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    5th Posting Prognosis of ESRD/ Hemodialysis


    5th Posting Prognosis of ESRD/ Hemodialysis Empty 5th Posting Prognosis of ESRD/ Hemodialysis

    Post  nancelle on Mon 06 Jul 2009, 12:30 am

    DYAD 1 : Nancelle Dumlao / Rodel Perez
    Prognosis of ESRD/ Hemodialysis

    By: Meyer, T (2007)

    As has been defined previously, ESRD or kidney failure is state where glomerular filtration rate (GFR) <15 mL/min/1.73 m2 (K/DOQI cited by Pradeep, 2009). However, even at the time the GFR has deteriorated to less than 60 ml/min/1.73 m2 (stage 3 kidney failure), signs and symptoms of the kidney faulire is already evident. This is due to the accumulation of organic body waste products which the kidney could no longer filter properly. Due to the inability of the kidneys to excrete the body’s waste products, uremic condition or uremia develops wherein there are imbalances in the extracellular volume and increase concentrations of ions that needs to be cleared through dialysis if the patient is to survive. Uremia is difficult to diagnose in the early stages of chronic kidney disease since signs and symptoms (e.g. fatigue) are not specific to the kidney disease. However, in the advanced stage of the kidney disease, signs and symptoms of uremia is easily identified and the recommended management would be either dialysis or transplantation. Nowadays, considering the difficulty of finding a kidney donor, the predominant mode of treatment is dialysis. Statistics in the USA show that in the year 2004, there are about 335,000 people who are in maintenance dialysis, some are receiving dialysis for decades. It is quite disappointing to note that the 5-year survival rates between 1995 and 1991 were below 35% for both hemodialysis and peritoneal dialysis, that these patients on the average go to the hospital at least twice a year and they have low quality of life. Moreover, even if these patients receive dialysis, uremia is not totally resolved. They experienced “residual syndrome” where the uremia is just partially treated wherein the ill effects of the disease (e.g. academia, hyperphosphatemia) still remain. In some patients, this is even aggravated by the presence of comorbidilities and old age.

    Chronic Kidney Disease and the Risks of Death, Cardiovascular Events, and Hospitalization

    By: Alan S. Go, M.D., Glenn M. Chertow, M.D., M.P.H., Dongjie Fan, M.S.P.H., Charles E. McCulloch, Ph.D., and Chi-yuan Hsu, M.D.

    This is a study conducted to find out whether chornic kidney disease (ESRD) independently increases the risk of any type of cardiovascular disease, the risk of death as well as the utilization of hospital or health care. As was said earlier there are over 300,000 ESRD patients receiving maintenance dialysis and among these patients more than 20 % lose their lives and more than 50% of deaths has been associated with cardiovascular disease. Using longitudinal measures of estimated GFR, a more accurate method of assessing kidney function than the measurement of serum creatinine alone, we examined the effect of the severity of kidney dysfunction on the risks of death, cardiovascular events, and hospitalization among a large, diverse group of adults. We hypothesized that there would be a graded, independent association between the estimated GFR and the risks of these outcomes. The method used for this study is longitudinal measures of estimated GFR ( as compared to using serum creatinine alone as was done in other studies) to find out the effect of the severity of kidney dysfunction on the risks of cardiovascular disease, death and hospitalization in a large, diverse groups of about 1,120,295 adults from Kaiser Permanente of Northern California, an integrated system of health care delivery in San Francisco, USA. It was hypothesized that there would be grade, independent relation between the estimated GFR and the risks mentioned above. The subjects were obtained from the Kaiser Permanente Renal Registry from January 1996 to December 2000 and for the m to qualify must have had their serum creatinine levels taken at least once during the period stated. Excluded are those patients who had kidney transplant or who was in maintenance dialysis already.

    The results were that the risk of dying increased as the GFR decreased below 60 ml/min/ 1.73 m2 of body-surface area which means that’s as chronic kidney disease deteriorates, then risk of death becomes higher as follows : estimated GFR of 45 to 59 ml per minute per 1.73 m2 has hazard ratio for death of 1.2; eGFR of 30 to 44 ml per minute per 1.73 m2 has death ratio of 1.8; eGFR of 15 to 29 ml per minute per 1.73 m2 has death ratio of 3.2; and eGFR < 15 ml per minute per 1.73 m2 has death ratio of 5.9. Likewise, the hazard ratio for risk of cardiovascular disease also increased as the estimated GFR decreases. Same is true with the risk of hospitalization which increased as kidney failure becomes worse.

