Home hemodialysis: six years' experience

Half a Century of Haemodialysis: Two Patient Journeys

The history of renal replacement therapy (RRT) for end-stage kidney disease (ESKD) started in 1960 and has reached, in these six decades, goals initially unforeseen. This report describes two patients who commenced dialysis at the age of 17 and 27, for 53 and 45 years, respectively, whereby the modality of RRT was mostly in the form of home haemodialysis. The history of these two patients, who started RRT in distant parts of the world, Australia and Croatia, highlights not only the advances made over time, to significantly delay the onset and reduce the morbidity and mortality associated with ESKD, but also underlines the importance of empowerment and commitment, added values in home haemodialysis.

A need for a paradigm shift in focus: From Kt/Vurea to appropriate removal of sodium (the ignored uremic toxin)

Hemodialysis for chronic renal failure was introduced and developed in Seattle, WA, in the 1960s. Using Kiil dialyzers, weekly dialysis time and frequency were established to be about 30 hours on 3 time weekly dialysis. This dialysis time and frequency was associated with 10% yearly mortality in the United States in 1970s. Later in 1970s, newer and more efficient dialyzers were developed and it was felt that dialysis time could be shortened. An additional incentive to shorten dialysis was felt to be lower cost and higher convenience. Additional support for shortening dialysis time was provided by a randomized prospective trial performed by National Cooperative Dialysis Study (NCDS). This study committed a Type II statistical error rejecting the time of dialysis as an important factor in determining the quality of dialysis. This study also provided the basis for the establishment of the Kt/V_urea index as a measure of dialysis adequacy. This index having been established in a sacrosanct randomized controlled trial (RCT), was readily accepted by the HD community, and led to shorter dialysis, and higher mortality in the United States. Kt/V_urea is a poor measure of dialysis quality because it combines three unrelated variables into a single formula. These variables influence the clinical status of the patient independent of each other. It is impossible to compensate short dialysis duration (t) with the increased clearance of urea (K), because the tolerance of ultrafiltration depends on the plasma-refilling rate, which has nothing in common with urea clearance. Later, another RCT (the HEMO study) committed a Type III statistical error by asking the wrong research question, thus not yielding any valuable results. Fortunately, it did not lead to deterioration of dialysis outcomes in the United States. The third RCT in this field ("in-center hemodialysis 6 times per week versus 3 times per week") did not bring forth any valuable results, but at least confirmed what was already known. The fourth such trial ("The effects of frequent nocturnal home hemodialysis") too did not show any positive results primarily due to significant subject recruitment issues leading to inappropriate selection of patients. Comparison of the value of peritoneal dialysis and HD in RCTs could not be completed because of recruitment problems. Randomized controlled trials have therefore failed to yield any meaningful information in the area of dose and or frequency of hemodialysis.

Effect of incident nocturnal home hemodialysis versus incident continuous ambulatory peritoneal dialysis on employment rate, clinical, and laboratory outcomes: A 1-year retrospective observation study

INTRODUCTION

While studies demonstrated favorable outcomes of nocturnal home hemodialysis (NHHD), direct comparison on employment rate, clinical and laboratory outcomes between the NHHD and continuous ambulatory peritoneal dialysis (CAPD) had not been previously performed.

METHODS

A 1-year retrospective observation study was performed in 20 incidents alternate night NHHD and 81 incident CAPD patients of Chinese ethnicity, who were sex, diabetic status, and Charlson comorbidity index matched, but not age due to our center's age limit for NHHD enrollment. The primary outcome was the difference in employment rate at 1 year. Secondary outcomes included differences in clinical parameters (weight, blood pressure, number of antihypertensive medication, dosage of phosphate binders, and erythropoietin stimulating agent) and laboratory parameters (residual renal function, mineral metabolic markers, hemoglobin).

