Nette, R.W.

Justification for a home-based education programme for kidney patients and their social network prior to initiation of renal replacement therapy (Article)

2011-05-30T00:00:00Z

In this article, an ethical analysis of an educational programme on renal replacement therapy options for patients and their social network is presented. The two main spearheads of this approach are: (1) offering an educational programme on all renal replacement therapy options ahead of treatment requirement and (2) a homebased approach involving the family and friends of the patient. Arguments are offered for the ethical justification of this approach by considering the viewpoint of the various stakeholders involved. Finally, reflecting on these ethical considerations, essential conditions for carrying out such a programme are outlined. The goal is to develop an ethically justified and responsible educational programme.

Development of the Rotterdam Renal Replacement Knowledge-Test (R3K-T) (Research Report)

2011-04-01T00:00:00Z

Introduction: There is currently a lack of validated or standardized measures to test the level of knowledge among renal patients regarding kidney disease and available treatment options. We conducted a pilot study to develop a questionnaire measuring knowledge of kidney disease, dialysis and transplantation options. The main aim of this study was to develop such an instrument for further use in research and practice. Method: An initial 61 item pool was generating by searching the literature and consulting experts in this area for additional items. This questionnaire was completed by 182 renal disease patients from 4 dialysis centers in the Rotterdam municipality. A factor analysis was conducted using the maximum likelihood factor method followed by direct oblimin rotation to obtain variance explained by each factor. Questions that loaded ≥ .30 on a factor were included. Results: Twenty-seven patients (24%) were in the pre-RRT phase, 60 (54%) were undergoing haemodialysis, 16 (14%) were undergoing peritoneal dialysis, and 9 (8%) had a graft failure. Forty (36%) were female and 72 (64%) were male. Age range 19-87 (median = 59). A factor analysis was conducted to reduce the number of items. This resulted in 30 items consisting of 5 subscales regarding knowledge on: kidney disease (5 items, α = .37), peritoneal dialysis (4 items, α = .73), haemodialysis (4 items, α = .41), kidney transplantation (12 items, α = .86), quality of life (5 items, α = .59). Discussion: This study aimed to develop an instrument with which knowledge of kidney disease and the related treatment options can be reliably measured. This study resulted in a short and easy to administer knowledge questionnaire. We intend to further explore the psychometric properties of this instrument and develop norm scores for the general public and patients at various stages of the disease and treatment. We have also considered translated versions of this questionnaire.

Blood volume regulation during hemodialysis (Doctoral Thesis)

2003-12-03T00:00:00Z

The blood pressure response during dialysis depends on blood volume preservation and/on changes in vascular tone. However, these two are not independent. In order to delineate the role of blood volume profiling in the prevention of intradialytic hypotension, more information is needed on the relationship between these physiological defense mechanisms. Therefore, we performed several studies to clarify this relationship and to improve the understanding of dialysis related hypotension. Such understanding is desperately needed before preventive measures can be initiated.

Preload dependence of new Doppler techniques limits their utility for left ventricular diastolic function assessment in hemodialysis patients (Article)

2003-01-01T00:00:00Z

Left ventricular (LV) hypertrophy leads to diastolic dysfunction. Standard Doppler transmitral and pulmonary vein (PV) flow velocity measurements are preload dependent. New techniques such as mitral annulus velocity by Doppler tissue imaging (DTI) and LV inflow propagation velocity measured from color M-mode have been proposed as relatively preload-independent measurements of diastolic function. These parameters were studied before and after hemodialysis (HD) with ultrafiltration to test their potential advantage for LV diastolic function assessment in HD patients. Ten patients (seven with LV hypertrophy) underwent Doppler echocardiography 1 h before, 1 h after, and 1 d after HD. Early (E) and atrial (A) peak transmitral flow velocities, peak PV systolic (s) and diastolic (d) flow velocities, peak e and a mitral annulus velocities in DTI, and early diastolic LV flow propagation velocity (V(p)) were measured. In all patients, the E/A ratio after HD (0.54; 0.37 to 1.02) was lower (P < 0.01) than before HD (0.77; 0.60 to 1.34). E decreased (P < 0.01), whereas A did not. PV s/d after HD (2.15; 1.08 to 3.90) was higher (P < 0.01) than before HD (1.80; 1.25 to 2.68). Tissue e/a after HD (0.40; 0.26 to 0.96) was lower (P < 0.01) than before HD (0.56; 0.40 to 1.05). Tissue e decreased (P < 0.02), whereas a did not. V(p) after HD (30 cm/s; 16 to 47 cm/s) was lower (P < 0.01) than before HD (45 cm/s; 32 to 60 cm/s). Twenty-four hours after the initial measurements values for E/A (0.59; 0.37 to 1.23), PV s/d (1.85; 1.07 to 3.38), e/a (0.41; 0.27 to 1.06), and V(p) (28 cm/s; 23 to 33 cm/s) were similar as those taken 1 h after HD. It is concluded that, even when using the newer Doppler techniques DTI and color M-mode, pseudonormalization, which was due to volume overload before HD, resulted in underestimation of the degree of diastolic dysfunction. Therefore, the advantage of these techniques over conventional parameters for the assessment of LV diastolic function in HD patients is limited. Assessment of LV diastolic function should not be performed shortly before HD, and its time relation to HD is essential.

