Incremental Initiation of Dialysis: One Center's Experience over a Two-Year Period

Objective

This pilot study describes our center's experience with peritoneal dialysis (PD) over the past 2 years using a “healthy start” dialysis protocol with an incremental approach to prescription management.

Design

Nonrandomized, prospective pilot study.

Setting

Single PD unit of a university teaching hospital.

Patients

Thirteen PD patients who initiated dialysis at our center from April 1997 to June 1999.

Methods

Patients initiating PD with residual renal Kt/V of 1.0 – 2.0/week were invited to participate. They were given an initial dialysis prescription so that total (residual renal + dialysis) weekly Kt/V exceeded 2.0. The dialysis prescription was “incrementally” increased as residual renal function (RRF) declined. Data collected for all patients included monthly serum chemistries, residual renal weekly Kt/V and creatinine clearance (CCr) at 1- to 2-month intervals, and peritoneal weekly Kt/V and CCr at 3-month intervals and 1 month after each prescription change.

Results

To date, we have followed 13 patients on our incremental PD protocol for a total of 159.3 patient-months. Mean serum albumin concentration and mean normalized protein equivalent of nitrogen appearance (nPNA) were stable throughout the study. Mean total Kt/V and CCr remained above the recommended targets of 2.0/wk and 60 L/wk, respectively. Residual renal function declined rather slowly in our PD patients. One patient died from complications of aortic valve surgery and a second died from pneumonia. A third patient died from peritonitis. One patient required a new Tenckhoff catheter after catheter migration. Three patients were temporarily switched to hemodialysis after a hernia repair, a pleural leak, and elective native/transplant nephrectomies, respectively. Two patients were permanently switched to hemodialysis: one after an episode of peritonitis, the second after accidentally damaging his PD catheter.

Conclusions

Providing incremental dialysis to maintain adequate total small solute clearance has been technically feasible in our patient population. However, a larger than expected number of complications was seen in our study. Fortunately, complications were easier to manage due to the presence of RRF. Because this study was not designed to compare outcome with that observed after traditional initiation of dialysis, further large-scale studies are needed.

Peritoneal Dialysis Case Forum

The Trials and Tribulations of an Adolescent Patient with End-Stage Renal Disease

Significance, Epidemiology, and Prevention of Peritoneal Dialysis Catheter Infections

Catheter infections are a major cause of morbidity, catheter loss, and transfer to hemodialysis. These infections are mainly due to S. aureus. To date, treatment is less than optimal. Therefore, the primary goal should be prevention of catheter infections. Prevention is based on improving catheter design and implantation technique while using careful exit-site care. Prophylaxis with antimicrobials such as intranasal mupirocin or the use of silverimpregnated catheters appears promising as a way to reduce the risk of developing S. aureus infections. To optimize patient outcome, one must focus on these preventive measures.

24-Hour Dialysate Collection for Determination of Peritoneal Membrane Transport Characteristics: Longitudinal Follow-Up Data for the Dialysis Adequacy and Transport Test (Datt)

Objective

To determine the ability of the dialysis adequacy and transport test (DATT) to monitor changes in peritoneal transport characteristics over time.

Setting

University-based peritoneal dialysis program.

Patients

One hundred patients on continuous ambulatory peritoneal dialysis who underwent 226 simultaneous DATTs and peritoneal equilibration tests (PET).

Methods

Retrospective analysis of DA TT and PET data.

Results

The mean 24-hour dialysate-to-plasma creatinine (cr) concentration ratio (DIP cr) from the DATT was 0.70±0.10, and the mean four-hour DIP crfrorn the PET was 0.68 ± 0.10. The correlation coefficient between the fourhour and 24-hour DIP cr was 0.81, and the standard error of estimate was 0.065. The mean (±SD) difference between the four-hour and 24-hour DIP cr was 0.023 ± 0.061. Fifty eight patients had two or more sequential DA TTs and PETs. For these 94sets of sequential DATTs and PETs, the mean (±SD) difference between the change in the four-hour DIP cr and the change in the 24-hour DIP cr was 0.020 ± 0.024, and the standard error of estimate was 0.064. In 17 patients a change in dwell volume from 2.0 L to 2.5 L occurred between the first and second measures of peritoneal membrane transport characteristics. The mean (±SD) difference between the change in the four-hour DIP cr and the change in the 24-hour DIP cr was 0.036 ± 0.055, and the standard error of estimate was 0.087.