FINDINGS

NHHD subjects were 5 years younger than CAPD patients, and they had higher employment rate (80% vs. 33.3%, P < 0.01) at 1 year, with age-adjusted odds ratio for employment was 6.10 (95% confidence interval 1.77-20.99, P = 0.04). They consumed less aluminum-based phosphate binder (0 vs. 1800 mg, P < 0.01), but showed no significant disparities in other clinical parameters. Residual renal function in both groups declined comparably, nonetheless NHHD group had lower serum phosphate (1.37 vs. 1.71 mmol/L, P = 0.01) and calcium phosphate product (3.13 vs. 4.12 mmol² /L² , P < 0.01), with similar hemoglobin levels.

DISCUSSION

NHHD appeared to offer higher employment rate, lower dosage of aluminum-based phosphate binder and mineral metabolic markers at 1 year compared with CAPD in Hong Kong.

Chronic Hemodialysis Therapy in the West

BACKGROUND

Chronic hemodialysis (HD) in the 1960s encompassed a wide variety of prescriptions from twice weekly to five times per week HD. Over time, HD prescriptions in the West became standardized at three times per week, 2.5-4 h per session, with occasional additional treatments for volume overload.

SUMMARY

When clinical trials of dialysis dose failed to show significant benefit of extending time compared with the traditional dialysis prescription, interest in more frequent HD was renewed. Consequently, there has been growth in home HD therapies as well as alternative dialysis prescriptions. Data from recent randomized clinical trials have demonstrated the benefits and risks of these more frequent therapies, with surprising differences in outcomes between short daily HD and long nocturnal HD. More frequent therapies improve control of both hypertension and hyperphosphatemia, but at the expense of increased vascular access complications and, at least for nocturnal HD, a faster loss of residual renal function.

KEY MESSAGES

In the West, the standard HD prescription is three treatments per week with a minimal time of 3.0 h and dialysis is performed in an outpatient dialysis center. A minority of patients will have a fourth treatment per week for volume issues. Alternative HD prescriptions, although rare, are more available compared to the recent past.

FACTS FROM EAST AND WEST

(1) While developed Western and Asian countries provide end-stage renal disease patients full access to HD, healthcare systems from South and South-East Asia can offer access to HD only to a limited fraction of the patients in need. Even though the annual costs of HD are much lower in less developed countries (for instance 30 times lower in India compared to the US), patients often cannot afford costs not covered by health insurance. (2) The recommended dialysis pattern in the West is at least three sessions weekly with high-flux dialyzers. Studies from Shanghai and Taiwan might however indicate a benefit of twice versus thrice weekly sessions. In less developed Asian countries, a twice weekly pattern is common, sometimes with dialyzer reuse and inadequate water treatment. A majority of patients decrease session frequency or discontinue the program due to financial constraint. (3) As convective therapies are gaining popularity in Europe, penetration in Asia is low and limited by costs. (4) In Asian countries, in particular in the South and South-East, hepatitis and tuberculosis infections in HD patients are higher than in the West and substantially increase mortality. (5) Progress has recently been made in countries like Thailand and Brunei to provide universal HD access to all patients in need. Nevertheless, well-trained personnel, reliable registries and better patient follow-up would improve outcomes in low-income Asian countries.

Should we extend the application of more frequent dialysis schedules? A 'yes' and a hopeful 'no'

Observational studies associate long dialysis intervals with an excess risk for mortality and cardiovascular disease hospitalizations. The application alternate day dialysis is an appealing possibility to reduce the cardiovascular burden of long dialysis intervals and a small pilot study demonstrated that this regimen allows safe reduction of dry body weight, BP and left ventricular mass index. However, the actual impact of alternate day hemodialysis and of frequent hemodialysis in general on survival remains unknown. Frequent dialysis schedules may increase the risk of arteriovenous fistula problems and the burden of disease and eventually reduce treatment adherence. Furthermore we cannot safely exclude that more frequent dialysis regimens may be harmful. On the other hand increasing the duration of dialysis and/or frequency of hemodialysis in patients with refractory fluid overload, uncontrolled hypertension, hyperphosphatemia, malnutrition or cardiovascular disease is of unquestionable benefit in these problematic patients.Thus the moderators conclusion to the question being asked is a yes and a hopeful "no". Whenever and wherever possible we should pro-actively apply more frequent dialysis regimens, starting with the alternate day approach, in problematic patients. However, extensive application of frequent hemodialysis schedules is by now unjustified. Evidence that these regimens are beneficial mainly derives from observational studies and the possibility that frequent schedules are harmful cannot be excluded. A clinical trial is needed.

