Many Kidney Disease Patients Unaware

Many people diagnosed with chronic kidney disease do not know they have the disease, according to report published in the March issue of the American Journal of Kidney Diseases.


Researchers at Vanderbilt University Medical Center in Nashville, Tennessee, surveyed 401 people with kidney disease attending a nephrology clinic. More than 75 percent of participants had stage 3 chronic kidney disease or above. While 94 percent of patients surveyed were aware they had a kidney “problem,” more than 30 percent were unaware they had a serious, potentially life-threatening disease. All of the patients surveyed were under the care of a kidney specialist, or nephrologist.

“The lack of awareness of chronic kidney disease among those who are affected appears to be greater than other health conditions,” said study co-author Dr. Julie Anne Wright from Vanderbilt’s Division of Nephrology and Hypertension. “Even when patients are under the care of specialists, they frequently have a limited understanding of fundamental topics, including symptoms, the course of kidney disease and risk factors such as diabetes and hypertension. This study highlights the need for providers to ensure that communication is not only delivered but understood between all parties involved.”

Beyond diagnosis awareness, results of the 34-question survey also showed that 78 percent of participants did not know that the disease may progress with no symptoms. More than 34 percent were unaware that they were at increased risk for heart disease and 32 percent did not know that the kidneys make urine.

Read entire article at Renal Business Today

Kidney Patients Ask for More Information on Options

Many kidney failure patients want more detailed information about their treatment choices, according to a new study.

More than 30 percent of the 1,000 U.S. patients who took part in an Internet survey said they felt that the different therapies -- in-center hemodialysis, peritoneal dialysis, home hemodialysis and kidney transplantation -- were not "equally or fairly presented to them."

Nearly 70 percent of the respondents told the researchers that they were not provided with specific education and training about home hemodialysis, a relatively new option that may offer some advantages -- including ease of treatment -- over in-center dialysis.

Overall, the participants were moderately to highly satisfied with their current treatment, but satisfaction was highest among transplant patients and home dialysis patients, and lowest among in-center dialysis patients.

Doctors had the most influence over people's choice of therapies, the survey found. And, what patients said they wanted most was more information on new treatment and improved medications.

The study was published online Feb. 17 in the Clinical Journal of the American Society of Nephrology.

"Dialysis patients should be provided with enough information to choose optimal therapies," Dr. Stephen Fadem, of Baylor College of Medicine in Houston, and lead author of the report, said in a news release from the American Society of Nephrology.  "Our survey shows that dialysis patients do not always receive uniform, thorough information about all possible treatment methods and, as a result, are only moderately satisfied with their pre-treatment education."

~BusinessWeek.com~

Foot Problems Common Among Dialysis Patients

What is the problem and what is known about it so far?
Foot problems are common among people with diabetes. Most often, they occur because of nerve damage or poor blood circulation in the feet and legs. People with diabetes can develop serious ulcers (open sores) on their feet that are likely to get infected and are difficult to heal. As a result, people with diabetes are more likely than others to eventually need foot or leg amputations. Studies have shown that diabetic foot problems are more common among some ethnic groups than others. Studies have also found links between foot problems and other complications of diabetes, such as kidney disease. More study is needed to fully understand such links and how they may help to identify those in need of help to avoid foot problems and amputations.

Why did the researchers do this particular study?
The researchers wanted to learn more about how frequent foot problems are among people from different ethnic groups who have diabetes and advanced kidney disease.

Who was studied?
The study included 466 patients with diabetes from different ethnic backgrounds in the United States and the United Kingdom. The patients were receiving dialysis therapy for kidney failure.

Read entire article here

CMS issues final rule for dialysis facility quality incentive program

The Centers for Medicare & Medicaid Services issued a final rule for the Quality Incentive Program that will establish performance standards for dialysis facilities and provide payment adjustments to individual End-Stage Renal Disease facilities based on how well they meet these standards.

The final rule establishes the ESRD QIP performance standards, sets out the scoring methodology CMS will use to rate providers quality of dialysis care, and establishes a sliding scale for payment adjustments based on the facilities performance.  CMS will assess each dialysis facility on how well its performance meets the standard for each measure and will calculate each facilities Total Performance Score. The maximum Total Performance Score a facility can achieve is 30 (10 points per measure).  Facilities that do not meet or exceed performance standards will be subject to a payment reduction of up to 2% depending on how far their performance deviates from the standards.