Conclusion

The DATT can be used to monitor for changes in peritoneal transport over time. It should not be used in patients receiving cycler therapy or in patients whose dwell times and dextrose concentrations vary markedly from day to day.

Comparison of a 2.5% and a 4.25% Dextrose Peritoneal Equilibration Test

Background

Ultrafiltration (UF) failure develops over time in some patients on peritoneal dialysis. The workup of UF failure can be difficult and the 4.25% peritoneal equilibration test (PET) has been suggested to be more useful than the 2.5% PET for the workup of UF failure. It is unknown how a 4.25% PET compares to a 2.5% PET in individual patients.

Objectives

To assess the differences in drain volumes and sodium sieving using a 4.25% PET compared to a 2.5% PET, and to determine whether peritoneal transport rates, in terms of dialysate-to-plasma (D/P) ratios, are comparable between the two.

Design

Pilot study with each patient serving as his or her own control.

Setting

Outpatient dialysis facility of Wake Forest University Baptist Medical Center.

Patients

47 patients, all of whom had a 2.5% PET and a 4.25% PET performed within 1 week of each other.

Outcome Measures

Dialysate-to-plasma ratios of urea and creatinine, dialysate total protein, and dialysate glucose compared to time zero (D/D0) at 0, 2, and 4 hours. Four-hour drain volumes and sodium sieving at 2 hours were also measured.

Results

There was reproducibility between the 2.5% and 4.25% PET for D/P ratios of urea and creatinine and for dialysate total protein. There were expected differences in drain volume, sodium sieving, and D/D0 glucose between the two methods.

Conclusions

The use of a 4.25% PET may be more useful for the workup of UF failure because of the accentuation of drain volume and sodium sieving, while remaining useful for prescription management.

The use of infrared thermography to investigate emotions in common marmosets

Measuring body surface temperature changes with infrared thermography has recently been put forward as a non-invasive alternative measure of physiological correlates of emotional reactions. In particular, the nasal region seems to be highly sensitive to emotional reactions. Several studies suggest that nasal temperature is negatively correlated with the level of arousal in humans and other primates, but some studies provide inconsistent results. Our goal was to establish the use of infrared thermography to quantify emotional reactions in common marmosets (Callithrix jacchus), with a focus on the nasal region. To do so we exposed 17 common marmosets to a set of positive, negative and control stimuli (positive: preferred food, playback of food calls; negative: playback of aggressive vocalizations, teasing; control: no stimulus). We compared nasal temperature before and after the stimuli and expected that highly aroused emotional states would lead to a drop in nasal temperature. To validate the thermography measure, we coded piloerection of the tail as an independent measure of arousal and expected a negative correlation between the two measures. Finally, we coded physical activity to exclude its potential confounding impact on nasal temperature. Our results show that all predictions were met: the animals showed a strong decrease in nasal temperature after the presentation of negative arousing stimuli (teasing, playback of aggressive vocalizations). Furthermore, these changes in nasal temperature were correlated with piloerection of the tail and could not be explained by changes in physical activity. In the positive and the control conditions, we found systematic sex differences: in males, the preferred food, the playbacks of food calls, as well as the control stimulus led to an increase in nasal temperature, whereas in females the temperature remained stable (preferred food, control) or decreased (playback of food calls). Based on naturalistic observations that document higher food motivation and competition among female marmosets, as well as stronger reactions to separation from group members in male marmosets, these sex differences corroborate a negative correlation between arousal and nasal temperature. Overall, our results support that measuring nasal temperature by infrared thermography is a promising method to quantify emotional arousal in common marmosets in a fully non-invasive and highly objective way.