    The study proved that the likelihood of a patient with chronic kidney failure to develop cardiovascular disease and the risk of visiting the hospital or a specialized health center becomes higher as the chronic kidney disease advances from stage 1 to 5. Moreover, the risk of death increases when eGFR decreases which shows that chronic kidney patients even in dialysis need to slow down the progression of the kidney failure to prolong their lives and have a better quality of life.

    1. Meyer, T., Hostetter , T. Uremia. New England Journal of Medicine. Volume 357:1316-1325, September, 2007.
    2. Go, A., Chertow, G., Fan, G., McCulloch, C., Hsu, C. Chronic Kidney Disease and the Risks of Death, Cardiovascular Events, and Hospitalization. New England Journal of Medicine. Volume 351:1296-1305, September, 2004.

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    5th Posting Prognosis of ESRD/ Hemodialysis Empty The Outcome of Acute Renal Failure by YuanShuHui&YangChunHua

    Post  YangChunHua on Mon 06 Jul 2009, 11:33 am

    Daily Hemodialysis and the Outcome of Acute Renal Failure

    Helmut Schiffl, M.D., Susanne M. Lang, M.D., and Rainald Fischer, M.D.

    January 31, 2002 Number 5

    The high mortality rate among critically ill patients with acute renal failure remains an unsolved problem in intensive care medicine, despite the fact that renal-replacement therapy has been available for decades. Many such patients have preexisting conditions that predispose them to acute renal failure and to concomitant extrarenal complications that cause multiorgan failure.

    Intermittent hemodialysis is widely used as renal-replacement therapy in patients with acute renal failure, but an adequate dose has not been defined. We performed a prospective study to determine the effect of daily intermittent hemodialysis, as compared with conventional (alternate-day) intermittent hemodialysis, on survival among patients with acute renal failure.
    A total of 160 patients with acute renal failure were assigned to receive daily or conventional intermittent hemodialysis. Survival was the primary end point of the study. The duration of acute renal failure and the frequency of therapy-related complications were secondary end points.
    The two study groups were similar with respect to age, sex, cause and severity of acute renal failure, medical or surgical intensive care setting, and the score on the Acute Physiology, Age, and Chronic Health Evaluation. Daily hemodialysis resulted in better control of uremia, fewer hypotensive episodes during hemodialysis, and more rapid resolution of acute renal failure (mean [±SD], 9±2 vs. 16±6 days; P=0.001) than did conventional hemodialysis. The mortality rate, according to the intention-to-treat analysis, was 28 percent for daily dialysis and 46 percent for alternate-day dialysis (P=0.01). In a multiple regression analysis, less frequent hemodialysis (on alternate days, as opposed to daily) was an independent risk factor for death.
    The high mortality rate among critically ill patients with acute renal failure who require renal-replacement therapy is related to both coexisting conditions and uremic damage to other organ systems. Intensive hemodialysis reduces mortality without increasing hemodynamically induced morbidity.

    Reference :
    1.Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000;356:26-30.
    2.Evanson JA, Ikizler TA, Wingard R, et al. Measurement of the delivery of dialysis in acute renal failure. Kidney Int 1999;55:1501-1508.
    3. Paganini EP, Kanagasundaram NS, Larive B, Greene T. Prescription of adequate renal replacement in critically ill patients. Blood Purif 2001;19:238-244.

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    5th Posting Prognosis of ESRD/ Hemodialysis Empty D4 RESPONSE TO ESRD 5TH POSTING

    Post  alkhaloidz on Mon 06 Jul 2009, 11:33 pm


    Survival Analysis of Korean End-Stage Renal Disease Patients According to Renal Replacement Therapy in a Single Center

    The study wasconducted to investigate clinical characteristics and any differential trends in survival among renal replacement therapy (hemodialysis [HD], peritoneal dialysis [PD], and kidney transplantation [KT]) in Korean end-stage renal disease (ESRD) population. The investigators tried to analyze retrospectively the survival rate adjusted by risk factors and the relative risk stratified by key risk factors among 447 ESRD patients who began dialysis or had a kidney transplant at Ajou University Hospital from 1994 to 2004.