Anticoagulation and dialysis access practice in home haemodialysis in the UK

Anticoagulation is an important component of haemodialysis treatment in all settings. The therapeutic options available for anticoagulation of home haemodialysis are similar to those for haemodialysis in other settings. However, dialysis sessions with a wide range of treatment durations are undertaken at home, which can require different approaches to anticoagulation. Conference delegates were asked about the types of anticoagulation used in home dialysis and about surveillance strategies for monitoring vascular access, and the results are presented and discussed.

Nocturnal hemodialysis in australia

BACKGROUND

Because home hemodialysis has long been a common Australian support modality, the advent of home-based nocturnal hemodialysis (NHD) in Canada stimulated the extension of our existing home- and satellite-based conventional hemodialysis (CHD) programs to NHD. As a result, the first government-funded, home-based, 6-nights-per-week NHD program in Australia began in July 2001.

METHODS

Sixteen patients have been trained for NHD; 13 dialyzed at home 8 to 9 hr per night for 6 nights per week, whereas 3 preferred to train for NHD at home using an 8- to 9-hr alternate-night regime.

RESULTS

The program experience to March 1, 2003, was 655 patient-weeks. Two patients had withdrawn for transplantation and 2 for social reasons, although 1 continues on alternate-night NHD. There hade been no deaths. Ten patients had dialyzed without partners. All patients ceased phosphate binders at entry. Thirteen of 16 discontinued all antihypertensive drugs. There were no fluid or dietary restrictions. Phosphate was added to the dialysate to prevent hypophosphatemia. Pre- and postdialysis urea and phosphate levels were broadly within the normal ranges. All patients reported restorative sleep; similarly partners reported stable sleep patterns and noted improved mood, cognitive function, and marital relationships in their NHD partners. Preliminary cost analyses show that whereas consumables had doubled, and epoetin and iron expenditures had risen by 28.9%, other pharmaceutical costs had fallen by 47%, and nursing wage costs were 48% of the notional cost had these patients remained on CHD. Three patients on NHD were retired, 7 worked full-time, 3 worked part-time, and 3 drew disability support, whereas previously on CHD, 3 were retired, 3 had worked full-time, 3 had worked part-time, and 7 had drawn disability support.

CONCLUSION

We believe that NHD is viable, safe, effective, and well accepted with significant lifestyle benefits and reemployment outcomes. Although initial setup costs are significant, NHD cost advantage over CHD progressively accrues as program numbers exceed 12 to 15 patients.

Evolution of home hemodialysis monitoring systems

Systems for monitoring hemodialysis patients at home have evolved during the past 30 years. They consist of hardware and software to record dialysis events from the home hemodialysis machine and transmit them to a server, which in turn sends the data to a remote central monitoring center. Most of the parameters monitored are related to machine function and events. At present, the only commonly monitored patient vital functions are pulse and blood pressure. The early systems used direct telephone lines and modem for telecommunication. The use of Internet links reduces the cost of the service and provides fast and safe transmission of the data. The actual value of these monitoring systems, the need for additional monitoring options, indications for specific groups of patients dialyzing at home, and acceptance by patients, physicians, and regulators will require further evaluation.

More frequent hemodialysis: back to the future?

