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Physiologic and psychosocial approaches to global management of the hemodialysis patient in the Southern Alberta Renal Program.

A tree has different meaning to individuals. For some, it represents life as it grows and matures. For others, it represents hope for the future. A tree can have many purposes: to bear fruit, to provide shade, to promote aesthetic value or to become a source of construction material. For these reasons we have chosen the tree as a foundation for our quality improvement process our Case Management Tree (see Figure 1). It symbolizes life and hope. Our tree is rooted in research and allows us to provide evidence-based nursing care. The tree provides shade just as we, as nurses, provide shelter in a safe environment by improving the practices we use to care for our patients. Our caring attitudes colour the daily picture we paint for our dialysis patients much as trees provide aesthetic value to their surrounding areas. Like the tree, we grow and change to construct new plans for patient care and lay the foundations for the building of future dialysis nursing trends. The quality indicators of responsible patient management are like the fruit of the tree, providing a measure of vigilance of the health of the dialysis patient care system. The tree, most importantly for our case management process, is intended to encourage hemodialysis nurses to think about quality indicators as a guide to assess patient care, evaluate therapeutic interventions and ultimately improve patient outcomes. A healthy tree will bring forth fruit and the fruits in our analogy are the patient care indicators.

As you reflect upon this analogy, we would like you to ask yourselves these questions:

1. Are you meeting your targets?

2. How can you improve your care to achieve your targets? What else can you change to ensure you reach your targets?

3. How can you help your patients meet these targets?

Our computerized charting system is called PARIS [PAtient-based Renal Information System] and it encompasses a monthly case management section with room for comments where indicators can be documented. The following indicators reflect the sections covered in our PARIS case management documentation. While we are aware that every dialysis unit does not necessarily use the same charting system, the following indicators are listed in the NKF KDOQITM guidelines and, therefore, you may want to ensure that the one used in your unit does include these indicators in some form (National Kidney Foundation: KDOQI, 2001).

Physiologic indicators

A. Dialysis adequacy:

How efficiently and adequately are we dialyzing our patients? To ensure efficiency and adequacy of dialysis or solute removal, adequacy should be measured and monitored routinely. There are two formulas we use in the Southern Alberta Renal Program (SARP) to assess adequacy based on urea clearance.

i. Urea Reduction Ratio (URR) is measured with monthly blood work through the Calgary Laboratories Services. We review this within the context of the KDOQI and the SARP recommendations:

SARP Target >70%; KDOQI Target >65%

ii. KT/V is measured with the same expectations as KDOQI: Target [greater than or equal to] 1.2

KT/V is measured during every treatment using Diascan technology. This is software imbedded in our hemodialysis (HD) machines that has the capability of measuring dialysis efficiency every time the patient dialyzes. Diascan provides instant trending of KT/V over time and the patient's real time value at the end of the treatment. One bonus of this dialysis evaluation tool is the ability to predict how efficiently the patient is being dialyzed, even at the start of the run (Lindsay et al., 2006).

What are the possible reasons for inadequate dialysis? The HD nurse will have to critically analyze the reasons for this and undertake appropriate interventions. Some of the usual causes are:

1. Access problems such as stenosis

2. Inadequate performance of the dialyzer. Perhaps there may be a need to change to a high flux, high efficiency dialyzer

3. Reduced blood flow (QB). A change in pump speed may be required

4. Reversed lines [in case of central venous catheter (CVC) use], which may lead to recirculation

5. Clotting (anticoagulation may need to be reviewed)

6. Treatment time ended prematurely or shortened. This usually occurs due to patient transportation problems, so rescheduling of patient pick-up time may be of value.

B. Blood pressure (BP) control and fluid management:

Maintaining blood pressure at target and managing fluids are major struggles for a lot of our patients and can be very challenging for staff while the patient is undergoing HD. Cardiovascular morbidity and mortality remain unacceptably high in HD patients, in part due to inability to control these two indicators (Johnson et al., 2009).

SARP and KDOQI BP Target:

* Pre HD: < 140/90 mmHg

* Post HD: < 130/90 mmHg

Target Weight:

* Target weight: Achieved 50% of the time

* Ideal weight gain < 1 kg per day

At SARP, our goal is to provide a safe and adequate dialysis fluid removal. How do nurses differentiate between body mass versus fluid gain? How accurate is the target weight or dry weight? The following are clinical presentations and plasma values that an astute nurse should be evaluating and assessing:

* Hypertension/hypotension-patient should be bringing in BP readings taken at home if available

* Facial and peripheral edema

* Crackles upon chest auscultation

* Cramping during dialysis or between dialysis days

* Obvious weight gain

* Increase in appetite

* Assessed adherence to antihypertensive medications; review times medications are taken (before or after dialysis)

* Nausea, vomiting, diarrhea

* Assessed sodium status based on Plasma Conductivity (pre and post dialysis) and Ionic Mass Balance.