CMS finalized three measures as the initial measure set during the first program year.  Two of these measures are designed to assess whether patients hemoglobin levels are maintained in an acceptable range, while the third measures the effectiveness of the dialysis treatment in removing waste products from patients blood.   
 
In future years CMS may add quality measures and establish additional performance standards that facilities will need to meet to receive full payment for the services they furnish to Medicare beneficiaries.

Read entire article here

Dialysis Data, Once Confidential, Shines Light on Clinic Disparities

For years, the government has collected a rich store of data about the performance of individual dialysis facilities. But it has kept nearly all the information secret from those it might benefit most: Patients.

Now ProPublica has obtained this data under the Freedom of Information Act. We are making a comprehensive set of clinic records publicly available  for the first time on our website.

Patients and others can search for a clinic and see how it compares on 15 key measures, ranging from mortality and hospitalization to transplant rates and infection control. Also on the site are historical reports dating to 2002.

Release of the data is long overdue, patient advocates say.

"It gives you a snapshot of what a clinic is about," said Roberta Wager, a past president of the American Association of Kidney Patients who works as a nurse and patient educator at several dialysis clinics in Texas. "This is your life. Wouldn't you want to have everything in your favor?"

There are almost 400,000 Americans who depend on chronic dialysis to do what their failed kidneys cannot, a number that has grown swiftly over the past two decades, spurred by epidemics of obesity and diabetes.


More than 5,000 facilities have sprung up to provide them with care, stretching into the nation's most rural areas and competing for patients in urban and suburban areas.

Patients today have more choice than ever. Yet most pick centers based on convenience, or on what their doctors suggest, with little notion that even clinics within the same communities can have substantial disparities.


In more than 200 counties nationwide, the data show, the gap between facilities with the best and worst patient survival, adjusted for case-mix differences, is greater than 50 percent. In areas such as Allegheny County, Pa., or Franklin County, Ohio, each with upwards of two dozen clinics, the differences are even more substantial, exceeding 200 percent.

There is also wide variability in how often patients at different clinics are hospitalized for septicemia. Although septicemia cases can be unrelated to dialysis, it is a significant risk for patients, who typically have their blood cleaned of toxins three times a week. Nationally, the rate was about 12 percent a year for 2006 to 2008. But in dozens of counties, the spread between facilities with the highest and lowest rates was more than 25 percentage points.

Read entire article here

Dialysis: An Experiment In Universal Health Care

Every year, more than 100,000 Americans start dialysis treatment, a form of chronic care given to people with failing kidneys. And for many, the cost is completely free. Since 1972, when Congress granted comprehensive coverage under Medicare to any patient diagnosed with kidney failure, both dialysis and kidney transplants have been covered for all renal patients.

But a new joint investigation between The Atlantic and ProPublica found many problems with dialysis in the U.S.: The cost of treatment is among the world's highest, while the U.S. mortality rate for dialysis patients is one of the world's worst. One in four patients will die within 12 months of starting treatment.

Investigative reporter Robin Fields, who spent the past year reviewing thousands of documents and interviewing more than 100 patients, doctors, policymakers and experts, found systematic failures in the way dialysis centers are set up in the United States.

"At clinics from coast to coast, patients commonly receive treatment in settings that are unsanitary and prone to perilous lapses in care," she writes in a piece that will be published in the December issue of The Atlantic. "Regulators have few tools and little will to enforce quality standards. Industry consolidation has left patients with fewer choices of provider. [And] the government withholds critical data about clinics' performance from patients, the very people who need it most."

Read more on A Growing Industry

Kidney Transplant Numbers Increase for Elderly Patients

Elderly patients with kidney failure get kidney transplants more often than they did a decade ago, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN). The results suggest that the chances of receiving a kidney transplant are better than ever for an older patient who needs one.

Kidney failure afflicts nearly half a million individuals in the United States, and 48% of sufferers are 60 years of age or older. Kidney disease patients who obtain a transplant live longer than those that remain on dialysis. Fortunately, living and deceased organ donations are on the rise; however, transplant waiting lists have become increasingly long as more and more people develop kidney dysfunction.

