality indicator program.

A process to collect universal, mandatory autotransfusion (ATS) procedure quality indicators to measure and monitor ATS quality improvement was designed and implemented by Fresenius Medical Care Extracorporeal Alliance (FMCEA) an outsource provider of extracorporeal services. The indicator program collected and evaluated data that reflect real-world extracorporeal clinical practices and outcomes. The indicator reports provide our clinicians, client physicians, and partner institutions with confidential reports that allow comparison of their practice to evidenced-based performance standards.

Designing an integrated extracorporeal therapy service quality system.

Reorganization in clinical operations of a national service provider organization, Fresenius Medical Care Extracorporeal Alliance (FMC-EA), provided the opportunity to overhaul and integrate quality systems. Under the new structure, the management of acute dialysis, apheresis, open-heart perfusion, and intraoperative autotransfusion services were combined into an integrated service portfolio supported by a multidisciplinary team of nurses, perfusionists, and technicians. This communication is intended to be a concise review of the literature that establishes the foundation for the new quality system as well as a discussion of the five clinical policies and clinical procedure guidelines that govern clinical behavior in mobile, point of care, acute extracorporeal therapy services.

A multicenter study of noncompliance with continuous ambulatory peritoneal dialysis exchanges in US and Canadian patients.

Recent evidence suggested that noncompliance (NC) with continuous ambulatory peritoneal dialysis (CAPD) exchanges may be more common in US than in Canadian dialysis centers. This issue was investigated using a questionnaire-based method in 656 CAPD patients at 14 centers in the United States and Canada. NC was defined as missing more than one exchange per week or more than two exchanges per month.

Complications of chronic renal insufficiency: beyond cardiovascular disease.

The less rigorous attention to the management of the complications of chronic renal insufficiency (CRI) and its comorbid conditions has potentially tragic consequences. In fact, with early recognition and intervention, many of the complications of CRI and its comorbid conditions can be ameliorated or prevented. We review here the most prevalent, troublesome, and potentially preventable complications and comorbidities of CRI with a view toward developing high-quality, cost-effective strategies for delivering early interventional care.

Renin-aldosterone system can respond to furosemide in patients with hyperkalemic hyporeninism.

Thirty-four patients (65.3+/-3.3 years of age, mean+/-SEM) with hyperkalemia (serum potassium >5.

Percentage body fat determination in hemodialysis and peritoneal dialysis patients: a comparison.

Objective: To evaluate percentage body fat in hemodialysis (HD) and peritoneal dialysis (PD) patients.

Design: A prospective study of 20 HD patients and 20 PD patients.

Setting: Sol Goldman Renal Therapy Center, Lenox Hill Hospital, New York, NY; Baumritter Kidney Center Albert Einstein College of Medicine, Bronx, NY; Body Composition Unit, St Luke's Roosevelt Hospital, Columbia University, New York, NY.

Comparison of five body-composition methods in peritoneal dialysis patients.

Body-composition assessment is an important method of evaluating nutritional status in peritoneal dialysis patients. Because body-composition measurement estimates have not been fully validated in this population, we assessed five body-composition methods in 30 well-dialyzed peritoneal dialysis patients. The techniques studied included bioelectrical impedance analysis, dual-energy X-ray absorptiometry, total-body potassium counting, and anthropometry by two techniques.

Fluid balance and renal response following dehydrating exercise in well-trained men and women.

We examined the recovery of plasma volume, plasma osmolality, renal water and sodium handling and fluid-regulating hormones to dehydrating exercise in well-trained women and compared them to men. Ten male and eight female athletes cycled at anaerobic threshold at an ambient temperature of 32 degrees C until dehydration by 3% of their body mass (mb). After exercise, they drank water equal to 1% mb and rested for 240 min.

Bioelectrical impedance analysis and dual energy x-ray absorptiometry to monitor nutritional status.

There exists an imperative to monitor changes in body composition in all dialysis patients on a regular basis to avoid overt malnutrition. In this regard, the absolute measurement of the fat-free mass assessment may not be as crucial as the serial measurement of fat-free mass with the same modality. A significant difference in measured fat and fat-free mass should be expected if different techniques are employed.

Pulsed laser deposition of thin film hydroxyapatite. Applications for flexible catheters.

Skin exit site infections are a major source of morbidity in patients with indwelling percutaneous catheters. Ceramic materials, such as hydroxyapatite (HA) and alumina, have demonstrated excellent biocompatibility and low rates of infection in soft tissues. Previous attempts to design ceramic materials for use as percutaneous connectors have resulted in rigid discs or solid cylindrical tubes.

Systemic effects of ingesting varying amounts of a commercial carbohydrate beverage postexercise.

Objective: Although the role of postexercise carbohydrate intake in the replenishment of muscle glycogen is well established, large amounts of carbohydrate may affect other systems which are recovering from exercise as well.

Methods: We varied the timing and amount of a commercial glucose polymer/fructose (CHO) beverage ingested postexercise in 2 groups of 8 normotensive men following 1 hour of cycling exercise. In Study A the subjects ingested 1 L of a 200 g CHO solution or 1 L of water (W) immediately postexercise.

Laboratory investigation of renal stone disease.

Renal stone disease is a chronic disease associated with a high rate of recurrences and hospitalizations. Over the past three decades, the incidence of nephrolithiasis has increased by 60% to 75%. Because there is a significant amount of morbidity associated with development of stone disease, a comprehensive yet simple evaluation to determine the cause of the problem is warranted.

Determining peritoneal dialysis prescriptions by employing a patient-specific protocol.

Objective: To develop a formula that would permit a rapid and simple calculation of required dialysate volume needed to provide a predetermined daily creatinine clearance.

Design: Prospective study of peritoneal dialysis patients followed for 6 months.

Setting: A primary care teaching hospital in New York.

Sucrose ingestion following exercise: selected cardiovascular, hormonal, renal, and metabolic effects.

Carbohydrates, frequently consumed following exercise for glycogen resynthesis, have been shown to have other systemic effects in resting men. We examined the effects of postexercise sucrose (a disaccharide carbohydrate) ingestion on the renal, cardiovascular, and sympathetic nervous systems. Eight men consumed 1 l of water (W) or 1 l of a 200 g sucrose solution (S) following 1 hour of bicycle exercise at 70% heart rate reserve.