Cost-effectiveness analysis of the treatment of end-stage renal disease in Brazil

Cost-effectiveness analysis compared four treatments of end-stage renal disease in Brazil: continuous ambulatory peritoneal dialysis (CAPD), in-center hemodialysis (HD), cadaver donor transplantation (CD-Tx), and living related donor transplantation (LR-Tx). After 2 years, the costs per year of survival were CAPD, $12,134; HD, $10,065; CD-Tx, $6,978; and LR-Tx, $3,022. The HD cost was lower than CAPD partially because of the reuse of hemodialyzers in Brazil. Although less cost-effective, both dialysis treatments yielded more years of survival after 2 years. This analysis reveals a trade-off between cost per year of survival and years of survival.     

Patients' decisions for treatment of end-stage renal disease and their implications for access to transplantation

Gaining access to kidney transplantation is a complex process that involves treatment decisions made by patients. Despite several advantages of kidney transplantation, some patients choose to remain on hemodialysis for treatment of end-stage renal disease. The present study was undertaken to describe the sociocultural factors influencing patients' decisions to remain on dialysis compared to those who sought a transplant. The study also examined whether African Americans made decisions different from European Americans which would offer insights into one of many factors resulting in them receiving disproportionately fewer kidney transplants. Using a qualitative approach supplemented by a quantitative approach, interviews employing open-ended questions and a card sort technique were conducted with 79 hemodialysis patients. Patients who preferred to remain on dialysis were significantly older and more likely to be unmarried and Protestant. The relationship between treatment decisions and ethnicity was inconclusive due to multiple, interrelated covariates. The three most common reasons patients reported for remaining on dialysis included: doing well on dialysis, fear of being "cut on" from a transplant, and knowing other patients whose kidney transplant failed. This study identified sociocultural and ethnomedical beliefs and values about the body and transplantation that inform patients' treatment decisions. This study also generated data that illuminate the complexity of patients' decisions and how these affect patients' preferences regarding transplantation. The results emphasize the need for policy makers to recognize patients' decisions when accounting for alleged difficulties in gaining access to transplantation.     

Rehabilitative training program for end-stage renal disease patients

Muscle mass, force, cardiorespiratory (aerobic) endurance, cardiovascular risk status, quality of life and even the efficiency of hemodialysis improves by a weekly 2-3 times 30-60 minute training program at 45-60 percent intensity in end-stage renal disease patients. The exercise can also be performed during the hemodialysis. Respecting the contraindications and limiting factors, most of the renal patients could gain advantages by regular exercise programs.     

临床路径在终末期肾脏病患者中的应用

目的探讨临床路径在终末期肾病患者中的应用效果。方法将60例终末期肾脏病患者随机分为路径组30例和非路径组30例,路径组采用制定好的临床路径实施诊疗、护理工作,非路径组采用传统方法进行诊疗,比较2组病人平均住院时间、平均住院费用,平均药品费、平均检验费、对医疗护理工作的满意度。结果路径组病人平均住院天数、平均住院费用、平均药品费、平均检验费明显低于非路径组(P<0.01),对医疗护理满意度明显优于非路径组(P<0.01)。结论在终末期肾病患者中实施临床路径可减少住院天数,降低住院费用,有利于病人主动参与诊疗和护理,促进了病人术后生活自理能力的恢复,提高病人的满意度。     