Burden and Correlates of Hospital Readmissions among U.S. Peritoneal Dialysis Patients

Background:Hospital readmissions are common among in-center hemodialysis patients, but little is known about readmissions among peritoneal dialysis (PD) patients. Using national administrative data, we aimed to examine the burden and correlates of hospital readmissions among U.S. PD patients.Methods:Among 10,505 adult U.S. PD patients with an index admission (first admission after 120 days on dialysis) between 31 January 2011 and 30 November 2014, readmissions were defined as new hospital admissions within 30 days of index discharge. Multivariable logistic regression was used to obtain adjusted odds ratios (ORs) for readmission.Results:Overall, 26.8% of index admissions were followed by a readmission. Readmitted patients were more likely to have congestive heart failure (31.0% vs 25.4%; p < 0.001) and peripheral arterial disease (11.6% vs 8.6%; p < 0.001) and had longer index admission length of stay (median = 4 vs 3 days; p < 0.001) than those who were not; age, sex, and race did not differ by readmission status. After adjustment for patient and index admission characteristics, longer length of stay (≥ 4 vs < 4 days, OR = 1.48, 95% confidence interval [CI] 1.35 - 1.62), peripheral arterial disease (OR = 1.31, 95% CI 1.16 - 1.57), congestive heart failure (OR = 1.25, 95% CI 1.13 - 1.39), and ischemic heart disease (OR = 1.12, 95% CI 1.01 - 1.24) were associated with higher likelihood of readmission; index admission due to peritonitis vs other causes was associated with lower likelihood of readmission (OR = 0.80, 95% CI 0.70 - 0.92).Conclusions:Our results suggest that, particularly in the absence of a PD-related cause of hospitalization such as peritonitis, PD patients may be at high risk for readmission and may benefit from closer post-discharge monitoring.

Post-hospitalization dialysis facility processes of care and hospital readmissions among hemodialysis patients: a retrospective cohort study

Background

Both dialysis facilities and hospitals are accountable for 30-day hospital readmissions among U.S. hemodialysis patients. We examined the association of post-hospitalization processes of care at hemodialysis facilities with pulmonary edema-related and other readmissions.

Methods

In a retrospective cohort comprised of electronic medical record (EMR) data linked with national registry data, we identified unique patient index admissions (n = 1056; 2/1/10–7/31/15) that were followed by ≥3 in-center hemodialysis sessions within 10 days, among patients treated at 19 Southeastern dialysis facilities. Indicators of processes of care were defined as present vs. absent in the dialysis facility EMR. Readmissions were defined as admissions within 30 days of the index discharge; pulmonary edema-related vs. other readmissions defined by discharge codes for pulmonary edema, fluid overload, and/or congestive heart failure. Multinomial logistic regression to estimate odds ratios (ORs) for pulmonary edema-related and other vs. no readmissions.

Results

Overall, 17.7% of patients were readmitted, and 8.0% had pulmonary edema-related readmissions (44.9% of all readmissions). Documentation of the index admission (OR = 2.03, 95% CI 1.07–3.85), congestive heart failure (OR = 1.87, 95% CI 1.07–3.27), and home medications stopped (OR = 1.81, 95% CI 1.08–3.05) or changed (OR = 1.69, 95% CI 1.06–2.70) in the EMR post-hospitalization were all associated with higher risk of pulmonary edema-related vs. no readmission; lower post-dialysis weight (by ≥0.5 kg) after vs. before hospitalization was associated with 40% lower risk (OR = 0.60, 95% CI 0.37–0.96).

Conclusions

Our results suggest that some interventions performed at the dialysis facility in the post-hospitalization period may be associated with reduced readmission risk, while others may provide a potential existing means of identifying patients at higher risk for readmissions, to whom such interventions could be efficiently targeted.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-0983-5) contains supplementary material, which is available to authorized users.