Elke Schaeffner, MD (Charité University Medicine, in Berlin, Germany), along with Caren Rose and John Gill, MD (St. Paul's Hospital, University of British Columbia, in Vancouver, Canada) examined whether elderly patients with kidney failure have better or worse access to transplants now than they did in the past. The study included patients with kidney failure in the United States aged 60 to 75 years listed in the United States Renal Data System between 1995 and 2006.

The study revealed that elderly patients rarely receive a transplant, but they were twice as likely to get one in 2006 as in 1995. (In 2006, they had a 7.3% likelihood of getting a transplant within three years of their first treatment for kidney failure.) Elderly patients now benefit from greater access to organs from living donors and older deceased donors compared to a decade ago. They also die less frequently while waiting for a kidney than they did in the past.

To read entire article click here

Diabetes and Kidney Disease

Diabetes mellitus, usually called diabetes, is a disease in which your body does not make enough insulin or cannot use normal amounts of insulin properly. Insulin is a hormone that regulates the amount of sugar in your blood. A high blood sugar level can cause problems in many parts of your body.

Are there different types of diabetes?

The most common ones are Type 1 and Type 2. Type 1 diabetes usually occurs in children. It is also called juvenile onset diabetes mellitus or insulin-dependent diabetes mellitus. In this type, your pancreas does not make enough insulin and you have to take insulin injections for the rest of your life.

Type 2 diabetes, which is more common, usually occurs in people over 40 and is called adult onset diabetes mellitus. It is also called non insulin-dependent diabetes mellitus. In Type 2, your pancreas makes insulin, but your body does not use it properly. The high blood sugar level often can be controlled by following a diet and/or taking medication, although some patients must take insulin. Type 2 diabetes is particularly prevalent among African Americans, American Indians, Latin Americans and Asian Americans.

Read entire article here

Study Finds Differences in Care for Patients Beginning on Dialysis

A study appearing in an upcoming issue of the Journal of the American Society Nephrology (JASN)says that kidney disease patients
insured by some federally sponsored national health care organizations are more likely to undergo an important predialysis procedure than patients with other types of insurance.

The results may provide insights into ways to improve kidney-related care for patients before they go on dialysis.

To read entire article, click here

Daily Hemodialysis Improves Depression and Recovery Time

Hemodialysis patients who transitioned from in-center to daily home dialysis regimens experienced significant improvements in depressive symptoms and post-dialysis recovery times, according to a new report published today in the American Journal of Kidney Diseases, the official journal of the National Kidney Foundation.

Patients who made the switch from the normal, thrice weekly in-center treatment regimen to a daily schedule, defined as six times per week, reported more than a 30% decline in depressive symptoms and an 87% drop in post-dialysis recovery time over a 12 month period.

The research team assessed 128 patients making the treatment regimen switch. Patients were assessed upon enrollment and then again four months and 12 months afterward. The average training period to complete the transition was 27 days.

