Seminars in dialysis
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Seminars in dialysis · Sep 2008
Practice GuidelineLocking solutions for hemodialysis catheters; heparin and citrate--a position paper by ASDIN.
There is wide variation in the use of solutions to "lock" or fill tunneled central venous catheters for dialysis. Some centers use undiluted heparin concentrations ranging from 1000 to 10,000 U/ml and other centers place from 1000 to 10,000 U per lumen. Based on available evidence, it appears that heparin 1000 U/ml, or 4% sodium citrate are suitable choices for lock solution to maintain patency of tunneled central venous catheters for dialysis. ⋯ Higher concentrations of heparin lock should be reserved for patients who have evidence of catheter occlusion or thrombosis when heparin is used at 1000 U/ml. Similar choices for lock solution are sensible for acute hemodialysis catheters. When heparin is used for catheter lock, the injected volume should not exceed the internal volume of the catheter.
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Seminars in dialysis · May 2008
Retrospective analysis of catheter recirculation in prevalent dialysis patients.
Catheter recirculation (CR) occurs when blood returning from the venous limb of the catheter re-enters the arterial limb of the catheter without passage through the circulation. Adequacy of dialysis is influenced by the degree of access recirculation. In this study we evaluate factors influencing the degree of dialysis central venous catheter (CVC) recirculation in prevalent hemodialysis patients. ⋯ These results are borderline significant if temporary catheters are included (p = 0.052); however, the overall p-value is only 0.80 for tunneled dialysis catheters. There was no correlation between CR and time on dialysis (p = 0.66) or time on the current catheter (p = 0.48). The current study suggests that the CVC recirculation is independent of catheter brand, type, time on dialysis, or time on current catheter.
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Seminars in dialysis · May 2008
EditorialPalliative care: misconceptions that limit access for patients with chronic renal disease.
There is an urgent need to incorporate palliative care into the treatment of patients with end-stage renal disease (ESRD). These patients have a shortened lifespan and face end-of-life decisions as renal function declines and renal replacement therapy becomes necessary. ⋯ Why, then, do patients with ESRD rarely receive expert palliative care services that have been shown to enhance the quality of life of patients with other life-limiting illnesses? The lack of access to palliative care can be attributed, in part, to misconceptions about its philosophy and goals. It is hoped that clarification of these misconceptions will facilitate integration of palliative care into routine nephrology practice.
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The role of the dialysis unit Medical Director has evolved over time to an expanded set of roles from one that used to be strictly "medical" to one that is more "managerial." Physicians providing these Medical Director services are facing increasing demands for a leadership role regarding clinical quality improvement and measurement of performance in core areas of care within the dialysis program. The dialysis Medical Director is asked to lead in group decision-making, in analyzing core process and patient outcomes and in stimulating a team approach to Continuous Quality Improvement (CQI) and patient safety. ⋯ Medical Directors are usually contractually linked to the dialysis programs for which they provide oversight and their contracts are explicit about the relationship they maintain and the role they are expected to play within dialysis companies (often called "provider organizations"). The evolution of the Medical Director role has led to a close relationship between the company that provides the dialysis services and the physician providing the medical oversight.
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Since the original description of the obesity-survival paradox in 1999, which suggested a survival advantage for overweight and obese patients undergoing hemodialysis, a large body of evidence supporting the paradox has accumulated. The reason for the paradox has yet to be defined. Better nutrition may be a partial explanation, or it may be that in uremic milieu, excessive fat and surplus calories might confer some survival advantage. ⋯ If proven to be correct, it might explain why peritoneal dialysis patients who receive excessive calories through dialysis do not exhibit the paradox and, secondly and more importantly, therapy could be directed to enhance a greater caloric intake by renal failure patients to engender a better survival outcome. Finally, other clinical settings, for example, congestive heart failure, have their own obesity-survival paradox. Thus, the paradox appears to be a wider phenomenon and might merely be the external expression of a larger principle yet to be uncovered.