Specific effect of the infusion of glucose on blood volume during haemodialysis (Article)

2002-01-01T00:00:00Z

BACKGROUND: Intradialytic morbid events such as hypotension and cramps during haemodialysis are generally treated by infusion of iso- or hypertonic solutions. However, differences may exist between solutions with respect to plasma refilling and vascular reactivity. METHODS: We compared the effect of no infusion (NI) with isovolumetric infusion of isotonic saline 0.9% (IS), saline 3% (HS), isotonic glucose 5% (IG), glucose 20% (HG) and mannitol 20% (HM), in six patients during the first hour of six standardized haemodialysis sessions with ultrafiltration. Relative blood volume was monitored continuously by measurement of the intravascular amount of protein. Blood pressure was measured by an oscillometric method, while cardiac output was measured by a thoracic impedance technique. RESULTS: At baseline, no differences in serum urea, sodium, potassium, glucose and osmolarity were found between the various infusion experiments. The maximum increase in relative blood volume directly after infusion was significantly greater with HG (5.1+/-0.7%) than with all other infusions (P<0.05). Stroke volume increased (21.0+/-19.2%, P<0.05) and total peripheral resistance decreased significantly (15.4+/-16.4%, P<0.05) after HG infusions. CONCLUSIONS: Infusion of hypertonic glucose during dialysis results in a greater increase in relative blood volume (RBV) than equal volumes of other solutions. As mannitol has the same osmolarity, molecule mass and charge, the greater increase in RBV following hypertonic glucose appears to be a specific effect, possibly related to a decline in vascular tone. It is therefore uncertain whether the observed increase in plasma volume during hypertonic glucose infusions will be of clinical benefit.

Variability of relative blood volume during haemodialysis (Article)

2000-01-01T00:00:00Z

BACKGROUND: A decrease in blood volume is thought to play a role in dialysis-related hypotension. Changes in relative blood volume (RBV) can be assessed by means of continuous haematocrit measurement. We studied the variability of RBV changes, and the relation between RBV and ultrafiltration volume (UV), blood pressure, heart rate, and inferior caval vein (ICV) diameter. METHODS: In 10 patients on chronic haemodialysis, RBV measurement was performed during a total of one hundred 4-h haemodialysis sessions. Blood pressure and heart rate were measured at 5-min intervals. ICV diameter was assessed at the start and at the end of dialysis using ultrasonography. RESULTS: The changes in RBV showed considerable inter-individual variability. The average change in RBV ranged from -0.5 to -8.2% at 60 min and from -3.7 to -14.5% at 240 min (coefficient of variation (CV) 0.66 and 0.35 respectively). Intra-individual variability was also high (CV at 60 min 0.93; CV at 240 min 0.33). Inter-individual as well as intra-individual variability showed only minor improvement when RBV was corrected for UV. We found a significant correlation between RBV and UV at 60 (r= -0.69; P<0.001) and at 240 min (r= -0.63; P<0.001). There was a significant correlation between RBV and heart rate (r= -0.39; P<0.001), but not between RBV or UV and blood pressure. The level of RBV reduction at which hypotension occurred was also highly variable. ICV diameter decreased from 10.3+/-1.7 mm/m(2) to 7.3+/-1. 5 mm/m(2). There was only a slight, although significant, correlation between ICV diameter and RBV (r= -0.23; P<0.05). The change in ICV-diameter showed a wide variation. CONCLUSIONS: RBV changes during haemodialysis showed a considerable intra- and inter-individual variability that could not be explained by differences in UV. No correlation was observed between UV or changes in RBV and either blood pressure or the incidence of hypotension. Heart rate, however, was significantly correlated with RBV. Moreover, IVC diameter was only poorly correlated with RBV, suggesting a redistribution of blood towards the central venous compartment. These data indicate that RBV monitoring is of limited use in the prevention of dialysis-related hypotension, and that the critical level of reduction in RBV at which hypotension occurs depends on cardiovascular defence mechanisms such as sympathetic drive.

Cardiologists' Use of clinical information for management decisions for patients with unstable angina: a policy analysis (Article)

1997-07-17T00:00:00Z

Previous studies of management of unstable angina have revealed substantial differences in management between different hospitals, especially with respect to the use of coronary angiography. Physicians in a hospital with angiography facilities were more inclined to perform angiography than were physicians in hospitals without these facilities, even when differences in patient populations were taken into account. The authors compared the management strategies of 18 cardiologists, working in hospitals with and without angiography facilities, using a series of paper-case summaries, in order to assess the contribution of individual variability between physicians to practice differences. Physicians who worked in a hospital with in-house angiography facilities were more inclined to request angiography in similar case summaries, but the inter-individual variation exceeded the between-hospital variation. The variation in individual policies with respect to the decision to initiate coronary angiography could be associated with differences in weighting clinical information. These results confirm that practice variations may have many causes: variability in patients' characteristics, variations in how physicians react to these, differences in the availability of services, and variability in thresholds for action.