An increase in the length of the standard in-center hemodialysis treatment by 30 to 45 minutes per session was not associated with an improvement in mortality in long-term hemodialysis patients enrolled in the HEMO study. Testing the possibility that delivering still higher doses of hemodialysis may have a beneficial effect on patient outcomes will require the use of more frequent hemodialysis or a much longer duration for each dialysis session. "Short-daily hemodialysis," actually 6 times per week hemodialysis for 1.5 to 3 hours per session, can provide some increase in small molecule clearance as measured by urea kinetics. "Long nocturnal daily hemodialysis," actually 6 times per week hemodialysis for 6 to 8 hours per session, provides a significant increase in both small-molecular-weight and large-molecular-weight clearance and often alleviates the need to take phosphate binders. The National Institutes of Health is sponsoring 2 clinical trials via the Frequent Hemodialysis Network to determine the impact of these 2 modalities on intermediate outcomes, compared with standard 3-times-per-week hemodialysis.

The early history of dialysis for chronic renal failure in the United States: a view from Seattle

Forty-seven years have passed since the first patient started treatment for chronic renal failure by repeated hemodialysis (HD) at the University of Washington Hospital in Seattle in March 1960, and some 34 years have elapsed since the United States Congress passed legislation creating the Medicare End-Stage Renal Disease Program. Many nephrologists practicing today are unfamiliar with the history of the clinical and political developments that occurred during the 13 years between these 2 dates and that led to dialysis as we know it today in this country. This review briefly describes these events. Clinical developments following introduction of the Teflon shunt by Belding Scribner and Wayne Quinton included empirical observations leading to better understanding of HD and patient management, out-of-hospital dialysis by nurses, bioethical discussions of the problems of patient selection, home HD, improved dialysis technology, intermittent peritoneal dialysis, including automated equipment for home use and an effective peritoneal access catheter, the arteriovenous fistula for more reliable blood access, dialyzer reuse, the first for-profit dialysis units, understanding of many of the complications of treatment, the first considerations of dialysis adequacy, early development of other technologies, and more frequent HD. Political developments began less than 3 years after the first Seattle patient began dialysis, but it took another 10 years of intermittent activities before Congress acted on legislation to provide almost universal Medicare entitlement to patients with chronic kidney disease requiring dialysis or kidney transplantation.

Mortality risk factors in chronic haemodialysis patients with infective endocarditis

BACKGROUND

It is well documented that infective endocarditis (IE) is strongly associated with morbidity and mortality in haemodialysis (HD) patients. Less clear are the mortality risk factors for IE, particularly in an urban African-American dialysis population.

METHODS

IE patients were identified from the medical records for the period from January 1999 to February 2004 and confirmed by Duke criteria. The patients were classified as 'survivors' and 'non-survivors' depending on in-hospital mortality, and risk factors for IE mortality were determined by comparing the two cohorts. Survivors were followed as out-patients with death as the endpoint.

RESULTS

A total of 52 patients with 54 episodes of IE were identified. A catheter was the HD access in 40 patients (74%). Mitral valve (50%) was the commonest valve involved, and Gram-positive infections accounted for 87% of IE. In-hospital mortality was high (37%) and valve replacement was required for 13 IE episodes (24%). On logistic regression analyses, mitral valve disease [P = 0.002; odds ratio (OR) = 15.04; 95% confidence interval (CI) = 2.70-83.61] and septic embolism (P = 0.0099; OR = 9.56; 95% CI = 1.72-53.21) were significantly associated with in-hospital mortality. Using the Cox proportional hazards model, mitral valve involvement (P = 0.0008; hazard ratio 4.05; 95% CI = 1.78-9.21) and IE related to drug-resistant organisms such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus sp. (P = 0.016; hazard ratio 2.43; 95% CI = 1.18-5.00) were associated with poor outcome after hospital discharge.

CONCLUSIONS

IE was associated with high mortality in our predominantly African-American dialysis population, when the mitral valve was involved, or septic emboli occurred and if MRSA or VRE were the causal organisms.