Education, especially on fluid and salt restriction, is imperative (Thomson, 2001). Our unit dietitian reviews these indicators on a monthly basis to implement ways through which fluids and sodium can be better managed. The fluid available for ultrafiltration or removal during dialysis is in the intravascular space. Problems with hypotension during and at the end of dialysis are usually due to rapid removal of fluid and the loss of osmolarity from the reduction of urea, glucose and middle molecules. We need to promote or enhance the movement of fluid and these solutes from the tissues to the circulation. We can achieve this through careful assessment and re-evaluation of the target weight, preferably every two weeks, as a minimum standard. Other strategies include adjusting dialysate temperature and prescribing different sodium (Na) and/or ultrafiltration (UF) profiling models. If the patient is a good candidate for nocturnal or home hemodialysis, our nurse clinician will carry out an individual discussion of the particulars of this self-managed modality with patients and their families. Nocturnal dialysis has been proven to be effective especially to those whose BP and weight gains are extremely hard to manage (Silverstein, 2007). Evidence has shown that it can even reverse the left ventricular hypertrophy or cardiac remodelling brought about by persistent and chronic fluid overload and high blood pressure (Chan, Floras, Miller, Richardson, & Pierratos, 2002).

C. Access function:

Vascular access is our patient's lifeline! The functionality of the access plays a major role in providing improved clearance and therefore improved outcomes. Maintenance of the access is imperative through routine and vigilant monitoring carried on a monthly basis.

Access Policy Guidelines--AV Fistula/AV Graft Targets:

* Access flow values should be AVF > 550 ml/ min and AVG > 650 ml/min

* > 20% decrease in flow may mean inflow stenosis. This is reported to the access clinic or nephrologist in a nonurgent manner

* > 50% decrease in flow requires immediate discussion with access team or nephrologist for intervention: fistulagram [+ or -] angioplasty

* Recirculation above 0% should be reported to the access team and nephrologist

Is the access performing as expected? Are we cannulating our access successfully? We have three tools to assess the performance of the AVF/AVG:

i. Dynamic flow monitoring is documented at the first few minutes of each patient treatment at a QB of 200 ml/min by measuring venous and arterial pressures. If, at any time, access problems are suspected based on these results, the nurses are educated to proceed and undertake a more complex measurement of access flow.

ii. The Transonic Flow QC Monitor uses ultrasound technology. It is the gold standard for direct flow measurement of the access and assessment of recirculation. It validates staff concerns on possibilities of access complications such as stenosis, and assists in gathering more accurate information in addition to the physical assessment of the access (observation, palpation and auscultation).

iii. The Diascane flow measurement is a feature of the Phoenix' machine. By measuring urea clearance (Kurea) in reversed and standard needle positions and entering the values through mathematical computations, access flow can be measured. However, there are a few caveats in undertaking this procedure to ensure accuracy.

What would be the reasons for decreased clearance in the AVF/AVG? Consider the potential of stenosis, immature vessel (poorly developed AVF), and needle placement.

Access Policy Guidelines--Central Venous Catheter Targets:

For patients with Central Venous Catheter as primary vascular access, staff monitor and document the following:

* Low QB

* Reversal of lines more than 50% of the time

* Line repairs

* Catheter migration

* Line exchange

* Line occlusion from fibrin or clot formation

* Cathflo [R] use to troubleshoot occlusion

* Evidence of infection

* Signs of/or documented central vein stenosis

D. Anemia management:

Anemia in end stage renal disease is usually caused by reduced erythropoietin production by the failing kidneys. As kidney function declines, almost all End-Stage Renal Disease (ESRD) patients will develop anemia and require intervention.

