By: D2- Gil Legarda and Joanalyn Balino
THE IMPACT OF GUIDELINES FOR THE PREVENTION OF
ANEMIA ON CLINICAL OUTCOME
Carol A. Pollock
Pollock made an analysis on the different researches and guidelines about the impact of anemia management in renal disease on clinical outcome. She summarized the different clinical practice guidelines on anemia management for renal disease. All the guidelines from different countries and regions uniformly recommend: (1) The minimum target hemoglobin(Hb) level is 11 g/DL; (2) Hb should not exceed 12 g/dL for those who have proven or possible cardiovascular disease; (3) Predialysis Hb levels should not exceed 14 g/ dL; (4) For hemodialysis population, Iron supplemattion is best administered intravenously; (5) serum ferritin > 100 g/L and a transferrin saturation of >20% should be the value to describe that iron storage is complete or sufficient. There were only low possibilities to assess the implementation of these guidelines. There were only few studies that provide evidences that a higher Hb confers a survival advantage in patients with chronic kidney impairment in patients.
Pollock cited different studies that discusses that higher Hb offer a survival advantage in patients with chronic kidney impairment These studies were: McDonald S, Russ G et al.(2003): approximately 16% of hemodialysis patients have Hb above 13 g/dL and if Hb between 11.0 and 11.9 g/dL there is a lower risk of mortality compared to Hb of 12 –14 g/dL. The mortality is similar with peritoneal dialysis patients with Hb between 10.5 and 12 g/dL and those who have Hb greater than 12 g/dL. Those with Hb > 12 g/dL survival is improved. Besarab et al.(1998) concluded that there is relatively strong evidence that a higher Hb target may increase mortality in patients with cardiovascular disease and perhaps in patients with diabetes mellitus. Ofsthun N. et al (2003) made an observational and longitudinal studies and suggested that there is no increased risk of death in patients on hemodialysis whose Hb is above 12 g/dL and a survival benefit occurs if Hb is between 12 and 13 g/dL and reduction in the number of hospitalizations and the length of stay in patients. Pisoni RL. et al. (2004) made an observational studies of hemodialysis patients (Hb above 12 g/dL) for each increase in Hb of 1 g/dL, an overall relative risk reduction in mortality of 5% was achieved But there is no significant reduction in hospitalization rate observed in patients whom Hb was above
The clinical factors of achieving Hb targets include:(1) Variability in hemoglobin Hb levels in individual patients;(2) thresholds for altering iron therapy and epoetin doses; (3) and variability in response to treatments aimed at improving Hb levels. When Hb concentrations are greater than 10 g/dL, there are benefits in quality of life, physical performance, and cognitive function. To optimize Hb concentrations and improve clinical outcomes, increasing iron supplementation and optimizing urea clearance are suggested in addition to prescribing epoetin.
Pollock C. (2004). THE IMPACT OF GUIDELINES FOR THE PREVENTION OF
ANEMIA ON CLINICAL OUTCOME. Peritoneal Dialysis International, Vol. 25, Supplement 3. Retrieved July 3, 2009 from http://www.pdiconnect.com/cgi/reprint/25/Suppl_3/S99?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=0&minscore=5000&resourcetype=HWCIT
5th POSTING- Peritoneal Dialysis: MORTALITY
By: Dyad2: Gil Legarda / Joanalyn Balino
Effects of Increased Peritoneal Clearances on Mortality Rates in Peritoneal Dialysis: ADEMEX, a Prospective, Randomized, Controlled Trial
By: RAMO´ N PANIAGUA, DANTE AMATO, EDWARD VONESH, RICARDO CORREA-ROTTER, ALFONSO RAMOS, JOHN MORAN, and SALIM MUJAIS.
Ramo’ N Paniagua et al. studies about the effects of increased peritoneal clearances on death dates in PD among patients with ESRD who were being treated with continous ambulatory peritoneal dialysis or CAPD. This study was carried out in a randomized controlled, clinical trial which the rsearchers called it adequacy of peritoneal dialysis in Mexico (ADAMEX). There were 965 subjects from 24 dialysis centers. These subjects were assigned to intervention group in a one is to one ratio through central randomization center. Subjects in control group continued with their existing peritoneal dialysis prescriptions. Inclusion citeria was subjects should undegone at least 3 months of peritoneal dialysis, ages between 18 to 70 years old, with prescription of four daily exchange of 2 liters and exhibited 60 L/week per set creatinine clearance. Patiebnts unable to give informed consent , with seropositive Hep B or HIV, receiving immunosuppressant medication, had malignancies, abdominal hernias or heart failure, had experienced a peritonitis episode for 1 month before enrolment of the study were excluded. The settings of the study where in 24 dialysis cneters in 14 Mexican cities. 21 of the dialysis centers were part of the Instituto Mexicano del Seguro Social, and 2 were part of the Instituti de Seguridad yServicios Sociales de los Trabajadores. The remaining center waas the Instituto Nacional de Ciencias Me dicas y Nutricio n Savador Zubira n in Mexico City. There were Clinical History assessment, Physical assessment and laboratory tests as baseline information and would served as an instrument for analysing data. The all in all analysis of patient survival was performed by the use of life-table techniques with comparisons made on the basis of the logic rank test. The assessment of the effectivity of the intervention suggested by the researchers served as the measures of outcomes. The limitation this study was the subjects were PD patients only and the Hemodialysis patients were not included also ESRD is the only disease included how about the kidney diseases prior to ESRD.
In terms of the demographic characteristics the both experimental and control groups were similar also in prevalence of coexisting conditions, causes of renal disease, peritoneal clearances residual renal function, peritoneal clearances before the intervention, multiple indicators of nutritional status and hematrocrit values. Peritoneal creatinine clearance and urea clearance were remained in the control group while in the intervention group peritoneal kt/V values and pcrCL increased and remained separated from the values for the entire duration of the study. Mortality rates were similar in the result for the both groups even if there was an adjustment for the factors associated with the survival.
This study provides factors which can affect the mortality in both different therapy or types of dialysis. It shows that small solute clearances can has an effect regarding the survival of patients whwnever patients were grouped according to variety of factors such as age, diabetes mellitus, serum albumin levels, normalized protein equivalent of total nitrogen appearance and anuria. There are some lockage in this study such as practices which may be added in the factors also the subcategorizing the patients according to age group if which patients can have an increased creatinine clearance or risk for death.
Paniagua R. (2002). Effects of Increased Peritoneal Clearances on Mortality Rates in Peritoneal Dialysis: ADEMEX, a Prospective, Randomized, Controlled Trial. Journal of the American Society of Nephrology Vol. 13 pages 1307–1320.
Last edited by gillegarda/joanalynbalino on Tue 07 Jul 2009, 2:13 am; edited 1 time in total