Click here to read entire article

Critical Limb Ischemia

From Woundresearch.com

Critical Limb Ischemia
PUBLICATION DATE: Aug 01 2008
Issue:
8

author:
Laura Bolton, PhD, FAPWCA

Dear Readers:
Critical limb ischemia (CLI), the most severe stage of peripheral arterial disease, affects 250,000 new patients annually in the United States with an estimated 40% requiring amputation within 12 months of a CLI episode, in addition to an annual mortality rate of more than 20%.1,2 Distal bypass surgery prompts healing of lower extremity ulcers associated with CLI if resulting arterial patency supports skin perfusion pressure of at least 35 mmHg.3 Surgical bypass of the occluded arterial segment improves3,4 and extends primary arterial patency, though there is insufficient evidence to support improved amputation rates or mortality compared to most other modalities.4 What options are available to the individual for whom bypass surgery is no longer feasible? This month’s Evidence Corner reviews two studies evaluating efficacy of modalities for treating CLI in patients without further vascular surgery options, as the search for an effective treatment of CLI continues.
Critical Limb Ischemia
Reference: Kavros SJ, Delis KT, Turner NS, et al. Improving limb salvage in critical ischemia with intermittent pneumatic compression: a controlled study with 18-month follow-up. J Vasc Surg. 2008;47(3):543–549.
Rationale: Intermittent pneumatic compression (IPC) is a noninvasive method of increasing arterial circulation and ameliorating intermittent claudication in patients with peripheral arterial disease (PAD).
Objective: Evaluate clinical efficacy of IPC in patients with chronic CLI, nonhealing foot ulcers, and minor toe or transmetatarsal amputation after further options for arterial revascularization had been exhausted.
Methods: This retrospective cohort study compared two similar groups, each consisting of 24 consecutive patients, for whom further surgical bypass was not an option, and were cared for in a multidisciplinary community clinic from 1998–2004. Resting ankle-to-brachial ratios of systolic blood pressure (ABI), sitting transcutaneous oximetry (TcPO2) duplex graft surveillance, and foot radiography confirmed vascular status. Both groups received weekly debridement and biologic dressings for tissue loss and nonhealing amputation wounds of the foot due to CLI. Intermittent pneumatic compression allocation was based solely on a patient’s willingness to use it. The IPC inflation pressure was 85 mmHg to 95 mmHg and was applied for 2 seconds with a 0.2-second rise, 3 cycles per minute, for three 2-hour daily sessions. Adherence was monitored closely. Healing outcomes were “favorable” if complete healing with limb salvage occurred during 18 months. Outcomes were considered “adverse” if nonhealing caused below-knee amputation during that time.
Results: Groups were comparable at baseline on all arterial and wound parameters; prior amputation and comorbid factors were assessed. Four patients (17%) in the control group and 14 IPC (58%) patients healed (P < 0.01). The likelihood of limb loss in the control group was 7 times that of IPC subjects who also increased in TcPO2 (P = 0.0038).
Authors’ Conclusions: When used within a protocol of standard wound care, IPC significantly improves clinical healing and below-knee amputation outcomes of patients with inoperable CLI. This research sets the stage for rigorous prospective, multicenter, randomized, controlled trials (RCTs) of IPC to establish its role in healing while clarifying its indications for use.
FGF-1 Gene Therapy Decreases Amputation Rates in Patients With CLI
Reference: Nikol S, Baumgartner I, Van Belle E, et al. Therapeutic angiogenesis with intramuscular NV1FGF improves amputation-free survival in patients with critical limb ischemia. Mol Ther. 2008;16(5):972–978.
Rationale: Although controversial, with its long-term effects under scrutiny, angiogenic growth factor therapy has been proposed for treatment of critical limb ischemia in end-stage PAD. Acidic fibroblast growth factor (FGF-1) is a potent mitogen for vascular endothelial cells, inducing blood vessel formation in vitro and in vivo. A plasmid-based gene transfer delivery system for FGF-1, NV1FGF with “Conditional Origin of Replication” (pCOR), reduces the potential for propagation in the host environment while sustaining local FGF-1 production permitting less frequent treatment.
Objective: A Phase 2b, double blind, randomized, placebo-controlled clinical trial investigated the efficacy and safety of intramuscular NV1FGF versus placebo in subjects with CLI at high risk of amputation.
Methods: A European multicenter trial screened 125 patients with CLI ineligible for revascularization as confirmed by a vascular surgeon. Each patient had at least 1 nonhealing ulcer, a TcPO2 £ 20 mmHg, ankle pressure
£ 70 mmHg, and toe pressure £ 50 mmHg. Patients were randomly assigned to receive 8 intramuscular injections of 2.5 mL NV1FGF in a 0.2 mg/mL solution (n = 59) or similar placebo injections (n = 56) on study days 1, 15, 30, and 45. Percent of patients with at least 1 ulcer completely healed at week 26 was the primary outcome. Secondary outcomes TcPO2, ABI, amputation, and death were evaluated at week 52.
Results: Among 107 subjects evaluated for healing, 19.4% of NV1FGF-treated and 14.3% of control patients healed during 26 weeks (P = 0.514; not significant). Likelihood of amputation or of major amputation was reduced in the NV1FGF group (P = 0.011), which also experienced improvement in time to death or major amputation. No other secondary outcomes were statistically significant. Adverse events were comparable in both groups, supporting the safety of NV1FGF.
Authors’ Conclusions: This was the first double blind, prospective RCT in patients ineligible for bypass surgery. Despite the fact that no improvement in wound healing was seen it showed the potential for NV1FGF to significantly reduce amputation risk, potentially lowering mortality rates in these high-risk patients.

