Transplantation: A Clinical Priority for our Renal Program
While we strive to avoid end-stage renal disease (ESRD) in our patients through the treatment of kidney disease and the implementation of strategies to slow progression of chronic disease disease, we know we won’t be successful with many of our patients.
For those patients who do reach ESRD, we know that kidney transplant is the treatment of choice and provides better long-term survival and improved quality of life compared to dialysis. It’s encouraging that patient survival and transplant success has been progressively improving over the years.
As part of our program wide strategy to increase pre-emptive transplant (transplantation before the start of dialysis) and rapid living donor transplant after the initiation of dialysis, Dr. Melanie Brown has created a brief set of educational slides that explain the value of kidney transplantation and dispels some of the associated myths.
The Nephrologists in the FHA Renal Program will be participating in a blitz educational campaign to share this information across our program. Over the next 6 weeks, Nephrologists will be presenting this informational across our various in-centre & community dialysis units, kidney care centres and peritoneal dialysis units. Assuming this goes well, we’ll try the same thing for our vascular access and home dialysis projects.
Optimizing Interventional Radiology Referrals for Vascular Access
Back in November 2011, I posted that we would target some reasonably aggressive goals for AV access rate in the FHA renal program.
For those who don’t recal, we’re aiming for:
Incidence of AVF + AVG = 33% at 12 months and 40% by 24 months
Prevalence of AVG + AVG = 65% at 12 months and 70% by 24 months
We’re about 6 months away from our first target and still much work remains to be done. I’m excited to announce the implementation of a triage tool that we hope will ensure our patients have their permanent AV access better maintained and salvaged when necessary. It won’t help to create AVFs more quickly if we don’t make sure to avoid premature access failure.
So, we’re going to start using a new form (though it may be slightly modified). This form provides radiology with additional clinical information regarding urgency of a patient’s need for intervention. It also ties clinical paramaters to our provincial wait time guidelines that were developed by the BCPRA Vascular Access Working Group.
Our hope is that this will allow our IR colleagues to better triage our referrals and use their limited time & resources more efficiently. Urgent cases should get seen urgently and cases that are less time sensitive can be done at a later date.
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Peritoneal Dialysis after Cardiac Surgery
As many are aware, there is some debate whether patients receiving peritoneal dialysis should be converted temporarily to hemodialysis around the time of cardiac surgery.
In a recent publication in Peritoneal Dialysis International, observational data suggests that PD patients do better than HD patients after cardiac surgery. To be clear, this paper does not address the question of whether switching PD patients to HD is a superior strategy to continuing PD around the time of surgery. However, the findings are reassuring in that patients on PD tend to do well compared to HD patients. It should be noted that the effort to match patients for comorbidity limits bias in favour of PD.
Comparing Cardiac Surgery in Peritoneal Dialysis and Hemodialysis Patients:
Perioperative Outcomes and Two-Year Survival
Victoria A. Kumar, Shubha Ananthakrishnan, Scott A. Rasgon, Eric Yan, Raoul
Burchette, and Karen Dewar
Perit Dial Int 2012;32 137-141
http://www.pdiconnect.com/cgi/content/abstract/32/2/137?etoc
Comparing Cardiac Surgery in Peritoneal Dialysis and Hemodialysis Patients: Perioperative Outcomes and Two-Year Survival
♦ Background: We sought to compare perioperative outcomes and 2-year survival in a cohort of peritoneal dialysis (PD) patients compared with matched hemodialysis (HD) patients who underwent cardiothoracic surgery at our institution.
♦ Methods: We obtained a list of all dialysis-dependent patients who underwent cardiac surgery (coronary artery bypass grafting, valve replacement, or both) at our center between 1994 and 2008. All patients undergoing PD at the time of surgery were included in our analysis. Two HD patients matched for age, diabetes status, and Charleston comorbidity score were obtained for each PD patient.
♦ Results: The analysis included 36 PD patients and 72 HD patients. Mean age, sex, diabetes status, cardiac unit stay, hospital stay, and operative mortality did not differ by dialysis modality. The incidence of 1 or more postoperative complications (infection, prolonged intubation, death) was higher for HD patients (50% vs. 28% for PD patients, p = 0.046). After surgery, 2 PD patients required conversion to HD. The 2-year survival was 69% for PD patients and 66% for HD patients (p = 0.73).