    In adjusted Cox survival curves, the KT patients had the best survival rate, and the HD patients had better survival than PD patients. The consistent trends in different subgroups stratified by age and diabetes were as following: 1) The risk of death for PD and HD was not proportional over time, 2) The relative risk of PD was similar or lower than that of HD for the first 12 months, but it became higher at later period. The significant predictors for mortality were age (over 55 yr), presence of diabetes, cerebrovascular accident at ESRD onset, and more than one time of hospitalization caused by malnutrition. Further large-scaled, multicenter-based comparative study is needed in Korean ESRD patients and more meticulous attention is required in high-risk patients.

    The result of the study is an eye-opener for those nurse researcher who are involved with ESRD patients. The development in this research will be able address the ever-changing needs of patients having this kind of condition. Furthermore, it can help to predict and prevent the factors that leads to mortality of the ESRD patients.

    Reference: Song YS et. al. Survival Analysis of Korean End-Stage Renal Disease Patients According to Renal Replacement Therapy in a Single Center. PMC. June 2006

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    Post  gillegarda/joanalynbalino on Tue 07 Jul 2009, 3:08 am

    By: Dyad2-Gil Legarda / Joanalyn Balino

    Comparing Mortality of Elderly Patients on Hemodialysis versus Peritoneal Dialysis: A Propensity Score Approach

    Winkelmayer C. W. et al. studied about the mortality of elderly patients on hemodialysis versus peritoneal dialysis. This research was done in a cohort study design. The purpose of this study was to evaluate the differences in death over the first year of renal replacement therapy between elderly patients n HD versus PD. The researchers identified all patients undergoing hemodialysis started from January 1, 1991 to June 30, 1996 there were about 2503 patients under the cohort study and 573 patients started the Renal replacement therapy on peritoneal dialysis. It required diagnosis to eliminate patients with acute renal failure also researchers excluded patients with health care providers difficult to identify. The settings of the study were in Brigham and Women’s Hospital at Harvard Medical School, and Department of Epidemiology at Harvard School of Public Health Boston, Massachusetts and Department of Health and Management Ben-Gurion University of the Negev, Beer-Sheba, Israel. The researcher used a membership form in New Jersey Medicaid a program as an indicator of low income and lower socio economic status. The researchers used logistic regression for each patient to calculate and estimate propensity score for those who were assigned in PD and HD. They also built multivariate Cox proportional hazards models. The limits of this study were only the patients having HD and PD was involved but the other types of PD were not included. Also only elderly patients were involve but the middle age and young adult who had had a HD and PD therapy were not included.

    Patients started Renal Replacement Therapy on peritoneal dialysis were less likely to be black and low SES also PD patients were more likely to have CAD, CHF, and mental disease other than depression compared with those patients started Hemodialysis. The researchers omitted the covariates for DM Nephropathy and HPN kidney disease due to their expected high co linearity with the respective co morbidities. It showed in this study that there were 23 percent mortality rate of the patients underwent peritoneal dialysis

    Based on our review hemodialysis is a better therapy for ESRD patients than Peritoneal dialysis. Peritoneal dialysis as a renal replacement therapy is a risk either on the early phase or later course of the treatment compared to treatment of hemodialysis. Patients who had diabetic nephropathy were more risk to mortality based on the researchers findings most especially if they underwent peritoneal dialysis. These ESRD patients needs guidance and choose the best treatment for them. Although financial matters affects the choice of the patients because the treatment of hemodialysis is very expensive compared to peritoneal dialysis.

    Winkelmayer C.W. et al. (2002). Comparing Mortality of Elderly Patients on Hemodialysis versus Peritoneal Dialysis: A Propensity Score Approach. Journal of the American Society of Nephrology Vol. 13 pages 2353–2362.
    byron webb romero
    byron webb romero

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    5th Posting Prognosis of ESRD/ Hemodialysis Empty FOLLOW-UP FOR HEMODIALYSIS PATIENTS

    Post  byron webb romero on Wed 08 Jul 2009, 7:17 am

    Dyad thee (3)
    Byron Webb A. Romero
    Von Deneb H. Vitto
    Raymond C. Ursal


    Agrani, Noorazarian, Rahbaninobar, Noori and Khosroshahi in a 2004 research study revealed that 22%, or 12 out of the 50 patients undergoing hemodialysiis (HD) manifested signs of impaired glucose tolerance. The study population consisted of 50 renal transplant patients, 50 HD patients and 50 healthy controls. Impaired glucose tolerance or control can be attributed to the formation of atherosclerosis which is a major risk factor or cardiac diseases. Patients undergoing renal transplants or HD are considered vulnerable or at high risk for cardiovascular diseases. Impairment in glucose tolerance in HD patients could signal further complications.