Nocturnal haemodialysis in Australia and New Zealand (Review Article)

Although early experience in Australia and New Zealand confirmed home haemodialysis to be well tolerated, effective and with lower morbidity and mortality compared with centre-based haemodialysis, the advent of ambulatory peritoneal dialysis and 'satellite' haemodialysis has led to a steadily declining home haemodialysis population. However, the emergence of nocturnal haemodialysis, as a safe and highly effective therapy, has added to the modality choices now available and offers a new, highly attractive home-based option with many advantages over centre-based dialysis. For the patient, nocturnal haemodialysis means fluid and dietary freedom, less antihypertensive medication, the abolition of phosphate binders, the return of daytime freedom and the capacity for full-time employment. Potential biochemical benefits include normalization of the blood urea, serum creatinine, albumin, beta(2) microglobulin, homocysteine and triglyceride levels and other nutritional markers. Improved quality of life and sleep patterns and a resolution of sleep apnoea have been shown. Left ventricular function has also shown marked improvement. For the provider, nocturnal home haemodialysis offers clear cost advantages by avoiding high-cost nursing and infrastructure expenditure. Although consumable and equipment costs are higher, the savings on wage and infrastructure far outweigh this added expenditure. These combined factors make nocturnal haemodialysis an irresistible addition to comprehensive dialysis services, both from a clinical outcome and fiscal perspective.

Home haemodialysis: 'home, home, sweet, sweet home!' (Review Article)

Home haemodialysis was first developed 40 years ago as a means of treating more patients with the limited funds then available. It soon became obvious that the treatment worked well and subsequent studies and experience have confirmed that it improves both mortality and morbidity and provides the best quality of life and other benefits for dialysis patients. The present review describes the history of the development of home haemodialysis in Seattle and elsewhere and the lessons learned about its benefits in the early days, which are just as relevant today. The advantages and disadvantages are discussed, as are the issues of which patients are candidates for this treatment and what is required of a home haemodialysis training and support programme. The decline in use of home haemodialysis in the USA and elsewhere is described and the actions that may already be beginning to reverse this trend. The role of home haemodialysis in giving the opportunity for longer hours of dialysis three times a week or on alternate nights is important. There is discussion of the relationship of home haemodialysis and peritoneal dialysis and its important future role as the means to enable treatment with more frequent short daily and long nightly haemodialysis.

Hemodialysis catheter-associated endocarditis: clinical features, risks, and costs

Endocarditis associated with vascular access catheters for hemodialysis (HD) is a catastrophic but not widely appreciated phenomenon. Its current incidence, clinical outcome, and associated costs are not easily ascertained. Increasing use of tunneled catheters for HD access may result in a larger pool of patients at risk for endocarditis. We present two representative cases, review recent trends, and assess the current potential for additional cases.

A brief history of home hemodialysis

Home hemodialysis for the treatment of end-stage renal disease was first developed in the early 1960s. Because of the benefits and cost-effectiveness, this modality of treatment was increasingly used; by 1973, when the Medicare End-Stage Renal Disease Program began, approximately 40% of all dialysis patients in the United States were on home hemodialysis. Since then, both the percentage and the number of patients on this treatment has steadily decreased, and such patients now comprise approximately 1.3% of the US dialysis population. Nevertheless, there has been a recent resurgence of interest in home hemodialysis, particularly related to reports of excellent results with daily home hemodialysis and the development of new equipment specifically designed for use in the home. Thus, this modality of treatment may be used more widely in the near future.

Nosocomial infections in the pediatric patient: an update

Substantial progress has been made in measuring the burden of nosocomial infection in pediatric patients, particularly in certain populations (e.g., critical care, immunocompromised, chronic care, and patients with acquired immunodeficiency syndrome) and after certain procedures (e.g., central catheter lines and open-sternum cardiovascular surgery). Preventive measures, such as the use of goggles, gowns, and gloves, have been subjected to new and additional study. The following report is a summary of recent progress. A review of factors responsible for infection in various patient care populations and settings and recommendations for control are presented.

