Poor Preparation Puts Many Dialysis Patients at Risk
Orlando, FL (April 14, 2010) — Patients with failing kidneys who are well prepared for dialysis when the time comes are much more likely to survive their first year of using the blood-cleansing machines, new findings being presented here today at the National Kidney Foundation's (NKF) Spring Clinical Meetings show.
But the investigators also found that most of the nearly 200,000 patients in their study were not prepared; 59 percent hadn't met a single one of the NKF's three goals for dialysis initiation.
"Most of the research in the area of pre-dialysis care has focused on getting the patients to see kidney specialists early to allow for adequate time for dialysis preparation," Dr. Yelena Slinin of the Minneapolis VA Medical Center and the University of Minnesota in Minneapolis, one of the new study's authors, says. "Our study revealed that even patients who have been seen by kidney specialists for over a year come to dialysis poorly prepared."
Kidney disease may produce no symptoms until very late in its course, so it is easy for patients and their health care providers to miss out on advance dialysis preparation, according to Dr. Slinin. The NKF has issued several guidelines over the past two decades as part of its Kidney Disease Outcomes Quality Initiative (K-DOQI) to help identify kidney disease earlier and improve dialysis care.
These guidelines include three recommendations specific to dialysis initiation. The first: patients should have a procedure that allows for more effective, less infection-prone access to their blood supply. These procedures must be done a few weeks before dialysis begins, and involve connecting a patient's artery to a vein either by forming a connection, or fistula, between the two blood vessels or with a graft. The arteriovenous fistula is least likely to lead to infection and longer-lasting, but both fistulas and grafts produce better outcomes than tunneled dialysis catheters, which allow for immediate use and involve putting a catheter into a large vein. "Sadly, this is the most common vascular access at dialysis initiation," Dr. Slinin notes. "Catheters are associated with very high infection and death rates compared to fistulas or grafts."
The NKF's other two dialysis initiation goals state that patients should have adequate levels of both hemoglobin and albumin in their blood. Hemoglobin levels show whether or not a person is anemic, while blood albumin is a marker of good nutrition.
Dr. Slinin and her colleagues looked at 192,307 patients who started dialysis between June 1, 2005, and May 31, 2007, to investigate whether patients who attained these goals would have a survival advantage. Fifty-nine percent had met none of them, 30 percent had met one, 9 percent achieved two, and just 2 percent had met all three goals. The more goals achieved, the more likely a patient was to survive; compared to people who had met none of the goals, people meeting one goal had a 19 percent lower risk of death; meeting two goals cut death risk by 47 percent; and meeting every goal reduced mortality by 66 percent.
The goal that brought the biggest survival benefit was having an arteriovenous graft or fistula in place, which in itself reduced mortality 44 percent. "Many of the early infectious deaths can be potentially prevented by having vascular access other than catheter at the start of dialysis," Dr. Slinin says. Optimum albumin levels reduced mortality by 33 percent, while adequate hemoglobin reduced death risk by 6 percent.
People can take iron supplements and an erythropoiesis-stimulating agent to ensure their hemoglobin levels are sufficient, the researcher adds, while eating a healthy diet helps maintain good albumin levels. "Because albumin can go down in the presence of many illnesses," she notes, "sometimes low albumin can be a marker of an ongoing inflammatory condition that needs attention."
Dr. Slinin concludes: "Our study emphasizes the benefit of predialysis care and the urgent need to define potential barriers to dialysis preparedness. We as nephrologists can do a better job. There is a lot of room for improvement."
The National Kidney Foundation is dedicated to preventing and treating kidney and urinary tract diseases, improving the health and well being of individuals and families affected by these diseases and increasing availability of all organs for transplantation.
For more information about organ donation, transplantation and dialysis contact the National Kidney Foundation at www.kidney.org.