Prevalence of Anti-Erythropoietin Antibodies in Hemodialysis Patients without Clinical Signs of Pure Red Cell Aplasia

BACKGROUND/AIMS

The prevalence of anti-erythropoietin antibodies in renal patients without clinical evidence of pure red cell aplasia (PRCA) who respond poorly to epoetin is unknown. This study tested for anti-erythropoietin antibodies in hemodialysis patients who were either hypo- or normoresponsive to epoetin treatment.

METHODS

Epoetin hyporesponsiveness (hemoglobin < or =10.5 g/dl and epoetin > or =9,000 IU/week) and normoresponsiveness (hemoglobin >10.5 g/dl and epoetin <7,000 IU/week) were arbitrarily defined. Prevalence of anti-erythropoietin antibodies in hemodialysis patients without symptoms of PRCA was determined by screening sera of 536 patients from 35 German KfH dialysis units, using enzyme-linked immunosorbent assay (ELISA). Positive results were verified by radioimmunoprecipitation assay (RIP) and neutralizing activity was determined by bioassay.

RESULTS

Anti-erythropoietin antibodies were detected in 3 hyporesponsive and 3 normoresponsive patients using ELISA. One patient per group was verified as borderline by RIP testing; the other 4 were negative. The bioassay was negative for 1 patient; the other died unrelated to PRCA before testing. Follow-up with RIP testing after 15 months under continuous epoetin treatment was negative (4 patients, 2 deceased).

CONCLUSION

This survey did not identify anti-erythropoietin antibodies in hemodialysis patient's hyporesponsive to epoetin and does not support presumptive antibody screening as a routine work-up in these patients.

[Shared decision-making as a new quality indicator in nephrology: a nationwide survey in Germany]

BACKGROUND AND PURPOSE

Shared decision-making (SDM) as a model in physician-patient interaction is gaining relevance in the German health system. By applying this model, mid- and long-term improvements are expected especially in the outcomes of chronic diseases. Up to now, there has hardly been any empirical data available in German health services research regarding the state and development of SDM. This study establishes a baseline and provides actual data on this subject based on a German-wide survey of end-stage renal disease (ESRD) patients.

METHODS

Standardized German-wide survey of 6,614 patients with ESRD. The questionnaire included an instrument to measure the patients' perceived involvement in care (PICS) which had been translated and validated before.

RESULTS

82% of the questioned patients feel their physicians facilitated involvement in decision making. 81% of the patients actively inform themselves concerning their disease and treatment options. 69% state that SDM has taken place. Age, years on dialysis and gender correlate with perceived involvement.

CONCLUSION

This paper provides a valid baseline for the prospective research of SDM in ESRD. The results indicate that dialysis patients are willing to participate in the process of medical decision-making. Characteristics and preferences of the patients should be taken into account not only in everyday clinical interactions. They could be monitored systematically within the framework of quality management and used as potential for quality improvement.

[Guideline-based medical quality management in dialysis. Motivation and structuring of a quality-management system and integration of earlier disease stages of chronic renal failure]

BACKGROUND AND PURPOSE

Health services are challenged by increasingly complex medical processes and economic restraints in an aging population. Under these circumstances, medical quality management is developed and increasingly applied to survey especially complex and expensive clinical processes in the sense of controlling. In this process, practicability and relevance are fundamental.

METHODS

This paper presents the well-established quality management system QiN (quality in nephrology) in the context of dialysis in end-stage renal disease.

RESULTS

A quality-management system is well applicable in the case of dialysis. It can positively influence relevant indicators of process and outcome quality, as demonstrated here by the example of dialysis quantity.

CONCLUSIONS

Outcome and process quality in dialysis are quantifiable via defined indicators oriented on evidence-based medicine. The program based on benchmarking of basic clinical indicators leads to improved care of dialysis patients. A quality-management program of this type can represent an essential component of interdisciplinary, structured treatment programs, thereby influencing the whole treatment process.