    Non-effective removal of toxins in HD compared with peritoneal dialysis (PD) can be a cause for the development of impaired glucose tolerance. This would lead to the common complication of hypertriglyceridemia (elevated triglyceride beyond normal values) in dialysis patients. Therefore, the research study implies that during follow-up for HD patients, glucose levels must be monitored as well as.

    While the result of the study is remarkable, it did not however discuss sampling method that was adopted in order to determine the number of their subjects or study population. Although basic to research, ethical considerations employed were not mentioned along the research procedure. In the light of addition to the body of knowledge, further studies must also be conducted with particular attention to the progression of atherosclerosis and its impact on HD and renal transplant population groups and shall include follow-up care.


    Argani, H., Noorazarian, A., Rahbaninobar, M., Noori, M., & Khosroshahi, H.T. (2004). Comparison of glucose tolerance in ranl recipients and hemodialysis patients. BMC Nephrology 2004, 5:11. Retrieved July 7, 2009 from , http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=522749.

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    5th Posting Prognosis of ESRD/ Hemodialysis Empty hemodialysis diagnostics

    Post  guomanman on Wed 08 Jul 2009, 9:19 am

    Dyad 6 guomanman and chenya

    Prevalence of HCV infection in the HD population:

    * Varies worldwide from 1% to more than 70%
    * In the USA, is overall 14% and 10-fold higher than in the general population
    * Is highly variable between units within the same country

    Total time spent on dialysis is among the risk factors for the presence of anti-HCV antibodies and/or HCV RNA. HCV is the major etiologic agent of chronic hepatitis and possible liver cirrhosis and hepatocarcinoma.

    This reference tool highlights select guidelines from the KDIGO Clinical Practice Guidelines for the Prevention, Diagnosis, Evaluation and Treatment of Hepatitis C in Chronic Kidney Disease for implementation in the U.S. and in accordance with KDOQI U.S. Commentary on the KDIGO Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in CKD.

    Detection and Evaluation of HCV in Chronic Kidney Disease (Guideline 1.2)

    Algorithm 1: CKD stage 5 hemodialysis diagnostic algorithm (Guideline 1.2) Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; CKD, chronic kidney disease; EIA, enzyme immunoassay; HCV, hepatitis C virus; NAT, nucleic acid test.

    In the setting of suspected nosocomial HCV infection in an HD facility, testing with NAT should be performed in all patients who may have been exposed (strong evidence* G 1.2.4). Repeat testing with NAT is suggested for initially NAT-negative patients within 2-12 weeks because of the risk of false negative NAT testing early after infection (weak evidence* G 1.2.4).
    Treatment of HCV infection in Hemodialysis

    1. Evaluate HCV-infected patients for antiviral treatment (weak evidence G.2.1.1)

    Treat HCV based on the potential benefits and risks of therapy, including:
    * Life expectancy
    * Candidacy for kidney transplantation
    * Comorbidities such as cardiovascular disease (weak evidence G.2.1.2).

    Start antiviral treatment if the HCV infection is acute. A waiting period beyond 12 weeks to observe spontaneous clearance (by NAT) is not justified (weak evidence G.2.1.3).

    Consider antiviral therapy for patients with HCV-related glomerulonephritis (GN) (weak evidence G.2.1.6).
    2. Use Interferon (IFN) Monotherapy in HD Patients (weak evidence G. 2.2.3)

    Alfa-2a IFN: 3mU SQ 3 times per week
    Alfa-2b IFN: 3mU SQ 3 times per week

    Patients with HCV genotypes 1 and 4 should receive 48 weeks of IFN therapy if an early viral response is obtained at 12 weeks (>2 log fall in viral titer).

    Patients with genotypes 2 and 3 should be treated for 24 weeks.

    Tolerance to IFN therapy is suggested to be lower in maintenance HD patients than in non-CKD patients infected with HCV

    Adverse Effects of IFN
    Flu-like illness
    Neurologic and cardiovascular disorders

    Absolute Contraindications to IFN Therapybr.

    Some Relative Contraindications to IFN Therapy4
    Decompensated liver disease
    Major neuropsychiatric disease
    Coronary or cerebrovascular disease
    Poorly controlled diabetes
    Obstructive pulmonary disease
    Active substance or alcohol abuse
    History of kidney or heart transplantation

    All patients >60 years of age are in a higher risk group for the development of serious adverse reactions to IFN and require individual decision-making.
    3. Monitor the response to antiviral therapy (G.2.3)

    How should response be assessed?
    Use sustained virologic response (SVR), defined as HCV RNA clearance 6 months after completion of antiviral treatment (weak evidence G.2.3.1).

