American journal of kidney diseases : the official journal of the National Kidney Foundation
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Two initiatives were launched in the closing years of the past century with the goal of improving the treatment outcomes of patients with kidney failure: the Kidney Disease Outcomes Quality Initiative, which formed expert panels to develop evidence-based clinical practice guidelines, and the Dialysis Outcomes and Practice Patterns Study (DOPPS), which now gathers data on practice patterns in dialysis facilities in 12 countries, including the United States. Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) program was established to promote worldwide coordination and integration of initiatives to develop and implement clinical practice guidelines and provides new opportunities of cooperation with the international scope of the DOPPS. ⋯ Linking the DOPPS scope of work with the KDIGO goals will help develop continuous quality improvement programs and the provision of direct feedback to participating dialysis centers throughout the world. This will establish an essential component in the translation to clinical practice of evidence-based guidelines worldwide.
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Comparative Study
Intra-access blood flow in patients with newly created upper-arm arteriovenous native fistulae for hemodialysis access.
The upper-arm native arteriovenous fistula for hemodialysis (HD) vascular access is an important option in the long-term HD population. This single-center cohort study evaluated intra-access blood flow (Q AC) in 3 variants of newly created upper-arm fistulae. ⋯ Upper-arm fistulae, regardless of type, provide excellent blood flows and should be considered routinely if a wrist fistula is not feasible. The patent alternate vein in the brachio-median antecubital or Gracz fistula may continue to drain a substantial amount of blood.
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The Kidney Disease Outcomes Quality Initiative Guidelines for Vascular Access in hemodialysis patients recommend native arteriovenous (AV) fistulae over AV grafts or catheters for permanent vascular access. They recommend letting fistulae mature > or =1 month before cannulation. ⋯ The DOPPS will continue to monitor practice trends and explore whether greater application of guidelines will lead to fewer access complications and improved longevity for hemodialysis patients.
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Experimental and some clinical data suggest that metabolic acidosis contributes to poor nutritional status, a strong predictor for mortality in hemodialysis patients. However, recent cross-sectional studies indicate that severe predialysis metabolic acidosis is associated with a greater normalized protein catabolic rate (nPCR) and greater serum albumin levels. Given this controversy, we analyzed data from the Dialysis Outcomes and Practice Pattern Study (DOPPS) for associations between predialysis serum bicarbonate and albumin concentrations, nPCR, and patient risk for mortality and hospitalization. ⋯ Moderate predialysis acidosis seems to be associated with better nutritional status and lower relative risk for mortality or hospitalization than is observed in patients with normal ranges of midweek predialysis serum bicarbonate concentration (approximately 24 mEq/L) or severe acidosis (<16 mEq/L).
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Comparative Study
Enhanced anticoagulant activity of enoxaparin in patients with ESRD as measured by thrombin generation time.
Patients with renal dysfunction who undergo systemic anticoagulation with enoxaparin are at increased risk for bleeding. Although there is decreased renal clearance of enoxaparin in this population, the clinical utility of monitoring antifactor Xa activity is controversial because it is weakly correlated to bleeding. The goal of this study was to investigate the role of other novel anticoagulation markers, such as thrombin generation time, platelet contractile force, and clot elastic modulus, while controlling for antifactor Xa activity in patients with and without renal dysfunction. ⋯ Antifactor Xa poorly predicts the degree of anticoagulation in patients with ESRD administered low-molecular-weight heparin (LMWH). Thrombin generation time may be a clinically useful anticoagulation monitoring tool to monitor LMWH therapy, especially in patients with renal dysfunction. Additional randomized prospective studies are needed to corroborate these findings.