...unclear. Quality often framed in terms of the high percentage of patients receiving Kt/V of greater than 1.2 or 1.4. The unfortunate inference here is that high quality hemodialysis care is defined as the waste clearing service of the urea molecule. Defining quality in this narrow way conflicts with the caring and compassionate nursing ethic. Furthermore, it places a high value on a single mathematically derived formula that ignores many other indicators of quality dialysis care. In this article, the authors examine some historical, political, and technical features of Kt/V and use the metaphor of a hangover to illustrate the overuse of Kt/V, arguing that nurses have embraced Kt/V at the expense of other core elements of dialysis nursing care

Kt/V (Over)Use

Since Kolff's first successful human dialysis treatment in 1944, there have been attempts to identify a gold standard marker of dialysis dose. The first evidence of the quantification of dose was reported in 1951 by Wolf, Remp, Kiley, and Currie (Henderson, 2004). Further developments throughout the 1960s and 1970s culminated in the National Cooperative Dialysis Study (NCDS) which established that a single pool Kt/V (spKt/V) of less than 1.0 is associated with increased patient mortality (Gotch & Sargent, 1985). Kt/V can be defined as the amount of urea clearance (K) multiplied by time (t) and divided by urea distribution volume (V). Current KDOQI, European, and Australian nephrology guidelines (CARI) suggest that the target dose of dialysis is a single pool Kt/V (spKt/V) of 1.4 or a urea reduction ratio (URR) of 70% (Kerr, Perkovic, Petrie, Agar, & Disney, 2005).

The acceptance and application of Kt/V as the measure of choice in the delivery of dialysis has been reflected in the large amount of medical literature committed to it. There has been far less discussion devoted to criticisms of Kt/V and to encouraging an approach to quality that includes more than Kt/V. Twardowski (2003 a,b) encouraged the implementation of other priorities in dialysis treatment such as blood pressure control, longer treatment times, limited ultrafiltration rates, absence of phosphate binders, normalized pre-dialysis bicarbonate and potassium levels, well-nourished patients, avoidance of inflammatory stimulation, and the minimization of middle molecules. Optimizing patient quality of life falls second to incenter, prescription-focused treatment schedules. Dialysis care requires caring clinicians with a high level of interpersonal skills who realize the unique individual needs of each patient on dialysis (Henderson, 2004). However, the above arguments discussing alternative measures of quality have been dominated by the literature examining the most accurate methods for measuring Kt/V (Bosticardo, Avalle, Giacchino, & Alloatti, 1995; Covic, Goldsmith, Hill, Venning, & Ackrill, 1998; Daugirdas, 1993; Kovacic, Rogulijic, Jukic, & Kovacic, 2003; Maduell et al., 1997; Yanai et al., 1993; Ziolko, Pietrzyk, & GrabskaChrzastowska, 2000).

The current use of Kt/V as the quality indicator of choice is an example of the development of knowledge influenced by doctors, scientists, and nephrology nurses. We concur with Blake (2003) who suggested that Kt/V has been embraced enthusiastically because it is scientific and measurable, and that few people (particularly patients) other than doctors, scientists, and nurses understand it. The measurable characteristic of Kt/V has been appealing to administrators, managers, and quality coordinators because of its ease of measurement and reporting characteristics. Furthermore, as nephrology clinicians, we can point to the benchmarked target outcomes presented in various...

NOTE: All illustrations and photos have been removed from this article.



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