Reverse audience effects on helping in cooperatively breeding marmoset monkeys

Cooperatively breeding common marmosets show substantial variation in the amount of help they provide. Pay-to-stay and social prestige models of helping attribute this variation to audience effects, i.e. that individuals help more if group members can witness their interactions with immatures, whereas models of kin selection, group augmentation or those stressing the need to gain parenting experience do not predict any audience effects. We quantified the readiness of adult marmosets to share food in the presence or absence of other group members. Contrary to both predictions, we found a reverse audience effect on food-sharing behaviour: marmosets would systematically share more food with immatures when no audience was present. Thus, helping in common marmosets, at least in related family groups, does not support the pay-to-stay or the social prestige model, and helpers do not take advantage of the opportunity to engage in reputation management. Rather, the results appear to reflect a genuine concern for the immatures' well-being, which seems particularly strong when solely responsible for the immatures.

Vascular Access Placement Order and Outcomes in Hemodialysis Patients: A Longitudinal Study

BACKGROUND

Arteriovenous accesses (AVA) in patients performing hemodialysis (HD) are labeled "permanent" for AV fistulas (AVF) or grafts (AVG) and "temporary" for tunneled central venous catheters (TCVC). Durability and outcomes of permanent vascular accesses based on the sequence in which they were placed or used receives little attention. This study analyzed longitudinal transitions between TCVC-based and AVA-based HD outcomes according to the order of placement.

METHODS

All 391 patients initiating chronic HD via a TCVC between 2012 and 2013 at 12 outpatient academic dialysis units were included in this study. Chronological distributions of HD vascular accesses were recorded over a mean (SD) of 2.8 (0.9) years and sequentially grouped into periods for TCVC-delivered and AVA-delivered (AVF or AVG) HD. Primary AVA failure and cumulative access survival were evaluated based on access placement sequence and type, adjusting for age.

RESULTS

In total, 92.3% (361/391) of patients underwent 497 AVA placement surgeries. Analyzing the initial 3 surgeries, primary AVF failure rates increased with each successive fistula placement (p = 0.008). Among the 82.9% (324/391) of TCVC patients successfully converted to an AVA, 30.9% returned to a TCVC, followed by a 58.0% conversion rate to another AVA. Annual per-patient vascular access transition rates were 2.02 (0.09) HD periods using a TCVC and 0.54 (0.03) HD periods using an AVA. Comparing the first AVA used with the second, cumulative access survivals were 701.0 (370.0) vs. 426.5 (275.0) days, respectively. Excluding those never converting to an AVF or AVG, 169 (52.2%) subsequently converted from a TCVC to a permanent access and received HD via AVA for ≥80% of treatments.

CONCLUSIONS

HD vascular access outcomes differ based on the sequence of placement. In spite of frequent AVA placements, only half of patients effectively achieved a "permanent" vascular access and used an AVA for the majority of HD treatments.

Effects of weight-based ultrafiltration rate limits on intradialytic hypotension in hemodialysis

INTRODUCTION

High ultrafiltration (UF) rates can result in intradialytic hypotension and are associated with increased mortality. The effects of a weight-based UF rate limit on intradialytic hypotension and the potential for unwanted fluid weight gain and hospitalizations for volume overload are unknown.

METHODS

This retrospective cohort study examined 123 in-center hemodialysis patients at one facility who transitioned to 13 mL/kg/h maximum UF rates. Patients were studied for an 8 week UF rate limit exposure period and compared to the 8-week period immediately prior, during which the cohort served as its own historical control. The primary outcomes were frequency of intradialytic hypotension events and percentage of treatments with a hypotension event.