Emergencies in continuous dialysis patients: diagnosis and management

The number of patients undergoing long-term hemodialysis and peritoneal dialysis is growing in the United States. To provide adequate emergent care to these patients emergency physicians must understand the alterations in normal physiologies present in these patients and how this may affect care. Cardiovascular disease and infection (especially Staphylococcus aureus sepsis) are the leading causes of death among dialysis patients. These patients are also subject to a significantly higher incidence of life-threatening electrolyte disturbances, particularly hyperkalemia and hypercalcemia, than the general population. Suicide, cardiac tamponade, intracranial hemorrhage, bleeding disorders, and bowel infarction are also much more frequent. The inability of dialysis patients to excrete drugs, metabolites, toxins, and fluids significantly alters their responses to common emergencies and should directly influence their care. Failure to recognize these differences in physiology may result in the use of standard forms of emergency therapy that may compound, rather than treat, the underlying disorder. Although most dialysis patients who come into an emergency department have conditions that can, and should, be managed by their nephrologist, the presence of a life threatening emergency requires prompt, appropriate therapy by the emergency physician.

The efficacy of ambulatory cardiac catheterization in the hospital and free-standing setting

The optimal site for performing cardiac catheterization depends upon complications of the procedure, access to care in the event of complications, costs, quality of the catheterization studies, access to the procedure, and patient satisfaction. Performing ambulatory cardiac catheterization at or adjacent to a hospital may assume equivalent access to emergent or urgent services, equivalent quality, and improved patient satisfaction at reduced cost for low-risk patients (stable coronary symptoms, no active congestive heart failure, no significant arrhythmias, and no significant comorbid factor--bleeding diathesis, renal insufficiency, uncontrolled systolic hypertension). However, moving an outpatient catheterization from the hospital site to a free-standing unit, physically remote from a hospital, may be associated with a reduction in access to emergency care and less standardized quality assurance.

Evaluation of antibiotics for home care programs

A number of antimicrobial agents have been used successfully to treat patients with chronic infectious diseases in the home health care environment. This diversity in types of antibiotics used reflects more than ten years' development of active home medical care programs. With continuing experience, it is clear that the number and types of antibiotics available on formulary for routine use in home programs can be condensed. Since a patient should in most cases be treated in the home environment with the same antibiotic that has demonstrated efficacy and safety upon initial therapy during hospitalization, the selection of available antibiotics will affect the hospital's formulary selection process. This process must critically evaluate the documented efficacy and safety of each agent, since the drug's primary use will be in a relatively uncontrolled environment, devoid of continuous professional assessment. The beta-lactam antibiotics appear to be preferred agents for outpatient use, particularly as monotherapy. These agents offer desirable in vitro activity and potency, ease of administration, overall efficacy, and safety. However, despite a preference for beta-lactam antibiotics, additional and alternative agents must be routinely available in program formularies.

Sex Selection Bias in Choosing a Dialysis Therapy

This investigation has sought to determine reasons for the disproportionately higher number of females entering CAPD as opposed to home hemodialysis. A sample of 295 home dialysis patients, 97 women and 198 men, were compared in terms of modality of choice, baseline demographic characteristics, treatment outcome, and quality of life. The results indicate that there is no apparent rationale for the current selection basis.