At SARP we have a nurse-managed Anemia Protocol by which RNs can administer and adjust erythropoiesis-stimulating agent (ESA) doses and supplemental iron. The indicators and target values are as follows:

Some additional highlights are:

* Upon admission to SARP, chronic patients will have the Anemia Protocol initiated unless otherwise specified by primary nephrologist

* A physician must be notified if an anemia situation occurs outside of the anemia protocol guidelines

* Baseline blood work is required prior to initiation of the protocol

* Maximum Aranesp [R] dose is 150 ug weekly and maximum Eprex [R] dose is 30,000 units weekly

* Aranesp [R] and Eprex [R] should not be increased by more than 30% increments at any given time, whereas dose decreases may be more than 30% increments

* Blood work, ESA doses and actions are to be charted in the Anemia Management Log each month and must be double checked by another nurse

* If for any reason the patient is to stop the Anemia Protocol, an order is to be written by the physician for discontinuation.

E. Nutritional status:

Many ESRD patients are malnourished. For this reason, periodic assessment of nutritional status is part of SARP's case management program. A panel of nutritional indicators, some of which are also inflammatory markers, are routinely measured.

Plasma albumin is associated with body protein stores. Low albumin may be suggestive of the following: malnutrition, underlying infection or inflammatory response, or under-dialysis (Kalantar-Zadeh et al., 2003).

* SARP Target: Albumin= 33-48 g/L

* KDOQI Target: > 40 g/L

Lipids are drawn yearly and every three to six months and if the patient is on a lipid-lowering medication.

High cholesterol in dialysis patients is strongly associated with high cardiovascular mortality. Paradoxically, low cholesterol has been associated with a worse prognosis, as it is linked to malnutrition, inflammation and dismal outcomes (Kovesday, Anderson, & Kalantar-Zadeh, 2007).

SARP and KDOQI Targets for lipid levels:

* LDL 2.5 mmol/L in non-diabetic, if diabetic < 2.0

* HDL ratio < 4.5 in non-diabetic, if diabetic < 4.0

We also take note of the following considerations when reviewing these parameters:

* Is the patient on Meals on Wheels?

* Has the patient been referred to the program dietitian?

Maintaining a normal potassium (K+) level is an important goal of hemodialysis. Hyperkalemia results mainly due to inability of the damaged kidneys to remove excess potassium.

Questions to consider and discuss with the team and patient are:

* What is the most current K+ value?

* What is the dialysate K+ prescription?

* What is the patient's dietary K+ intake? Should you refer to the program dietitian?

SARP and KDOQI Target: K+ = 3.5-5.5 mmol/L

F. Bone disease prevention and management:

As kidney dysfunction progresses, there is an inability to properly regulate mineral and bone metabolism. When the GFR falls, phosphate (PO4-) excretion is affected, leading to hyperphosphatemia. In addition, the kidneys are not able to activate Vitamin D such that calcium absorption via the gas-trointestinal system is decreased. This leads to hypocalcemia. The parathyroid gland senses the low calcium level and secretes parathyroid hormone (PTH) in order to release calcium from the bones to the circulation, often at the expense of the bones. Consequently, bone structure is weakened this condition is called Renal Osteodystrophy or Renal Bone Disease. The parathyroid gland becomes increasingly unable to control this disordered system and continues to work overtime, resulting in Secondary Hyperparathyroidism. The excessive calcium pulled from bone can deposit in the intima and/or medial layers of the arteries, causing arteriosclerosis and arteriolar calcification. The resulting skin necrosis is a painful and life-threatening complication called Calciphylaxis (Michael & Garcia, 2004).

Alkaline Phosphatase or ALP is measured as part of the mineral and bone profile because it is a marker of bone formation. A high ALP may indicate high-turnover bone disease as seen in Renal Osteodystrophy.

SARP targets:

* Calcium: 2.1-2.55 mmol/L

* Phosphate: 1.1-1.8 mmol/L

* Alkaline phosphatase: 30-130 u/L

* PTH: 100-500ng/L

KDOQI targets:

* Calcium: 2.20-2.37 (< 2.54) mmol/L

* Phosphate: 1.13-1.78 mmol/L

* Alkaline phosphatase: 30-145 u/L

* PTH: 150-300 u/L

Some questions for staff to consider are:

* What are your patient's laboratory values related to Bone and Mineral Disorder?

* Are they on phosphate binders? How are they taking them? Are they on active Vitamin D Therapy?

* Are patients compliant to regular medication intake? How about their dietary regimen?

G. Diabetes status:

One out of three patients with CKD has diabetes (Canadian Institute for Health Information, 2009). Our goal is to have well-controlled blood glucose levels. This is difficult. Blood glucose levels can fluctuate widely. At SARP, we have a Diabetic Nurse Clinician whose expertise is invaluable in managing patients with diabetes and renal complications. The care of these patients is unique in the sense that uremia and dialysis can complicate glycemic control due to alterations in the secretion and clearance of insulin. In our program, we measure Hemoglobin Al C and consider the value a reasonable reflection of glycemic control.