FINDINGS

The delivered UF rate was lower during the exposure compared to the baseline period (mean UF rate 7.90 ± 4.45 mL/kg/h vs. 8.92 ± 5.64 mL/kg/h; P = 0.0005). The risk of intradialytic hypotension was decreased during the exposure compared to baseline period (event rate per treatment 0.0569 vs. 0.0719, OR 0.78 [95% CI 0.62-1.00]; P = 0.0474), as was the risk of having a treatment with a hypotension event (percentage of treatments with event 5.2% vs. 6.8%, OR 0.75 [95% CI 0.58-0.96]; P = 0.0217). Subgroup analyses demonstrated that these findings were attributable to patients with high baseline UF rates. Statistically significant differences in all-cause or volume overload-related hospitalization were not observed during the exposure period.

DISCUSSION

A weight-based UF rate limit of 13 mL/kg/h was associated with a decrease in the rate of intradialytic hypotension events among in-center hemodialysis patients.

Intensive Hemodialysis and Potential Risks With Increasing Treatment

Although intensive hemodialysis (HD) can address important clinical problems, increasing treatment also introduces risks. In this review, we assess risks pertaining to 6 domains: vascular access complications, infection, mortality, loss of residual kidney function, solute balance, and patient and care partner burden. In the Frequent Hemodialysis Network (FHN) trials, short daily and nocturnal schedules increased the incidence of access complications, although the incidence of access loss was not statistically higher. Observational studies indicate that infection-related hospitalization is an ongoing challenge with short daily HD. Excess risk may be catalyzed by poor infection control practices in the home setting in which intensive HD is typically delivered, but with fixed probability of bacterial contamination per cannulation, greater treatment frequency necessarily increases the risk for infectious complications. Buttonhole cannulation may increase the risk for metastatic infections. However, intensive HD in the home setting is associated with lower risk for infection than peritoneal dialysis. Data regarding mortality are equivocal. With extended follow-up of individuals in the FHN trials, short daily HD was associated with lower risk relative to the usual schedule, whereas nocturnal HD was associated with higher risk. In many, but not all, observational studies, short daily HD has been associated with lower risk than both in-center HD and peritoneal dialysis; however, observational studies are subject to unmeasured confounding. Intensive HD can accelerate the loss of residual kidney function in new dialysis patients with substantial urine output and can deplete solutes (eg, phosphorus) to the extent that supplementation is necessary. Finally, intensive HD may increase burden on patients and caregivers, possibly leading to technique failure. Some of these problems might be addressed with careful monitoring, so that relevant interventions (eg, antibiotics, retraining, and respite care) can be delivered. Ultimately, intensive HD is not a panacea for end-stage renal disease. Potential benefits and risks of treatment should be jointly considered.

Early hospital readmission among hemodialysis patients in the United States is associated with subsequent mortality

Dialysis providers in the United States may soon be held accountable for their patients' 30-day hospital readmissions. However, few studies have evaluated the timing of readmissions, which determines the window in which dialysis providers could act to prevent readmission. We therefore examined the timing of readmissions of hemodialysis patients in the United States and its association with mortality among 285,795 prevalent adult Medicare-primary hemodialysis patients from a national registry. Patients had at least one hospitalization in 2010-2013 (first index) and survived for 30 days or more. Readmission timing was defined as 0-7, 8-14, or 15-30 days after the index discharge. Multivariable Cox proportional hazards models were used to estimate the association between readmission timing (referent no readmission) and mortality, censored at one year. Overall, 23.1% of patients had readmissions within 30 days of the index discharge, of which over one-third (35.9%) were within the first week. Regardless of timing, patients with readmissions had a higher risk of death within one year, compared to those with no readmissions, with hazard ratios of 2.04 (95% confidence interval 2.00-2.09) for being readmitted within 15-30 days; 1.98 (1.93-2.04) for being readmitted within 8-14 days; and 1.76 (1.71-1.80) for being readmitted within 0-7 days. Thus, opportunities for dialysis providers to intervene and prevent early readmission may be limited. Regardless of the timing, readmission appears independently associated with a substantially increased risk of mortality in this population.

