Ask the Doctor
Questions about kidney disease? Risk factors? Signs and symptoms? Are you concerned about yourself, a friend or family member? Ask Dr. Spry.
October 1 , 1997
In an effort to lower the unacceptably high death rate of dialysis patients in the United States, the National Kidney Foundation (NKF) today announced new wide-ranging guidelines for dialysis treatment.
For most patients, the National Kidney Foundation's recommendations will mean a higher dose of dialysis than they receive now. For some patients, they will mean longer periods of dialysis or use of a more efficient dialyzer. All patients should have the results of their dialysis measured more often, using standardized tests, in order to correct promptly for inadequate doses of dialysis treatment.
The 114 guidelines are the first comprehensive effort to standardize dialysis practices in the more than 3,000 dialysis facilities in the U.S. "Patients' survival and well being depend on our ability to convince all parties—the government, the medical profession and patients themselves—that we all have a role to play in bringing better care to everyone on dialysis," said Dr. Garabed Eknoyan, president of the National Kidney Foundation.
"Nearly one-fourth of the patients on dialysis in the U.S. die each year. That figure is needlessly high and avoidable," noted Dr. Nathan Levin, who co-chaired the NKF-Dialysis Outcome Quality Initiative (DOQI) with Dr. Eknoyan. "Implementation of these new guidelines should lower the death rate and provide a better quality of life for patients with kidney disease."
Today's recommendations focus on four areas: hemodialysis, peritoneal dialysis, vascular access and anemia. In abbreviated form, the guidelines call for a minimum dose of dialysis for both hemodialysis and peritoneal dialysis patients and a requirement that the dose be formally measured at least once per month for hemodialysis. For peritoneal dialysis, it should be measured at least twice during the first six months and every four months thereafter.
While the NKF-DOQI guidelines acknowledge the need for dialyzer (blood filter) reuse, they set a new standard for that reuse: Dialyzers must be tested before each use to ensure that they still have at least 80% of their original capacity. The guidelines call for earlier initiation of peritoneal dialysis when kidney function drops below a specific level, rather than waiting for the patient to become symptomatic or sick.
An important issue for all dialysis patients is regular access to the circulatory system. The NKF-DOQI recommendations reveal a strong preference for connecting the patients' own arteries and veins (known as arteriovenous fistula) rather than artificial implants. The guidelines provide criteria for selecting the type and location for this vascular access, and recommend placement early enough to allow for its use when needed.
In the area of anemia, which plagues most people with kidney failure, the guidelines call for a proper and early evaluation. A hematocrit (the amount of red cells in the blood) of 33 to 36% is recommended as the target range for treatment of anemia. The recommendations call for a strategy that provides a sufficient amount of epoetin and iron to achieve the target.
Today's NKF-DOQI announcement follows two and a half years of work involving more than 3,000 health care providers. Participating were physicians, nurses, patients, dietitians and social workers, as well as managed care and government health-care policy professionals.
In defining the guidelines more than 11,000 articles were reviewed, analyzed and summarized. The guideline development process was funded by an unrestricted grant from Amgen.
"One of our goals was to take knowledge based on an intensive review of the literature and, when evidence was not available, combine it with the best practices currently used in dialysis clinics," said Dr. Levin. "Combining that experience with an intensive review of the medical literature provided us with the best possible information."
One of the ongoing goals of the NKF is providing information that enables dialysis patients and their families to become better informed about medical care and treatment.
"The guidelines give patients important specific information to actively participate in decisions regarding their own health care. No longer will they have to simply receive treatment -- with the guidelines as support, they can insist on better quality care," stressed Dr. Levin. To facilitate this, the National Kidney Foundation has developed a comprehensive implementation plan that is focused on three areas: tools and strategies that will facilitate compliance with the guidelines; patient and professional education; and evaluation of the impact of the guidelines. Implementation programs will include education and practical tools for both patients and professionals.
"The NKF -DOQI reaffirms that our nation's 25-year experience with single-payer universal coverage for a disease category has saved thousands of lives," said Dr. Eknoyan. "But we can do better. Adoption of these guidelines will not only increase survival rates, it will improve the quality of life for kidney failure patients on dialysis," he continued.
The National Kidney Foundation is dedicated to preventing kidney and urinary tract diseases, improving the health and well-being of individuals and families affected by these diseases and increasing the availability of all organs for transplantation.