|
Article Excerpt
Clinical research continues to increase nurses' understanding of the factors that affect outcomes in patients on dialysis. However, despite this wealth of data and corresponding improvements in technological and therapeutic treatment options, mortality rates in patients on dialysis continue to be significantly higher than they are in the general population. For example, among prevalent patients who are 65 years of age and older and are on dialysis, mortality rates are six times higher than they are for individuals of the same age in the general population (United States Renal Data Service, 2008).
The highest risk of mortality is often observed at the initiation of dialysis, especially in the first 3 months. An analysis conducted by the Dialysis Outcomes and Practice Patterns Study (DOPPS) assessed early mortality rates among 4802 patients who initiated hemodialysis between 1996 and 2004 (Bradbury et al., 2007). In this analysis, 17.5% of the patients died during the first year of dialysis, with 46% of these deaths occurring within the first 120 days.
Individual patient characteristics play a significant role in survival. However, analyses of data from large epidemiological studies encompassing hundreds of thousands of patients on dialysis indicate that outcomes can also be significantly affected by factors that can be modified by clinical practice patterns (Port, Pisoni et al., 2004). This article provides an overview of the association between patient outcomes and modifiable components of care that are influenced by day-to-day nursing practices, such as vascular access, dialysis dose, albumin levels, interdialytic weight gain (IDWG), anemia, and mineral and bone disorders.
Vascular Access and Patient Outcomes
Decades of clinical data have confirmed the association between vascular access type and outcomes in patients on dialysis. The representative U.S.-based Choices for Health Outcomes in Caring for ESRD (CHOICE) study, for example, reported survival data for 616 patients for up to 3 years after hemodialysis was initiated (Astor et al., 2005). Overall, 1084 accesses were used over this period (185 arteriovenous [AV] fistulae, 296 AV grafts, and 603 central venous catheters) for a total of 1381 person years of vascular access exposure. Patients who dialyzed with a central catheter or AV graft rather than an AV fistula had an adjusted relative hazard of death that was 47% and 21% higher, respectively.
Data also indicate that the choice of vascular access can affect the risk for early mortality at the initiation of dialysis. The DOPPS assessed a randomized, stratified selection of 4802 evaluable patients who were receiving hemodialysis in the United States between 2001 and 2004 to determine the risk of early death among those starting dialysis with a catheter versus an AV fistula (Bradbury et al., 2007). A survival analysis using logistic regression was used to test for differences in mortality rates for early versus late periods (0 to 120 days versus 121 to 365 days). Compared with patients dialyzing with an AV fistula, those dialyzing with a catheter had a 71% increase in the risk of mortality during the first 120 days and a 42% increase in the risk of mortality between 121 and 365 days after initiating dialysis.
Data have also shown that patients dialyzing with synthetic grafts rather than AV fistulae experience an alarming increase in the frequency of stenosis, thrombosis, and infection requiring a 2.4 to 7.1-fold higher frequency of salvage procedures (angioplasty, thrombectomy, or surgical revision) (Allon & Robbin, 2002) and significantly higher rates of hospitalization (Centers for Medicare & Medicaid Services [CMS], 2004). Even more dismal statistics are associated with the use of catheters. For example, dialysis facilities with more than 28% of patients using catheters have a 28% increase in the risk of all-cause hospitalization (P = 0.01) and a 63% increase in the risk of hospitalization for access repair, septicemia, or infection (P= 0.001) (Pisoni et al., 2001).
Although fistula placement has increased since the advent of the Fistula First program, there is a significant difference between AV fistula placement and use among patients on hemodialysis. For example, while 57.7% of patients on hemodialysis had a fistula placed, only half were using it for dialysis. In addition, the increase in fistula placement and corresponding decrease in AV grafts has been accompanied by a troubling increase in the use of temporary and permanent catheters (Fistula First, 2009; Spergel, 2008).
Data from the DOPPS reveal the potential impact that a nurse advocate can have on patient acceptance of AV fistulae. In an analysis of 133 U.S. dialysis facilities, patients were more than twice as likely to use a graft instead of a fistula if their nephrologist or nurse preferred grafts over fistulae (adjusted odds ratio = 2.3; P< 0.01) (Young et al., 2002). These...
|