SARP Targets

* HgbAl C every 3 months: < 8%

* Blood sugars are checked mid-run on dialysis and documented on the treatment log

KDOQI Targets:

* HgbAlC <7%

* Glucose: diabetes (fasting): 4-6 mmol/L; if non-fasting > 6.0 mmol/L

H. Immunization and infectious disease monitoring:

Dialysis patients, by nature and the characteristics of their disease, are at higher risk of morbidity and mortality from the Hepatitis B virus (Burdick et al., 2003). Each new patient is monitored for their immunization status and infectious diseases status as follows:

* Hepatitis B status is checked upon admission and every 6 months

* Hepatitis B Surface Antigen is measured to establish if the patient is actively infected

* Hepatitis B Surface Antibody titers are measured to establish presence and level of immunity

* Vaccination is administered to improve or boost immunity if the patient has no natural or acquired antibodies. Guidelines are well defined in our SARP Hepatitis Policy

* Vancomycin Resistant Enterococcus (VRE) and Methicillin-Resistant Staph Aureus (MRSA) testing is done upon admission and yearly, as well as on the first dialysis treatment upon return from travel outside of the SARP program and the first dialysis treatment after discharge from hospitalization.

* Hepatitis C is checked upon admission and yearly

* HIV is checked upon admission and yearly, only if active on transplant list

* Pneumococcal vaccination is administered upon admission and after five years (Patients can only receive a maximum of two pneumococcal injections in their lifetime).

Psychosocial indicators

I. Advanced care planning and goals of care:

Conversations on advanced care planning and goals of care can be initiated by any of our staff. Health care professionals and individuals, family, or other designated representatives work together to make sure that the wishes of the patients are considered and followed. In our program, we consult our Advance Care Planning Leader who further explores and plans with the patient and their family if they choose to discontinue their dialysis. In addition, we can consult our Social Worker and Spiritual Leader who may participate in discussions with our patients on this very sensitive subject. We also have a Palliative Care Team exclusively dedicated to renal patients and led by a nephrologist to support the patients in their end of life journey. Our nurses refer to the palliative team especially when the patient's health status declines and the team assists them in facilitating comfort and other supportive measures.

* We have created a Goals of Care document that is reviewed annually by the nephrologist and/or when a patient's health care status changes.

J. Residence:

What type of support is available at home? A lot of our patients who are elderly and fragile need support if they still live at home. Sometimes, it is our nurses' astute assessment that uncovers areas of concern or safety risks that signal the inability of the client to live safely at home.

Residential options:

* Private home (alone/with spouse/with caregiver)

* Assisted living (designated/private/nursing home)

* Retirement living/lodge (subsidized/private).

K. Mobility/activity:

SARP is one of the hemodialysis programs that pioneered the use of an exercise program while the patient is undergoing dialysis. Patients are put on a stationary exercise bike and are supervised by our kinesiologist while exercising. Their vital signs--including oxygen saturation--are monitored over the length of the exercise regimen. The length of the exercise session can range between five minutes to an hour, depending on the patient's condition and capabilities. Evidence has shown that intradialytic exercise has a wide range of benefits from improved clearance, prevention of hypotension and improved overall well-being (Painter & Zimmerman, 1986; Leung, 2004). Strengthening and stretching exercises are also part of the exercise program.

Documentation standards:

* Exercise program participation and tolerance

* Use of mobility aids (cane, walker, or wheelchair

L. Resources:

At SARP, we adopted a multidisciplinary team approach in order to provide holistic care for renal patients. The team enables them to adapt to the challenges of the disease itself and the changes in lifestyle that go along with it.

The following resources are available to patients:

* Social work

* Palliative care

* Row Your Own Boat program (self-management workshop)

* Spiritual care

* Interpretive services

* Dietary consults

* Wound clinic

* Home care

M. Transportation:

One of the major challenges of our patients is their access to transportation to hemodialysis treatments. Some are unable to continue to drive due to safety issues. Some depend on their family members to bring them to and from the dialysis centres.

The following information is documented:

What modes of transportation does the patient use?

* Handibus (assisted transportation)

* Family

* Friend/self?

N. Miscellaneous:

This portion of the case management program is a screening tool to track patients' other health issues and concerns.

