Patient referral is influenced by dialysis centre structure in the Diamant Alpin Dialysis cohort study

Background. Late referral (LR) to the nephrologist of patients with progressing chronic kidney disease (CKD) has numerous deleterious effects and is observed in many countries. The contributing factors associated with LR are controversial and poorly defined. We hypothesized that these factors might be better identified by analysing patients starting dialysis in three distinct European countries within the same area. Method. The referral and progression of kidney failure patterns were analysed with demographic, clinical and biological data in 279 non-selected consecutive patients starting dialysis in eight centres of three adjacent regions in France, Italy and Switzerland. Results. Early referral (>6 months before the start of dialysis) was seen in 200 patients (71.6%), intermediate referral (1-6 months) in 42 (15.1%) and LR (<1 month) in 37 (13.3%). However inter-centre variations were between 2 and 19% for LR and 6-50% for combined late and intermediate referral. There were no differences at the national levels, but LR was more frequent in the large city centres than in the private or regional structures, with 31 out of 169 (18.3%), two out of 55 (5.4%) and four out of 55 (7.3%), respectively, of their patients (P<0.01). By multivariate analysis, it appears that, besides the presence of an active cancer and the CKD progression rate, the centre structure and the referring physician (primary care physicians and nephrologists are less responsible for LR than other medical specialists) play a significant role in the practice of LR. Conclusions. Within a dialysis cohort spread over adjacent regions of three countries, LR has the same global distribution pattern, indicating that different health and social security systems do not play a major role in inducing or preventing this practice. The contributing factors for LR that were identified are the type of the referring physician and the structure of the dialysis unit. Both factors are potential targets for an educational and collaborative approac

Equal levels of blood pressure control in ESRD patients receiving high- efficiency hemodialysis and conventional hemodialysis

The present study compared the status of hypertension and adequacy of blood pressure control in 73 end-stage renal disease (ESRD) patients treated with four different modalities of hemodialysis, namely, conventional hemodialysis (CHD) with cuprophan 1.1m2 at a blood flow rate of 300 mL/min, high-efficiency hemodialysis (HED) with cuprophan 1.6 m2 at a blood flow rate of 450 to 500 mL/min, high-flux hemodialysis (HFD) with F80 polysulfone 1.8 m2 at a blood flow rate 500 mL/min, and high-flux hemodiafiltration (HDF) with F80 2 x 1.8 m2 in series at a blood flow rate of 600 to 650 mL/min. Thirty of the 73 patients (41/%) were receiving one or more antihypertensive agents to control their hypertension. The percentage of patients taking antihypertensive medication was less in the groups treated with HED, HFD, and HDF compared with the CHD group; 38%, 39%, and 39%, respectively, in the HED, HFD, and HDF groups versue 56% in the CHD group. Control of systolic hypertension was achieved in a higher percentage of patients treated with HED, HFD, and HDF compared with patients treated with CHD. Sixty-two percent of HED, 58% of HFD, and 61% of HDF patients compared with 44% of CHD patients had systolic blood pressure less than 150 mm Hg, whereas 77% of HED, 76% of HFD, and 78% of HDF patients compared 56% of CHD patients had diastolic blood pressure less than 90 mm Hg. However, the differences in the use of antihypertensive medication and control rates of hypertension did not reach statistical significance. The average blood pressure of all patients was 144/89 mm Hg; this did not differ significantly between the four groups. There also were no significant differences is etilogy of ESRD, hematocrit, biochemical data, as well as use and dose of recombinant human erythropoletin between the four groups. Compare with the CHD patients, the average treatment times with high-efficiency treatments were shorter, with HDF patients showing the shortest mean treatment time of 157 ± 41 minutes per hemodialysis session. The mean Kt/V was higher in the groups treated with HED, HFD, or HDF (1.31 ± 03, 1.30 ± 0.4, and 1.43 ± 0.3, respectively) then in the CHD group (1.12 ± 0.3; P \u3c 0.05). Interdialytic weight gain also did not differ among the four groups. There was no correlation between predialysis mean arterial pressure and either treatment time (r=0.04, P=NS), Kt/V (r = 0.03, P=NS), ultrafiltration rate (r=0.06, P=NS), or interdialytio weight gain (r= 0.08, P=NS). There also was no significant association between Kt/V and use of antihypertensive medications (chi-square = 1.76, P = NS). There was, however, a significant positive correlation between interdialytic weight gain and treatment time (r = 0.33, P \u3c 0.01). We conclude that the use of short dialysis sessions with efficient hemodialysis treatments, namely, HFD and HDF, was associated with similar levels of blood pressure control in ESRD patients

The OPTIMA Study: Assessing a New Cinacalcet (Sensipar/Mimpara) Treatment Algorithm for Secondary Hyperparathyroidism

Background and objectives: Cinacalcet, a novel calcimimetic, targets the calcium-sensing receptor to lower parathyroid hormone (PTH), calcium, and phosphorus levels in dialysis patients with secondary hyperparathyroidism (SHPT). This study compared the efficacy of a cinacalcet-based regimen with unrestricted conventional care (vitamin D and phosphate binders) for achieving the stringent National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) targets for dialysis patients