♦ Conclusions: Our findings suggest that, compared with HD patients, PD patients who require cardiac surgery do not experience more early complications or a lesser 2-year survival and that 2-year survival for dialysis patients after cardiac surgery is acceptable.
Published literature: PD start for urgent dialysis
In a recent publication in the American Journal of Kidney Disease, Ghaffari et al demonstrate a successfully implemented urgent-start PD program.
This case series confirms the feasibility of supporting decision making in patients with CKD who present with advanced disease and describes an easily replicable model of starting peritoneal dialysis therapy on short notice. This is attractive as a strategy as it could increase the number of patients who are involved in modality selection while reducing the number of patients who start dialysis with a central venous catheter (with the associated increased risk of complications and death).
The FHA renal program is committed to supporting urgent transitions to PD for patients who present with advanced disease and has successfully been implementing this type of program for some time now. It’s great to see our strategy shared and promoted in the medical literature.
Read MoreRenal Program Clinical program Indicator (You’re Flagged)
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Alteplase: Program savings
This guest post was written by Kim Norman, BA (hons) Nursing who is the Clinical Nurse Educator for ARHCC and ACDU Hemodialysis Units in the Fraser Health Renal program.
It became quite frustrating to watch, as a Clinical Nurse Educator, the use of alteplase within our Renal Program at a cost of $64 a vial.
After identifying a $100,000 expenditure on alteplase use within the hospital hemodialysis units it was time to ask why, what could be done to reduce costs and how? This needed to be done while keeping in mind the best interests of the patients in relation to best practices.
After identifying a huge cost to our Renal program what was also highlighted in the review process was a large cost in sterile supplies. Alteplase and sterile supplies added up to $716,000 being spent each year in the FHA hemodialysis units.
After collaborating with the community dialysis staff, educators across Canada and within my own province of BC, we identified products that could potentially cut the cost of alteplase by reducing the exposure of the hub of a catheter to air (theory, not evidence based) by using a needle-less hemodialysis cap designed to withstand the blood pump speeds of dialysis.
The needless cap would also potentially reduce the costs of our sterile supplies due to the cap only needing to be changed every 7 days.
Once the product had been approved by the leadership team, the educators made all efforts (through education) to implement the device along with streamlining our hemodialysis access and flushing techniques. The implementation did not go without its barriers which are highlighted in the education powerpoint; such barriers are still being addressed between the educators and the company who distributes the device.
We are now one year post implementation and have seen a significant reduction in total costs. Specifically, we’re seeing approximately $112K reduction in sterile supply costs and $23K reduction in tPA costs per year.
In fast paced hemodialysis units, we have received reports that this new intervention allows for more efficient use of time at the bed side.
The cost savings documents and education tool are attached for review.
Cost analysis:
Tego Connectors FHA Cost Analysis
Kim Norman
Clinical Nurse Educator
Fraser Health Renal Program.
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Update on Home Hemodialysis Referrals
This post is contributed by Terry Satchwill BHSc, Manager, Renal Services (Peritoneal Dialysis, Home Hemodialysis, Kidney Care Centre, Renal Care Coordinators)
The FHA Renal program is trying to ensure that all patients who may be candidates for Home Hemodialysis (HHD) can get timely access to the program.
One of the first steps to get onto home hemodialysis is to get referred. So here’s a quick review of the referral process, the referral form, the inclusion/exclusion criteria and some quick facts.
In addition, information pamphlets, DVD’s and posters are available. Please call the HHD office (604-777-8734) to replenish supplies if any are running low & we will arrange to have them delivered to your unit.
We are pleased to announce up-coming education sessions called Hidden Treasures of Home Hemodialysis. The goal of these sessions is to educate staff and physicians about the benefits of HHD, to clarify the processes of referral, to give you an opportunity to meet some of the current HHD patients and hear their stories and to generally dispel some of the myths that surround HHD. Our HHD educators are making arrangements with your local renal educators to come to your areas starting in February. Watch for the dates!
Some quick facts:
• Referrals can come from anyone on the interdisciplinary team or the patient.
