Sawin D.A.,Fresenius Medical Care North America
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis | Year: 2012
Although dialytic removal of phosphate significantly contributes to the management of phosphate levels in end-stage renal disease, many patients on peritoneal dialysis (PD) still do not reach optimal phosphate control. The present review discusses the impact of PD modality--continuous ambulatory (CAPD) or automated (APD)--on phosphate removal. Relevant factors are the diffusive properties of the phosphate anion and the kinetics of phosphate distribution in various body compartments. Confounders that potentially affect comparisons of phosphate clearances in CAPD and APD are differences in residual renal function, membrane transport status, and prescribed dialysis dose. The evidence reviewed here is not strong enough to clearly determine if one modality has a clear advantage with respect to phosphate removal. In the absence of final proof the data suggest that, given the same residual renal function and dialysis dose, CAPD might be slightly more effective than APD at peritoneal phosphate clearance, especially in low transporters.
Himmele R.,Fresenius Medical Care North America
Advances in peritoneal dialysis. Conference on Peritoneal Dialysis | Year: 2011
Glucose degradation products (GDPs) are highly reactive precursors of advanced glycation end-products (AGEs). High glucose concentrations, GDPs, and AGEs can activate specific pathways, including inflammatory and oxidative stress response pathways, which may adversely affect the cardiovascular system. This review discusses the impact and possible mechanisms of action of GDPs and AGEs with regard to cardiovascular toxicity in chronic kidney disease patients. The AGE-RAGE pathway appears to be particularly important in the pathogenesis of cardiovascular diseases in dialysis patients. In the absence of definitive proof from randomized controlled trials, mounting evidence suggests that high levels of GDPs and AGEs play a role in the pathophysiology of cardiotoxicity.
Wingard R.L.,Fresenius Medical Care North America
Nephrology news & issues | Year: 2012
The rate of rehospitalization is at a critical level. Twenty percent of all Medicare patients are rehospitalized within 30 days of discharge, and this rate is even higher (36%) for end-stage renal disease patients. Dialysis-dependent patients are commonly discharged from the hospital with a decline in various health measures (such as hemoglobin, albumin, and estimated dry weight) when compared to pre-hospital values, making the common response to resume previous orders" in the outpatient setting inadequate. Both quality of care and financial penalties by the Centers for Medicare & Medicaid Services have set the stage for partnerships between dialysis providers and hospitals to develop strategies to reduce readmissions for ESRD patients, and provide for the "RightReturn" to the outpatient setting with resumption of their daily lives at home in optimal health.
Maddux F.W.,Fresenius Medical Care North America
Blood Purification | Year: 2012
This article provides a perspective on the impact of the bundled end-stage renal disease prospective payment system on patient care. As the first year of the bundle comes to a close, we are beginning to see information about practice pattern changes that have resulted and the impact of those changes on the care of patients with renal disease. This review recognizes the background of the prospective payment system for renal replacement therapy and its evolution to include multiple components, as well as a description of the features of this payment system that are expected to have an impact on the clinical care by nephrologists and dialysis providers. Some of the expected impact on the dosing of erythropoiesis-stimulating agents, consolidation of dialysis providers, and a move toward more measurement are beginning to be seen. This brief summary not only reviews the components of the bundled payment system, but also the anticipated impact and some early information on the response to these predicted findings in the industry. © 2012 S. Karger AG, Basel.
Maddux F.W.,Fresenius Medical Care North America |
Nissenson A.R.,HealthCare Partners
Clinical Journal of the American Society of Nephrology | Year: 2015
The medical director has been a part of the fabric of Medicare’s ESRD program since entitlement was extended under Section 299I of Public Law 92-603, passed on October 30, 1972, and implemented with the Conditions for Coverage that set out rules for administration and oversight of the care provided in the dialysis facility. The role of the medical director has progressively increased over time to effectively extend to the physicians serving in this role both the responsibility and accountability for the performance and reliability related to the care provided in the dialysis facility. This commentary provides context to the nature and expected competencies and behaviors of these medical director roles that remain central to the delivery of high-quality, safe, and efficient delivery of RRT, which has become much more intensive as the dialysis industry has matured. © 2015 by the American Society of Nephrology