    When should further monitoring occur?
    If SVR is achieved, repeat test with NAT every 6 months to ensure patient remains nonviremic (weak evidence G.2.3.2).

    Which patients with HCV infection should be followed for HCV-associated comorbidities?

    * All patients, regardless of treatment or response (strong evidence G.2.3.3).
    * For patients with evidence of clinical or histologic cirrhosis, evaluate very 6 months (strong evidence G.2.3.3).

    Hemodialysis Units: Preventing HCV Transmission (Guideline 3)

    Hemodialysis units have responsibility to ensure implementation of, and adherence to, strict infection-control procedures designed to prevent nosocomial transmission of blood-borne pathogens, including HCV (strong evidence G.3.1) between patients in their care, either directly or via contaminated equipment or surfaces (see Tables 1 and 2).

    Regular observational audits of infection-control procedures are suggested for inclusion in performance reviews of hemodialysis units (weak evidence G.3.2).

    * Center-wide issues to consider: Dialysis unit design should facilitate implementation of infection control strategies
    * Time between shifts should be sufficient to enable effective machine and surface decontamination
    * Strategically position gloves around the unit to facilitate quick access
    * Ease of disinfection should be a consideration when selecting new equipment
    * Ensure that infection-control staff training and vigilance is maintained during changes to staff-to-patient ratios or employment of new staff
    * Carry out regular risk assessments and develop procedures to reduce or remove hazards

    * Not Recommended: Isolating HCV-infected patients as an alternative to strict infection-control procedures for preventing transmission of blood-borne pathogens (weak evidence G.3.1).
    * Using dedicated dialysis machines for HCV-infected patients (moderate evidence G.3.1).

    * When dialyzer reuse is unavoidable: Dialyzers of HCV-infected patients can be reused provided there is implementation of, and adherence to, strict infection-control procedures (weak evidence G.3.1).

    A "dialysis station" is the space and equipment within a dialysis unit that is dedicated to an individual patient. This may take the form of a well-defined cubicle or room, but there is usually no material boundary separating dialysis stations from each other or from the shared areas of the dialysis unit.

    A "potentially contaminated" surface is any item of equipment at the dialysis station that could have been contaminated with blood, or fluid containing blood since it was last disinfected, even if there is no evidence of contamination.

    A program of continuing education covering the mechanisms and prevention of cross infection should be established for staff caring for hemodialysis patients. Appropriate information on infection control should also be given to nonclinical staff, patients, caregivers and visitors.

    Hand Hygiene
    Staff should wash their hands with soap or an antiseptic hand-wash and water, before and after contact with a patient or any equipment at the dialysis station. An antiseptic alcohol gel rub may be used instead when their hands are not visibly contaminated.

    In addition to hand washing, staff should wear disposable gloves when caring for a patient or touching any potentially contaminated surfaces at the dialysis station. Gloves should always be removed when leaving the dialysis station.

    The risks associated with the use of physiologic monitoring equipment (e.g., blood pressure monitors, weight scales, access flow monitors) for groups of patients should be assessed and minimized. Blood pressure cuffs should be dedicated to a single patient or made from a light-colored, wipe-clean fabric.

    Medications and other supplies should not be moved between patients. Medications provided in multiple-use vials, and those requiring dilution using a multiple-use diluent vial, should be prepared in a dedicated central area and taken separately to each patient. Items that have been taken to the dialysis station should not be returned to the preparation area.

    After each session, all potentially contaminated surfaces at the dialysis station should be wiped clean with a low-level disinfectant if not visibly contaminated. Surfaces that are visibly contaminated with blood or fluid should be disinfected with a commercially available tuberculocidal germicide or a solution containing at least 500 p.p.m. hypochlorite (a 1:100 dilution of 5% household bleach).

    Waste Management
    Needles should be disposed of in closed, unbreakable containers that should not be overfilled. A "no-touch" technique should be used to drop the needle into the container, as it is likely to have a contaminated surface. If this is difficult due to the design of the container, staff should complete patient care before disposing of needles.