APOL1 renal-risk genotypes associate with longer hemodialysis survival in prevalent nondiabetic African American patients with end-stage renal disease

Relative to European Americans, evidence supports that African Americans with end-stage renal disease (ESRD) survive longer on dialysis. Renal-risk variants in the apolipoprotein L1 gene (APOL1), associated with nondiabetic nephropathy and less subclinical atherosclerosis, may contribute to dialysis outcomes. Here, APOL1 renal-risk variants were assessed for association with dialytic survival in 450 diabetic and 275 nondiabetic African American hemodialysis patients from Wake Forest and Emory School of Medicine outpatient facilities. Outcomes were provided by the ESRD Network 6-Southeastern Kidney Council Standardized Information Management System. Dates of death, receipt of a kidney transplant, and loss to follow-up were recorded. Outcomes were censored at the date of transplantation or through 1 July 2015. Multivariable Cox proportional hazards models were computed separately in patients with nondiabetic and diabetic ESRD, adjusting for the covariates age, gender, comorbidities, ancestry, and presence of an arteriovenous fistula or graft at dialysis initiation. In nondiabetic ESRD, patients with 2 (vs. 0/1) APOL1 renal-risk variants had significantly longer dialysis survival (hazard ratio 0.57), a pattern not observed in patients with diabetes-associated ESRD (hazard ratio 1.29). Thus, 2 APOL1 renal-risk variants are associated with longer dialysis survival in African Americans without diabetes, potentially relating to presence of renal-limited disease or less atherosclerosis.

Survey of home hemodialysis patients and nursing staff regarding vascular access use and care

Vascular access infections are of concern to hemodialysis patients and nurses. Best demonstrated practices (BDPs) have not been developed for home hemodialysis (HHD) access use, but there have been generally accepted practices (GAPs) endorsed by dialysis professionals. We developed a survey to gather information about training provided and actual practices of HHD patients using the NxStage System One HHD machine. We used GAP to assess training used by nurses to teach HHD access care and then assess actual practice (adherence) by HHD patients. We also assessed training and adherence where GAPs do not exist. We received a 43% response rate from patients and 76% response from nurses representing 19 randomly selected HHD training centers. We found that nurses were not uniformly instructing HHD patients according to GAP, patients were not performing access cannulation according to GAP, nor were they adherent to their training procedures. Identification of signs and symptoms of infection was commonly trained appropriately, but we observed a reluctance to report some signs and symptoms of infection by patients. Of particular concern, when aggregating all steps surveyed, not a single nurse or patient reported training or performing all steps in accordance with GAP. We also identified practices for which there are no GAPs that require further study and may or may not impact outcomes such as infection. Further research is needed to develop strategies to implement and expand GAP, measure outcomes, and ultimately develop BDP for HHD to improve infectious complications.

Risk of catheter-related bloodstream infection in elderly patients on hemodialysis

BACKGROUND AND OBJECTIVES

Elderly patients require tunneled central vein dialysis catheters more often than younger patients. Little is known about the risk of catheter-related bloodstream infection in this population.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study identified 464 patients on hemodialysis with tunneled central vein dialysis catheters between 2005 and 2007 and excluded patients who accrued <21 catheter-days during this period. Outpatient and inpatient catheter-related bloodstream infection data were collected. A Cox proportional hazards regression analysis adjusting for sex, ancestry, comorbidites, dialysis vintage, dialysis unit, immunosuppression, initial catheter site, and first antimicrobial catheter lock solution was performed for risk of catheter-related bloodstream infection between nonelderly (18-74 years) and elderly (≥ 75 years) patients.

RESULTS

In total, 374 nonelderly and 90 elderly patients with mean (SD) ages of 54.8 (12.3) and 81.3 (4.9) years and dialysis vintages of 1.8 (3.3) and 1.5 (2.9) years (P=0.47), respectively, were identified. Mean at-risk catheter-days were 272 (243) in nonelderly and 318 (240) in elderly patients. Between age groups, there were no significant differences in initial catheter site, type of catheter lock solution, or microbiology results. A total of 208 catheter-related bloodstream infection events occurred (190 events in nonelderly and 18 events in elderly patients), with a catheter-related bloodstream infection incidence per 1000 catheter-days of 1.97 (4.6) in nonelderly and 0.55 (1.6) in elderly patients (P<0.001). Relative to nonelderly patients, the hazard ratio for catheter-related bloodstream infection in the elderly was 0.33 (95% confidence interval, 0.20 to 0.55; P<0.001) after multivariate analysis.