Treatment bias in the management of end-stage renal disease

A study was conducted of 419 patients with end-stage renal disease (ESRD) being treated by center or home hemodialysis or by renal transplantation at four facilities located within 2.5 km of each other. The objectives were to examine the distribution of patients among the three modes of treatment and to analyze patient transfers to alternate modes of ESRD therapy. While white patients at each facility were comparable (P greater than 0.05) on age, sex, travel time to treatment, marital status, work or employment status, and the presence of diabetes mellitus, the distribution of patients among the treatment modes differed significantly (P less than 0.001) across the facilities. Similarly, the sociodemographic and diagnostic characteristics of the nonwhite patients were comparable at each of the facilities (P greater than 0.05); however, despite observable variation among the facilities in the distribution of these patients, the differences did not achieve statistical significance (P greater than 0.05). Patient transfers to alternate modes of ESRD therapy were infrequent, and among center hemodialysis patients, the distribution of transfers differed significantly across the facilities (P less than 0.001). It is concluded that the distribution of patients was dependent on the patient's initial mode of therapy and the staff attitudes at the individual facilities.

Pain, control over treatment, and compliance in dialysis and transplant patients

Pain was surveyed via structured interview and the McGill Pain Questionnaire in 53 dialysis and 27 transplant patients. Increased patient control over the dialysis procedure was not associated with a reduction in pain though perceived control may have been. Compliance with the dialysis regimen did not predict pain and the validity of the category "dialysis headache" was questioned. Overall, transplant recipients did not report significantly less pain than dialysis patients. Self-reported depression was correlated positively with pain. The clinical implications of these findings are discussed.

Physical activity and employment status of patients on maintenance dialysis

Existing data on the clinical outcome of maintenance dialysis for end-stage kidney disease focus mainly on the duration of life. We surveyed 18 dialysis centers to gain a broader overview of the current status of 2481 patients on dialysis, irrespective of the type or location of dialysis. The results suggest that 12 per cent of dialysis patients are diabetics and that 53 per cent are 50 years of age or older. There was considerable variation among centers in the degree of rehabilitation; nevertheless, only 60 per cent of the nondiabetic patients and 23 per cent of the diabetic patients were capable of a level of physical activity beyond that of caring for themselves. Only one quarter of the patients worked outside the home, whereas one third worked at home. These results suggest that a larger proportion of dialysis patients than previously suspected are severely debilitated. There is a need for improved data on the quality and length of life of patients on maintenance dialysis.

Mechanism and prevention of cardiac arrhythmias in chronic hemodialysis patients

We monitored, by the Holter method, 23 clinically stable maintenance hemodialysis patients for 5 +/- (SEM) 2 hours before hemodialysis, 5.0 +/- 0.5 hours during hemodialysis, and 13 +/- 3 hours after hemodialysis. Of 23 patients, 9 (39%) had unexpected frequent or complex ventricular arrhythmias recorded and after hemodialysis with a potassium dialysate bath concentration of 2.0 mEq/liter. Patients with ventricular arrhythmias were more likely to be using digoxin (8/9 vs. 1/4) and to have evidence of left ventricular hypertrophy (9/9 vs. 7/4 than were those patients without arrhythmias. Of these 9 patients with arrhythmias, 6 underwent repeat Holter monitoring during multiple dialysate protocols. Of the 6 patients, 4 had a significant reduction in the frequency of ventricular ectopy when a dialysate of 3.5 mEq/liter potassium was used (P < 0.05), but of these 6, 3 still had complex arrhythmias. The use, however, of a 3.5 mEq/liter potassium dialysate plus the administration of a 400-mg dose of quinidine sulfate orally 45 min prior to hemodialysis was successful in reducing ventricular ectopic frequency and complexity in all the patients studied. Conclusion. Maintenance hemodialysis patient using digoxin and with left ventricular hypertrophy have an unexpectdly high indicence of occult, potentoial serious, ventricular arrhythmias during and after hemodialysis, revealed by Holter monitoring. There is preliminary evidence that a low-potassium bath concentration may play a role in predisoposing patients to these arrhythmias. Further prospective studies with largaer number of patients will be needed, however, to evaluate the significance of these findings.

