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Karavetian M.,American University of Beirut | Ghaddar S.,DaVita Inc
Journal of Renal Care | Year: 2013

Objective: To examine the effect of self-management dietary counselling (SMDC) on adherence to dietary management of hyperphosphatemia among haemodialysis patients. Design: An eight-week cluster based randomised control trial. Participants: 122 stable adult patients were recruited from an HD unit in Sidon, Lebanon. Study groups were: full intervention (A) (n = 41), partial intervention (B) (n = 41) and control (C) (n = 40). Intervention: Group (A) received SMDC, Group (B) received educational games only and Group (C) did not receive any research intervention. Main Outcome Measures: Serum phosphorus (P), Calcium Phosphate product (Ca × P) and two questionnaires: patient knowledge (PK) and dietary non-adherence (PDnA) to P reduced diet. Results: Group A experienced a significant improvement in mean (± SD) P (6.54 ± 2.05 - 5.4 ± 1.97 mg/dl), Ca × P (58 ± 17 - 49 ± 12), PK scores (50 ± 17 - 69 ± 25%) and PDnA scores (21.4 ± 4.0 - 18.3 ± 2.0). Group B experienced a significant improvement in Ca × P (52 ± 14-45 ± 16). Group C did not experience any significant change post intervention. Conclusion: Our findings demonstrate the importance of patient-tailored counselling on serum P management. © 2012 European Dialysis and Transplant Nurses Association/European Renal Care Association.

Gutekunst L.,DaVita Inc
Journal of Renal Nutrition | Year: 2016

Control of serum phosphorus (PO4) has been long recognized as a goal in the nutritional and medical management of the patients with chronic kidney disease. Phosphate-binding compounds were introduced in the 1970s for the treatment of hyperphosphatemia in patients on dialysis after it was observed that oral administration of aluminum hydroxide as an antacid also reduced serum PO4 levels. Forty years later, aluminum is very seldom used as a phosphate binder as many other safer compounds are now available. This article is a comprehensive review, geared to the renal dietitian, of the most common binder categories. It will discuss pharmacokinetics, side effects, initial and optimal doses, phosphate affinity, and controversies of use. It will also review two novel approaches to serum PO4 management in chronic kidney disease patients receiving dialysis and provide a new calculation by which binders can be compared. © 2016 National Kidney Foundation, Inc.

Noori N.,University of California at Los Angeles | Kalantar-Zadeh K.,University of California at Los Angeles | Kovesdy C.P.,Salem Veterans Affairs Medical Center | Bross R.,University of California at Los Angeles | And 2 more authors.
Clinical Journal of the American Society of Nephrology | Year: 2010

Background and objectives: Epidemiologic studies show an association between higher predialysis serum phosphorus and increased death risk in maintenance hemodialysis (MHD) patients. The hypothesis that higher dietary phosphorus intake and higher phosphorus content per gram of dietary protein intake are each associated with increased mortality in MHD patients was examined. Design, setting, participants, & measurements: Food frequency questionnaires were used to conduct a cohort study to examine the survival predictability of dietary phosphorus and the ratio of phosphorus to protein intake. At the start of the cohort, Cox proportional hazard regression was used in 224 MHD patients, who were followed for up to 5 years (2001 to 2006). Results: Both higher dietary phosphorus intake and a higher dietary phosphorus to protein ratio were associated with significantly increased death hazard ratios (HR) in the unadjusted models and after incremental adjustments for case-mix, diet, serum phosphorus, malnutrition-inflammation complex syndrome, and inflammatory markers. The HR of the highest (compared with lowest) dietary phosphorus intake tertile in the fully adjusted model was 2.37. Across categories of dietary phosphorus to protein ratios of< 12,12 to< 14, 14 to< 16, and ≥16 mg/g, death HRs were 1.13,1.00 (reference value), 1.80, and 1.99, respectively. Cubic spline models of the survival analyses showed similar incremental associations. Conclusions: Higher dietary phosphorus intake and higher dietary phosphorus to protein ratios are each associated with increased death risk in MHD patients, even after adjustments for serum phosphorus, phosphate binders and their types, and dietary protein, energy, and potassium intakes. Copyright © 2010 by the American Society of Nephrology.

Krishnan M.,DaVita Inc
Nephrology news & issues | Year: 2011

Comparative Effectiveness Research (CER) has become positioned to inform health care decision-making with passage of the health care reform law, "Patient Protection and Affordability Care Act of 2010". As the name suggests, CER attempts to understand the relative efficacy between two therapies to allow clinicians, health care providers, and others to make rational decisions when evaluating therapeutic options. This is particularly relevant in the nephrology community as the dawn of bundled payments approaches. The current evidence base for CER studies is especially curtailed as a result of limited head-to-head clinical trials in patients with end-stage renal disease. Specifically, CER for available oral vitamin D agents approved for use in ESRD is lacking. The inclusion of oral vitamin D in the bundled payment system in 2011 may lead more clinicians to examine which oral vitamin D analog to prescribe to their patients, making this an especially timely topic.

Maddux F.W.,Fresnius Medical Care | McMurray S.,DaVita Inc | Nissenson A.R.,DaVita Inc
Clinical Journal of the American Society of Nephrology | Year: 2013

Under the Patient Protection and Affordable Care Act of 2010, accountable care organizations (ACOs) will be the primary mechanism for achieving the dual goals of high-quality patient care at managed per capita costs. To achieve these goals in the newly emerging health care environment, the nephrology community must plan for and direct integrated delivery and coordination of renal care, focusing on population management. Even though the ESRD patient population is a complex group with comorbid conditions that may confound integration of care, the nephrology community has unique experience providing integrated care through ACO-like programs. Specifically, the recent ESRD Management Demonstration Project sponsored by the Centers for Medicare & Medicaid Services and the current ESRD Prospective Payment System with it Quality Incentive Program have demonstrated that integrated delivery of renal care can be accomplished in a manner that provides improved clinical outcomes with some financial margin of savings. Moving forward, integrated renal care will probably be linked to provider performance and quality outcomes measures, and clinical integration initiatives will share several common elements, namely performance-based payment models, coordination of communication via health care information technology, and development of best practices for care coordination and resource utilization. Integration initiatives must be designed to be measured and evaluated, and, consistent with principles of continuous quality improvement, each initiative will provide for iterative improvements of the initiative. © 2013 by the American Society of Nephrology.

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