Clinical Perspective
Both publications aim to improve the lot of patients with serious vascular impairment, using either biochemical or physical modalities. Plasmid gene transfer of NV1FGF administered once every 2–3 weeks for the first 7.5 weeks of care appears to save limbs, though its effect on ischemic ulcer healing remains uncertain. Other plasmid growth factors either lack healing and amputation effects5 or heal wounds without reducing amputation.6 The capacity to save limbs in high-risk patients for whom surgery is no longer an option is equally compelling for NV1FGF and IPC. Limb salvage plus the healing benefits of properly applied IPC are unprecedented, although it was a small retrospective study and was potentially biased by selection of IPC-willing patients. Larger prospective RCTs on patients with CLI, perhaps comparing IPC with and without NV1FGF, would seem necessary. As a physical modality, IPC may be compatible with gene or biochemical therapy. These studies open potential care options for patients with CLI who are faced with possible amputation.

References:
1. Dormandy J, Heeck L, Vig S. The fate of patients with critical leg ischemia. Semin Vasc Surg. 1999;12(2):142–147.
2. Dormandy J, Mahir M, Ascady G, et al. Fate of the patient with chronic leg ischaemia: A review article. J Cardiovasc Surg. 1989;30(1):50–57.
3. Tsuji Y, Hiroto T, Kitano I, Tahara S, Sugiyama D. Importance of skin perfusion pressure in treatment of critical limb ischemia. WOUNDS. 2008;20(4):95–100.
4. Fowkes F, Leng GC. Bypass surgery for chronic lower limb ischaemia. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD002000.
5. Powell RJ, Simons M, Mendelsohn FO, et al. Results of a double-blind, placebo-controlled study to assess the safety of intramuscular injection of hepatocyte growth factor plasmid to improve limb perfusion in patients with critical limb ischemia. Circulation. 2008;118(1):58–65.
6. Kusumanto YH, van Weel V, Mulder NH, et al. Treatment with intramuscular vascular endothelial growth factor gene compared with placebo for patients with diabetes mellitus and critical limb ischemia: a double-blind randomized trial. Hum Gene Ther. 2006;17(6):683–691.

PVD Study

Objective: We studied the effectiveness of a screening program for peripheral vascular disease (PVD) carried out by trained renal nurses in patients with and without diabetes on continuous ambulatory peritoneal dialysis (CAPD).

Patients and Methods: We recruited 30 stable diabetic and 30 stable non diabetic CAPD patients into this cross-sectional study. Trained renal nurses measured the patients' ankle-to-brachial systolic pressure index (ABI) using a Doppler ultrasound machine and their foot vibration perception (VPT) using a biothesiometer, and administered a questionnaire on foot symptoms. An ABI < 1.0 was regarded as abnormal and suggestive of the presence of PVD. An ABI < 0.7 or > 1.3 was regarded as severely abnormal. Findings for VPT were classified as normal or abnormal. Patients were then followed for 1 year for any overt development of clinical PVD, leg complications, and other vascular complications and for clinical outcome.

Results: The mean age of the patients was 63 ± 9 years, and the ratio of men to women was 1:1.3. An abnormal ABI was seen in 22 patients (37%). The questionnaire detected clinical PVD symptoms in 3 patients. Abnormal ABI and VPT findings were more frequent in diabetic patients. After 12 months of follow-up, patients with an abnormal ABI (and particularly those with a severely abnormal ABI) were more likely to develop leg complications and any type of cardiovascular disease than were patients with a normal ABI. Foot vibration perception had no predictive value on subsequent development of leg complications. When risk factors including age, ABI, and VPT were analyzed by logistic regression, only ABI was a significant independent predictor of subsequent lower-limb vascular complications [odds ratio (OR): 21.0; 95% confidence interval (CI): 2.35 to 187.0; p = 0.00064]. The OR for moderately abnormal ABI was 13.0 (95% CI: 1.015 to 166.3); for severely abnormal ABI, it was 27.4 (95% CI: 2.35 to 187.0, p = 0.0045).

Conclusions: Measurement of ABI by Doppler ultrasound is a useful and effective screening test for PVD in CAPD patients. In this study, VPT was not shown to be predicative of future leg complications, indicating that peripheral neuropathy plays a less important role in the development of such complications. Our results proved that trained renal nurses can play an active role in detecting foot problems in renal patients by ABI measurement.

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