Potential effect of self-care algorithms on the number of physician visits

To assess the potential effect of self-care algorithms on the number of physician visits, actual visits from the Seattle Virus Watch were compared retrospectively with those recommended by clinical algorithms for common illnesses from the book, Take Care of Yourself, by Vickery and Fries. From a total of 3929 illnesses, records indicating the presence of the index symptom for eight algorithms were identified, determining whether the criteria for seeing a physician were met and whether a physician visit was recorded. The number of visits observed was compared to the number of visits recommended by the algorithms. Strict adherence would have increased the number of visits over that observed for five, remained the same for two, and decreased for one of the algorithms. These results indicate that adherence to some commonly promulgated self-care algorithms may increase rather than decrease the number of physician visits.

Pediatric home care: an ambulatory "special care unit"

A pediatric home care program is described which has operated as an ambulatory special care unit in an urban hospital center since 1970. The program provides care for seriously or chronically ill children, who would not be adequately served through traditional ambulatory services because of either the severity and complexity of their medical problems or the inability of their families to use such services. An interdisciplinary PHC team provides comprehensive pediatric care and integrates medical and psychosocial services for the child and family. This form of special ambulatory care appears to offer advantages to patients who are at risk in existing ambulatory schemes and is an alternative to inpatient care.

Predicting treatment costs and life expectancy for end-stage renal disease

To estimate the cumulative 10-year direct medical costs and life expectancy associated with different methods of treatment for end-stage renal disease, we assessed predictively three treatment transition options. It is predicted that if 1000 patients shift from facility to home dialysis for each of 10 years, life expectancy of the cohort will not be reduced, but there will be a reduction of $241 million in total costs. The same number shifting from facility dialysis to cadaveric transplantation are predicted to have a $279 to $330 million reduction in total costs but a reduction of 7 to 17 per cent in life expectancy. Shifting from home dialysis to transplantation is predicted to reduce total costs by +103 to $142 million, and life expectancy by 10 to 20 per cent. As new program policies for treatment of end-stage renal disease are developed, their effect on both costs and life expectancy needs to be considered.

Analysis and outcome of 1063 patients trained for home hemodialysis

Between 1967 and 1973, 12 home dialysis training centers (HDTC), under contract to the health Resource Administration, Department of Health, Education, and Welfare, reported training 1063 patients. Mean training time was 69 days; mean patient age was 40 yr with a range of 12 to 75 yr. Survival rates were 87% at one year, 74% at two years, 62% at three years, 54% at four years and 52% at five years. Male to female ratio was 3.2; there was no significant survival difference between sexes. Patients under 50 yr of age had significantly greater survival than did patients 50 yr and older. A "good" health status classification, defined by activity tolerance, signs and symptoms at the beginning of home dialysis, was associated with more favorable survival than were lower health ratings. Patients with glomerulonephritis, pyelonephritis and polycystic disease had better survival than did patients with diabetic, hypertensive and other renal disease etiologies. Although 51% of the patients lived 50 to 400 or more miles from the HDTC, their survival was not different from patients living less than 50 miles from the HDTC. Survival rates for patients with less than ten years of education were not significantly different from those with formal education as high as the university graduate level. Forty-seven percent of the patients were restored to full activity. These survival results are comparable with those reported for other modes of dialysis and transplantation and indicate that home dialysis is an acceptable form of therapy for a variety of patients.

The dialysis patient and attitudes towards work

Home dialysis is considered as work and as the home patient's main job. Reasons for the belief of many staff members that employment is the only acceptable form of work and some of the effects this has on patient attitudes and planning are discussed. The physical and emotional stresses under which dialysis patients have to live are described as being similar to those of soldiers in combat. Helping patients to develop and utilize financial and other resources is viewed as an aid in reducing the incidence of “combat fatigue” and as fostering positive patient-staff relationships. The advantages of staff members' confining performance expectations as much as possible to the treatment area and of helping patients to maintain direction and control of their personal affairs, including decisions concerning employment, are stressed.