The following authors of NN&I’s March 2013 cover story, “Reducing rates of hospitalizations by objectively monitoring volume removal,” collaborated on the answers:
Tom F. Parker, III, MD, chief medical officer for Renal Ventures Management • Raymond Hakim, MD, professor of medicine at Vanderbilt University School of Medicine • Allen R. Nissenson, MD, the chief medical officer of DaVita • Franklin W. Maddux, MD, the chief medical officer at Fresenius Medical Care • Richard Glassock, MD, emeritus professor of medicine at the Geffen School of Medicine at the University of California at Los Angeles
Question: What do you think is the biggest barrier to meaningful improvements in outcomes for dialysis patients?
Answer: The barriers are the current models of care with emphasis on measures that do not translate to significantly improved outcomes. It is unlikely that continuing to tweak anemia, metabolic bone disease, and another way to calculate Kt/V will measurably change mortality, hospitalizations, or quality of life, since the major causes of mortality and hospitalizations in ESRD are cardiovascular and often related to fluid overload. The other barriers to meaningful improvements in outcomes of dialysis patients are the high use of catheters as access and the emphasis on dialyzing patients in as short a time as possible, leading to rapid fluid removal and cardiovascular instability.
Q: The article talks about moving away from the renal diet to a more focused diet. Can you expand on this? Is the renal diet to broad?
A: The renal diet has mostly focused on calories, nitrogen, and phosphorous control, with equal or less emphasis on sodium and water. Sodium and water should be moved to the forefront. In addition, it must be recognized that the caloric and protein intake of patients is, on average, below recommended guidelines, and therefore, encouraging increased dietary intake should be considered. Finally, we must begin to account for the significant losses of amino acid during dialysis and attempt to replace those losses as quickly as possible, possibly with nutritional supplements provided during dialysis.
Q: What needs to be done to make extra-cellular volume assessment a model for “optimal” dialysis, rather than relying on Kt/V alone?
A: Currently, normalized extracellular volume is subjectively determined by the physician, usually without rigorous clinical exam and very infrequently. This is called “dry weight.” It is usually determined by making the patient hypovolemic during dialysis, inducing intradialytic symptoms and cardiac stunning, and is not re-assessed frequently enough, for example after hospitalizations or other acute events. There has been little attention to using objective techniques. These techniques are beginning to emerge and the caregiver needs to move from subjective, traditional education and making the patient sick during dialysis, to more objective methodologies performed more frequently.
Q: What is an important message you want our readers to get from your article?
A: Reliance on Kt/V to determine sufficient dialysis is no longer acceptable. Equal or greater attention to volume control using objective assessment, as well as the rate of fluid removal (not to exceed 10 ml/kg/hour) is essential to improving outcomes, such as mortality, hospitalizations and rehospitalizations, and quality of life.