    The used extracorporeal circuit should be sealed as effectively as possible before transporting it from the dialysis station in a fluid-tight waste bag or leak-proof container. If it is necessary to drain the circuit, or to remove any components for reprocessing, this should be done in a dedicated area away from the treatment and preparation areas.
    Table 2. Hygienic Precautions for Hemodialysis (Dialysis Machines)

    The "transducer protector" is a filter (normally a hydrophobic 0.2 mm filter) that is fitted between the pressure monitoring line of the extracorporeal circuit and the pressure-monitoring port of the dialysis machine. The filter allows air to pass freely to the pressure transducer that gives the reading displayed by the machine, but it resists the passage of fluid. This protects the patient from microbiologic contamination (as the pressure monitoring system is not disinfected) and the machine from ingress of blood or dialysate. An external transducer protector is normally fitted to each pressure monitoring line in the blood circuit. A back-up filter is located inside the machine. Changing the internal filter is a technical job.

    A "single-pass machine" is a machine that pumps the dialysate through the dialyzer and then to waste. In general, such machines do not allow fluid to flow between the drain pathway and the fresh pathway except during disinfection. "Recirculating" machines produce batches of fluid that can be passed through the dialyzer several times.

    Transducer Protectors
    External transducer protectors should be fitted to the pressure lines of the extracorporeal circuit. Before commencing dialysis, staff should ensure that the connection between the transducer protectors and the pressure-monitoring ports is tight, as leaks can lead to wetting of the filter.

    Transducer protectors should be replaced if the filter becomes wet, as the pressure reading may be affected. Using a syringe to clear the flooded line may damage the filter and increase the possibility of blood passing into the dialysis machine.

    If wetting of the filter occurs after the patient has been connected, the line should be inspected carefully to see if any blood has passed through the filter. If any fluid is visible on the machine side, the machine should be taken out of service at the end of the session so that the internal filter can be changed and the housing disinfected.

    External Cleaning
    After each session, the exterior of the dialysis machine should be cleaned with a low-level disinfectant if not visibly contaminated.

    If a blood spillage has occurred, the exterior should be disinfected with a commercially available tuberculocidal germicide or a solution containing at least 500 p.p.m. hypochlorite (a 1:100 dilution of 5% household bleach) if this is not detrimental to the surface of dialysis machines. Advice on suitable disinfectants, and the concentration and contact time required, should be provided by the manufacturer.

    If blood or fluid is thought to have seeped into inaccessible parts of the dialysis machine (for example, between modules, behind blood pump), the machine should be taken out of service until it can be dismantled and disinfected.

    Disinfection of the Internal Fluid Pathways
    It is not necessary for the internal pathways of a single-pass dialysis machine to be disinfected between patients, unless a blood leak has occurred, in which case both the internal fluid pathways and the dialysate-to-dialyzer (Hansen) connectors should be disinfected before the next patient. If machines are not subjected to an internal disinfection procedure, staff should ensure that sufficient time is available between patients for the external surfaces to be disinfected. Machines with recirculating dialysate should always be put through an appropriate disinfection procedure between patients.

    These Clinical Practice Guidelines are based on the best information available at the time of publication. They are designed to provide information and assist decision-making. They are not intended to define a standard of care and should not be construed as one, nor should they be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources and limitations unique to an institution or a type of practice. Every health care professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. The recommendations for research contained within this document are general and do not imply a specific protocol.

    Kidney Disease Outcomes Quality Initiative (KDOQI) makes every effort to avoid any actual or reasonably perceived conflicts of interest that may arise as a result of an outside relationship or a personal, professional or business interest of a member of the Work Group. Specifically, all members of the Work Group are required to complete, sign, and submit a disclosure and attestation form showing all such relationships that might be perceived as actual or perceived conflicts of interest. This document is updated annually and information is adjusted accordingly. All reported information is on file at the National Kidney Foundation.


    * National Kidney Foundation. KDIGO clinical practice guidelines for the prevention, diagnosis, evaluation, and treatment of hepatitis C in chronic kidney disease. Kidney International. 2008 (suppl 1); 73:S1-S99.
    * Alter MJ. Epidemiology of hepatitis ? in the West. Semin Liver Dis. 1995 15-5-14.
    * Management of hepatitis C. NIH Consensus Statement. 1997 March 24-26,15(3)
    * World Health Organization. Hepatitis C prevention and treatment. Available at http://www.who.int/csr/disease/hepatitis. Accessed on October 3, 2008.
    * KDOQI U.S. commentary on the KDIGO clinical practice guideline for the prevention, diagnosis, evaluation, and treatment of hepatitis C in CKD.

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