Evidence-based medical quality management in dialysis - Part I: Routine implementation of QiN, a German quality management system

Increasing medical complexity, centrifugal forces of medical subspecialization and growing economic constraints are the key reasons for the introduction of quality management into routine care processes such as dialysis. Adequate quality assurance and improvement must be implemented in order to supply medical staff, care providers, and patients with the necessary information on critical issues of clinical management of dialysis patients. QiN (Quality in Nephrology), the quality management program of the largest German dialysis provider, is outlined here as a practicable example. The first of 2 parts provides information on the structure, implementation of QiN and achieved clinical improvement in routine care. The second part (quotation) analyzes longitudinal data in order to differentiate whether observed improvements during more than 5 years of QiN can be ascribed to the intervention (application of QiN) or whether they are due to other factors such as generally improved medical knowledge.

Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database

Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PortoPH) are pulmonary vascular consequences of advanced liver disease associated with significant mortality after orthotopic liver transplantation (OLT). Data from 10 liver transplant centers were collected from 1996 to 2001 that characterized the outcome of patients with either HPS (n = 40) or PortoPH (n = 66) referred for OLT. Key variables (PaO2 for HPS, mean pulmonary artery pressure [MPAP], pulmonary vascular resistance [PVR], and cardiac output [CO] for PortoPH) were analyzed with respect to 3 definitive outcomes (those denied OLT, transplant hospitalization survivors, and transplant hospitalization nonsurvivors). OLT was denied in 8 of 40 patients (20%) with HPS and 30 of 66 patients (45%) with PortoPH. Patients with HPS who were denied OLT had significantly worse PaO2 compared with patients who underwent transplantation (47 vs. 52 mm Hg, P <.005). Transplant hospitalization survival was associated with higher pre-OLT PaO2 (55 vs. 37 mm Hg; P <.005). MPAP was significantly higher (53 vs. 45 mm Hg; P <.015) and PVR was significantly worse (614 vs. 335 dynes. s. cm(-5); P <.05) in patients with PortoPH who were denied OLT compared with patients who underwent transplantation. Transplant hospitalization mortality was 16% (5/32) in patients with HPS and 36% (13/36) in patients with PortoPH. All of the deaths in patients with PortoPH occurred within 18 days of OLT; 5 of the 13 deaths in patients with PortoPH occurred intraoperatively. We concluded that patients with HPS (based on a combination of low PaO2 and nonpulmonary factors) and patients with PortoPH (based on pulmonary hemodynamics) were frequently denied OLT because of pre-OLT test results and comorbidities. For patients who subsequently underwent OLT, transplant hospitalization mortality remained significant for both those with HPS (16%) and PortoPH (36%).

Anti-neutrophil cytoplasmic antibodies (ANCA) directed against bactericidal/permeability increasing protein (BPI): a new seromarker for inflammatory bowel disease and associated disorders

It was our purpose to determine the immunodiagnostic value of ANCA directed against BPI in diseases known to be associated with ANCA, such as ANCA-associated vasculitides, inflammatory bowel disease (IBD) and the associated condition primary sclerosing cholangitis. The immunoreactivity of recombinant PBI (rBPI) was established in order to develop an ELISA specific for rBPI. By means of this assay, BPI-ANCA were assessed in sera of 178 patients with IBD or the associated disorder primary sclerosing cholangitis, 112 patients with ANCA-associated vasculitides, and in sera of 182 disease and 140 health controls. BPI-ANCA were found to be closely associated with IBD and primary sclerosing cholangitis (34% and 44% of ANCA-positive sera, respectively). By contrast, BPI-ANCA positivity was low (<10%) in the double-negative sera of patients with ANCA-associated vasculitides and in disease and health controls. BPI-ANCA appear to constitute an important marker for IBD and primary sclerosing cholangitis, but not for the ANCA-associated vasculitides.