Increased resting energy expenditure in patients with end-stage renal disease

BACKGROUND: Protein-calorie malnutrition is a significant problem for patients with end-stage renal disease. Increased resting energy expenditure may be an important contributing factor. We postulate that resting energy expen diture in the different stages of renal disease and treatments may be different. METHODS: Resting energy expenditure was measured using a whole-room indirect calorimeter (metabolic chamber) along with nutritional parameters and body composition after 12-hour fasting in 15 patients with advanced chronic renal failure patients, 15 patients on chronic hemodialysis, and 10 patients on peritoneal dialysis. Patients on hemodialysis were assessed on a non-dialysis day. A 2-day dietary recall was used to assess energy intake. RESULTS: Resting energy expenditure, adjusted for fat-free mass, was similar in patients on hemodialysis and peritoneal dialysis but significantly higher than in patients with chronic renal failure (p < .05). Resting energy expenditure in all patients were generally higher (10% to 20%) than predicted values using standard equations derived in normal and obese populations, whereas daily energy intake was less (26% to 34%) than energy expenditure for all groups, adjusted for light daily activity. CONCLUSIONS: End-stage renal disease patients displayed increases in resting energy expenditure over the predicted values derived using normal populations. Resting energy expenditure was significantly higher in patients receiving dialysis, regardless of the modality, than patients with chronic renal failure. Daily energy intake was substantially less than required in all patient groups studied, suggesting that patients with renal failure could develop protein-calorie malnutrition because of increased resting energy expenditure, which is exacerbated by dialysis.     

Dialysis care, cardiovascular disease, and costs in end-stage renal disease in Brazil

OBJECTIVES: This study evaluates the cost of dialysis care in Brazil, including costs of ambulatory care and hospital admissions due to all causes and cardiovascular events. METHODS: Data were analyzed for 200 patients with end-stage renal disease (ESRD) on chronic hemodialysis in Brazil between 2001 and 2004. Main end points were all-cause mortality, all-cause hospital admissions, and cardiovascular events. Direct costs of dialysis treatment and complications were computed from the perspective of two payers, the Ministry of Health (MoH) and private health insurance (PHI). RESULTS: Mean number of days of hospitalization was 12 per patient-year. There were 105 cardiovascular events; the most frequent events were coronary disease (n = 59, 56 percent) and congestive heart failure (n = 26, 25 percent). The rate of cardiovascular events was 193 per 1,000 patient-years. There were 43 deaths, and the death rate was 79 per 1,000 patient-years. Median cost per hospital admission was US$ 675 and US$ 932 from the perspective of the MoH and PHI. For admissions due to cardiovascular causes, the corresponding costs were US$ 1,639 and US$ 4,499, respectively. Mean global cost per patient-year for chronic hemodialysis therapy was US$ 7,980 and US$ 13,428 from the perspective of the MoH and PHI, respectively. CONCLUSIONS: Patients on chronic hemodialysis care incur significant healthcare resources due to the costs of dialysis and complications, notably cardiovascular disease. New disease management programs aimed at reducing cardiovascular morbidity and efficient use of resources are critical to ensuring the sustainability of treatments for ESRD in Brazil.     

Implanted renal replacement for end-stage renal disease

The nearly 400000 American patients on dialysis suffer high cardiovascular and infectious mortality, but there is now evidence that this morbid phenotype can be rescued by intensive dialytic therapy. Self-care dialysis at home is limited by patient fears about skill and safety. An implanted artificial kidney would provide the benefits of intensive therapy while avoiding the focal points of patient concern. Hollow fiber polymer membranes and dialytic waste removal are lifesaving innovations but are difficult to adapt to implantable therapies. Biomimetic membranes and living cells can replicate the native kidney's strategy for waste removal. Three key technology developments are necessary for implementation of an implantable artificial kidney: high efficiency ultrafiltration membranes, control of blood-materials interactions such as thrombosis and fouling, and stable differentiated function of renal proximal tubule cells in an engineered construct. There has been significant progress in demonstrating proof-of-concept experiments in each key technology area.     

The relationship of health locus of control to patients with end-stage renal disease

Twenty-eight patients with end-stage renal disease receiving dialysis at the University of Utah Medical Center were the subjects of a nonequivalent control group study. This study was designed to measure the impact of a preventive aerobic exercise/educational intervention on the patients' locus of control. A creative incentive plan was utilized to motivate patients to accept responsibility for acquire cardiovascular fitness. There were no statistically significant differences before and after the intervention, as measured by the Multidimensional Locus of Control scale. The absence of change was partly attributed to an unusual internal orientation at the pretest level. Of the four factors examined that might account for this finding, the one that emerged with a statistically significantly high correlation was the duration on dialysis.     