Examples of miscellaneous items that are documented are as follows:

* Skin/wound concerns

* Foot assessment at monthly intervals (referral to wound clinic PRN)

* Hospitalizations

* New diagnosis/health issues

* Oxygen use

* Cognitive impairment or dementia
Anemia           SARP target   KDOQI target

Hemoglobin       95-115 g/L    100-120 (max

Iron Saturation  20-50%        > 20%

Ferritin         200-800 ng/L  > 200


Although we do not have the image of the case management tree posted in our hemodialysis unit, it has been used as a means for staff to envision the holistic approach required in providing case management. Like a real tree, case management can only flourish and produce fruit when all elements of patient care are taken into consideration. In SARP, case management is performed on all patients monthly by nursing staff to ensure the vigilance required for this holistic approach. We are starting, informally, to observe a change in our patient outcomes based upon the broad spectrum of monitoring and documentation of our case management parameters within our Primary Access Regional Information System (PARIS) charting tools. In addition, this process has opened dialogue between nurses and their patients, allowing conversation to occur that may have otherwise gone unsaid. It promotes and builds upon the therapeutic relationship between nurses and their patients, which can only lead to improved expression of needs--and, thereby, the opportunity to meet those needs. The fruit of our labours, then, becomes superior patient outcomes.


The authors would like to acknowledge the support of Bonnie Couture, RN, CNeph(C), for the editing of this manuscript prior to submission.

Copyright [c] 2012 Canadian Association of Nephrology Nurses and Technologists


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Chan, C., Floras, J., Miller, J., Richardson, R., & Pierratos, A (2002). Regression of left ventricular hypertrophy after conversion to nocturnal dialysis. Kidney International, 61, 2235-2239.

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Kovesday C.P., Anderson J.E., & Kalantar-Zadeh, K. (2007). Inverse association between lipid levels and mortality in men with chronic kidney disease who are not yet on dialysis: Effects of case mix and the malnutrition-inflammation-cachexia syndrome. Journal of the American Society of Nephrology, 18, 304-311.

Leung, R. (2004). Physiological effects of exercise during dialysis on chronic renal failure patients. Journal of Exercise Science and Fitness, 2(1), 30-351

Lindsay, R., Sternby, J., Olde, B., Persson, R., Thatcher, M.E., & Sargent, K. (2006) Hemodialysis blood access flow rates can be estimated accurately from on-line dialysate urea measurements and the knowledge of effective dialyzer urea clearance. Clinical Journal of the American Society of Nephrology, 5, 960-964.

Michael, M., & Garcia, D. (2004). Secondary hyperparathyroidism in CKD: Clinical consequences and challenges. Nephrology Nursing Journal, 31(2), 185-194.

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Silverstein, F. (2007, November). Nocturnal dialysis offers better health while you sleep. American Association of Kidney Patients: aakpRENALIFE. Retrieved from

Thomson, C. (2001). Advising dialysis patients to restrict fluid intake without restricting sodium intake is not based on evidence and is a waste of time. Nephrology Dialysis Transplantation, 8, 1538-1542.

By Tina Cormier, RN, BScN, CNeph(C), Ofelia Magat, RN, BScN, CNeph(C), Suzy Hager, RN, Fanny Ng, RN, BN, and Miran Lee, RN, BN Tina Cormier, RN, BSc1V, CNeph(C), Staff Nurse, Community Hemodialysis, Sheldon M. Chumir Health Centre, Alberta Health Services, Calgary, AB

Ofelia Magat, RN, BSc1V, CNeph(C), Clinical Nurse Educator, Community Hemodialysis, Sheldon M. Chumir Health Centre, Alberta Health Services, Calgary, AB

Suzy Hager, RN, Staff Nurse, Community Hemodialysis, Sheldon M. Chumir Health Centre, Alberta Health Services, Calgary, AB

Fanny Ng, RN, BN, Staff Nurse, Community Hemodialysis, Sheldon M. Chumir Health Centre, Alberta Health Services, Calgary, AB

Miran Lee, RN, BN, Staff Nurse, Apheresis, Foothills Medical Centre, Alberta Health Services, Calgary, AB

Address correspondence to: Tina Cormier, RAI, BSc1V, CNeph(C), 6 Elgin Meadows Road, SE, Calgary, AB T2Z 0S1


Submitted for publication: October 17, 2011.

Accepted for publication in revised form: January 8, 2012.
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Author:Cormier, Tina; Magat, Ofelia; Hager, Suzy; Ng, Fanny; Lee, Miran
Publication:CANNT Journal
Geographic Code:1CANA
Date:Apr 1, 2012
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