CONCLUSION

Elderly patients on hemodialysis using tunneled central vein dialysis catheters are at lower risk of catheter-related bloodstream infection than their younger counterparts. For some elderly patients, tunneled central vein dialysis catheters may represent a suitable dialysis access option in the setting of nonmaturing arteriovenous fistulae or poorly functioning synthetic grafts.

Treatment options for renal cell carcinoma in renal allografts: a case series from a single institution

Renal cell carcinoma (RCC) is more common in renal transplant and dialysis patients than the general population. However, RCC in transplanted kidneys is rare, and treatment has previously consisted of nephrectomy with a return to dialysis. There has been recent interest in nephron-sparing procedures as a treatment option for RCC in allograft kidneys in an effort to retain allograft function. Four patients with RCC in allograft kidneys were treated with nephrectomy, partial nephrectomy, or radiofrequency ablation. All of the patients are without evidence of recurrence of RCC after treatment. We found nephron-sparing procedures to be reasonable initial options in managing incidental RCCs diagnosed in functioning allografts to maintain an improved quality of life and avoid immediate dialysis compared with radical nephrectomy of a functioning allograft. However, in non-functioning renal allografts, radical nephrectomy may allow for a higher chance of cure without the loss of transplant function. Consequently, radical nephrectomy should be utilized whenever the allograft is non-functioning and the patient's surgical risk is not prohibitive.

Early trends from the Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS)

BACKGROUND

Launched in January 2011, the prospective payment system (PPS) for the US Medicare End-Stage Renal Disease Program bundled payment for services previously reimbursed independently. Small dialysis organizations may be particularly susceptible to the financial implications of the PPS. The ongoing Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS) was designed to describe trends in care and outcomes over the period of PPS implementation. This report details early results between October 2010 and June 2011.

STUDY DESIGN

Prospective observational cohort study of patients from a sample of 51 small dialysis organizations.

SETTING & PARTICIPANTS

1,873 adult hemodialysis and peritoneal dialysis patients.

OUTCOMES

Secular trends in processes of care, anemia, metabolic bone disease management, and red blood cell transfusions.

MEASUREMENTS

Facility-level data are collected quarterly. Patient characteristics were collected at enrollment and scheduled intervals thereafter. Clinical outcomes are collected on an ongoing basis.

RESULTS

Over time, no significant changes were observed in patient to staff ratios. There was a temporal trend toward greater use of peritoneal dialysis (from 2.4% to 3.6%; P = 0.09). Use of cinacalcet, phosphate binders, and oral vitamin D increased; intravenous (IV) vitamin D use decreased (P for trend for all <0.001). Parathyroid hormone levels increased (from 273 to 324 pg/dL; P < 0.001). Erythropoiesis-stimulating agent doses decreased (P < 0.001 for IV epoetin alfa and IV darbepoetin alfa), particularly high doses. Mean hemoglobin levels decreased (P < 0.001), the percentage of patients with hemoglobin levels <10 g/dL increased (from 12.7% to 16.8%), and transfusion rates increased (from 14.3 to 19.6/100 person-years; P = 0.1). Changes in anemia management were more pronounced for African American patients.

LIMITATIONS

Limited data were available for the prebundle period. Secular trends may be subject to the ecologic fallacy and are not causal in nature.

CONCLUSIONS

In the period after PPS implementation, IV vitamin D use decreased, use of oral therapies for metabolic bone disease increased, erythropoiesis-stimulating agent use and hemoglobin levels decreased, and transfusion rates increased numerically.