Ischemic ocular motor nerve palsy in three patients with end-stage renal disease

Three patients on long-term hemodialysis therapy presented with sudden-onset isolated abducent nerve palsy. Two patients had ipsilateral eye pain. Computed tomographic scan or magnetic resonance imaging of the head did not reveal intracranial lesions responsible for the palsy. During the follow-up, the abducent nerve palsy of all three patients was resolved. Based on these findings, the three patients were diagnosed as having ischemic ocular motor nerve palsy. Although patients with end-stage renal disease often possess risk factors for ischemic ocular motor nerve palsy (hypertension, diabetes and atherosclerosis), the occurrence of ischemic ocular motor nerve palsy in the course of end-stage renal disease is rare.     

终末期肾脏病患者血清脂联素水平及与炎症因子的相关性研究

目的检测终末期肾脏病（ESRD）患者血清脂联素（ADPN）、肿瘤坏死因子-α（TNF—α）、超敏C反应蛋白（hs—CRP）及肾功能水平，探讨ESRD患者血清ADPN水平的变化及与炎症因子的关系。方法选择ESRD患者60例，分为3组：肾衰非透析组（18例）、血液透析组（22例）和腹膜透析组（20例）。另设健康对照组（20例）。用ELISA方法检测血清ADPN、TNF—α和hs—CRP。比较各组间的差别。结果ESRD患者血清ADPN水平在肾衰非透析组[（15．88±4．94）mg／L]、血液透析组[（14．26±4．54）mg／L]和腹膜透析组[（14．55±3．51）mg／L]均显著升高（与对照组[（4．95±2．19）mg／L]相比，P〈0．01），但非透析和透析各组之间的差异无统计学意义（P〉0．05）。ESRD患者的血清TNF—α和hs—CRP水平在透析和非透析各组亦显著升高（与对照组相比，P〈0．01），并且在透析患者显著高于非透析患者（P〈0．01）。ESRD患者的血清ADPN水平与TNF—α呈正相关（r≥0．478，P〈0．01），与肾小球滤过率呈负相关（r≥-0．582，P〈0．01）。结论ESRD患者的血清ADPN水平明显升高，并与TNF—α、肾小球滤过率等因素有关。     

Skin wounds associated with calciphylaxis in end-stage renal disease patients on dialysis

Calciphylaxis is a rare complication of chronic renal failure mostly with poor prognosis. Painful lesions on various skin surface areas are the most prominent feature of this serious disease. Subsequent infection of necrotic skin tissue is associated with the risk of sepsis. Pathophysiology is unclear, but several risk factors are known. The most important risk factor is impaired calcium-phosphate metabolism. Our paper describes two cases of different forms of calciphylaxis in patients with chronic renal failure. In the first case, pamidronate and cinacalcet were used for treatment. In the second described case, calciphylaxis was associated with secondary hyperparathyroidism and immediate subtotal parathyroidectomy was performed. Both patients were successfully treated, using systemic approach as well as dedicated local care for healing of skin wounds.     

Group participation and survival among patients with end-stage renal disease.

All 126 End-Stage Renal Disease (ESRD) patients who entered dialysis between 1971 and 1981 at the Harlem Hospital Center, New York City, were separated into those who had participated in a patient support group and those who had not done so. Patients who engaged in the group activities survived considerably longer than non-participants. Family history of renal disease, psychiatric illness, blood urea nitrogen (BUN), and creatinine were also related to survival, but, education, religion, marital status, and age were not. When 13 psychosocial and physiological covariates were controlled for in a Cox proportional hazard analysis, the group participation effect remained substantial.     

The financing and organization of medical care for patients with end-stage renal disease in Sweden

The total health care expenditure as a percentage of the gross domestic product in Sweden is 9.2%, and health care is funded by global budgets almost entirely through general taxation. The prevalence rate of end-stage renal disease (ESRD) in Sweden is 756 per million. Fifty-two percent of ESRD patients have a functioning transplant. Almost all ESRD treatment facilities are public. Compared with other Dialysis Outcomes and Practice Patterns Study (DOPPS) countries, the salaries for both nephrologists and professional dialysis unit staff are low. Sweden’s high cost per ESRD patient, relative to other DOPPS countries, may be a result of expensive and frequent hospitalizations and aggressive anemia treatment strategies.