• If your patient is somewhat hemodynamically unstable this does not necessarily mean they will not do well on HHD. As a matter of fact they may do better!
• Patients do not necessarily need a helper and do not need to own their own home to be candidates for HHD.
• The HHD team will consult with the patients’ primary nephrologist as to their suitability for HHD.
• At the moment, we have 2 training sites- TCDU & PCDU
Nephrologist order to refer to HHD
• Complete application form & fax with the order to HHD office at 604-464-1403
or
• if time is limited, just fax the referral order to the same number
Referral to Home Hemodialysis Team
• Complete application form & fax to HHD office at 604-464-1403
or
• Phone call to HHD office (604-777-8734) stating patient name (with spelling) & dialysis unit
Patient expression of interest
• Patient can call the HHD office directly & leave their name & phone number or the name of their dialysis unit
• Patient can ask their nurse, social worker, dietitian or nephrologist to refer them & follow the process above
Salt Restriction May Delay or Prevent the Need for Dialysis in our Kidney Care Centre Program
Salt restriction has always been recommended for patients with kidney disease. There is now additional evidence that salt restriction may be a critical intervention in slowing progression of chronic kidney disease.
In the article ‘Sodium Intake, ACE Inhibition, and Progression to ESRD‘ by Vegter et al, we find important epidemiologic evidence that urinary sodium consumption (as measured by urinary sodium excretion) is associated with development of kidney failure in patients with nondiabetic kidney disease. Specifically, too much salt may minimize the protective effect of ACE inhibitors or ARBs in patients with proteinuric kidney disease.
This information further supports the important work our KCC dieticians do to decrease the chance our patients will require dialysis.
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Surgical PD Clinic Come to ARH
The PD program has been pushing to increase access to services for patients in Fraser East. While we’ve been able to rapidly expand the medical aspects of PD care in the Abbotsford Hospital, we’ve been slower to ramp up surgical support.
I’m excited to report that as of February 2012, Dr. Peter Blair will be seeing patients in a “Surgical PD Clinic”. This clinic will ensure that patients needing a PD catheter surgically inserted or who need a hernia repaired to facilitate PD, can see a surgeon in consultation much closer to home. Previously, all patients needed to travel to New Westminster to seek surgical consultation.
For the time being, we’ve been unsuccessful in securing OR time at ARH to have surgery performed so patients will still need to travel to RCH for the required surgery. But we will continue to work to arrange surgical time at ARH.
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Diane Watson Visits FHA Renal and Shares Her Successes in Optimizing Urgent Dialysis Starts
The FHA Renal Team was pleased to host Diane Watson, NP from the University Health Network (UHN) in Toronto, Ontario. Diane has been working for many years with patients who have started dialysis suboptimally in hospital. Her results are nothing short of miraculous.
We know that many patients would prefer home dialysis if given the opportunity. At the same time, patients starting dialysis urgently never get the opportunity for the independence and improved quality of life we see with independent modalities. Prior to starting her role as “transition nurse”, 87% of UHN patients starting dialysis urgently in-hospital ended up on in-centre hemodialysis and only 13% on home dialysis.
Since the start of her work, the UHN is now seeing only 37% patients remaining on in-centre hemodialysis with 63% migrating to home or independent dialysis.
I should point out that I had the opportunity to work with and learn from Diane when I was a medical resident and Nephrology trainee. Not only does she facilitate choice and better outcomes for her patients, but she has a marvelous way with patients and her families, providing them with reassurance and hope.
Diane spent 2 days with our renal team - 1 day of workshops with a large multi-disciplinary group and a second day of rounds with the medical staff. Our program was energized by her presentation in a way I haven’t seen before. I’m exceptionally optimistic we’ll have the opportunity to learn from and adopt some of her techniques in order to provide our patients who start dialysis in an unexpected fashion with the best possible outcomes.
Not only does her care result in better patient choice and outcomes, but it is also highly cost effective. The UHN experience suggests that her work saves exceptionally large sum that can be reinvested into other areas of the renal program.
For anyone who did not have the opportunity to attend, I’ve included her presentation here:
Vancouver 2012 Increasing use of Home Dialysis
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