The Old Paradigm The full container

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The Old Paradigm (The full container) Fistula First Utilize Kt/V for "satisfactory" dialysis 3 – 4 hours, thrice week after week Manage ASCVD "Advance" treatment: pallor (EPO and Iron), divalent particles (phosphate covers), PTH (Vitamin D), lipids, BP control, appraise "dry weight" Restrictive eating regimens Early Start

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The State of Renal Care in the U.S. Difficulties and Changes "We can improve" Dallas, Texas June, 2010

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The Boston Steering Committee Conclusions The model of dialytic care since the 1970s is lacking: the nephrology group likely utilized inadequate - maybe even imperfect – science, at any rate as we probably am aware the science now the suppliers and payers upheld the model for a long time. The issue is proliferated by how we measure ourselves: Clinical Performance Measures ; (CPMs; CPGs; i.e., HGB, Kt/V, Ca, P, … ) Though tremendously supportive, current CPMs don't give the ability to anticipate the results that we had sought after, either for the patient or the office. Current CPMs represent just around 14% of the quantifiable contrasts in office results (SMRs). Importantly, an excessive number of patients are biting the dust, hospitalizations are too high, and cost is tremendous. The Boston meeting presumed that now we have the data to change this

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To achieve: The REASONS for the Boston Meeting Mortality patterns Hospitalization patterns Costs SUMMARY of Boston Meeting information, conclusions and suggestions ACTIONS to execute change, since the meeting

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Dallas M and M Conference

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The Boston meeting inferred that – now – we can show improvement over this.

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The Boston meeting inferred that we can take care of this.

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once more, it was reasoned that we can take care of this.

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$34B if different payors included

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Our Current Milieu of Care 20% of office patients kick the bucket every year; 70% expired in 5 years; Up to 40% mortality in the primary year A program that expenses $34+,000,000,000/year With a cost of $60 – 80,000 PPPY with the distinction in light of AV get to alone $20,000 PPPY in hospitalizations, for the most part because of cardiovascular ailment and contamination Less than 20% restoration 110,996 new ESRD patients – 2007 101,688 In Center HD 6506 PD (6875 in 2005) 2665 Pre-emptive transplant (2424 in 2005)

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Possible Therapies CAPD CCPD Conventional In Center Nocturnal In Center Conventional HHD Nocturnal HHD Short Daily HHD Transplant Living Cadaveric Palliative Therapies Stratified by Nephrologists' Choice Transplantation Nocturnal HHD Nocturnal In-focus and Short Daily HHD Conventional HHD CAPD and CCPD Conventional In Center Palliative Therapies and Outcomes Results from a casual review at 2008 ASN

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98% would pick contrasting options to traditional care. In the event that we will pick ordinary treatment for patients, then we have to improve. How about we at any rate take care of business.

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To Accomplish This Morning The REASONS for the Boston Meeting Mortality Hospitalization patterns and causes Costs A SUMMARY of Boston Meeting information, conclusions and suggestions ACTION since the meeting

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Primary Issues Identified (4 days, >1700 PPT Slides) Infection and AV Access Cardiovascular Disease Inflammation The Dialysis Dose The First Year

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Catheter Events and Hospitalizations Fistula occasions and intricacy are .2 to .4 as common

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Consequences of Catheters 22% irresistible difficulties, with septic joint inflammation, endocarditis and osteomyelitis 43% higher cardiovascular related demise rate than fistulas in a few studies AVF following 90 days with 29% diminishment taking all things together cause mortality contrasted with catheters Greater all cause and contamination related hospitalizations Reduced dialysis ampleness, poorer personal satisfaction and more prominent expenses

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Infection Trends Infection hospitalizations considerably expanding over recent years, to a great extent because of catheters Infection hospitalizations expanding at a rate more prominent than cardiovascular hospitalizations Much higher expenses in patients with catheters There is even likely a linkage between one get to contamination and related continuous danger of death Higher mortality in catheter patients and offices with more catheters (and unions)

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Boston Meeting Recommendations #1: Infection and Access Acknowledge: The catheter issue is IATROGENIC Hospitals, wellbeing arranges, nephrologists, suppliers and vascular specialists (as of now, half essential disappointment rate) must be responsible for lessening catheter situation CMS should seriously think about moving catheters, as a CPM, to the extremely largest amount of investigation and studies and place less accentuation on CPMs that have little effect in results They simply finished up a TEP to make simply such proposals, which are presently being viewed as Vaccination, as a CPM, should be a critical part of office practice and responsibility

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Primary Issues Infection and AV Access Cardiovascular Disease Inflammation The Dialysis Dose The First Year

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ASCVD is obviously not the main source of CV passing, and these years we've focused on hemoglobin, calcium, phosphorus, lipids and so forth – to settle the cardiovascular issue. We've basically been taking a gander at the wrong results measures to enhance mortality, hospitalizations and cost connected with CV illness.

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It's LVH and Cardiomyopathy % LVH glassock

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THEME: Alterations in LV Mass in CKD/ESRD are an Example of What isn't right with Conventional Regimens of Treatment

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The Core Issues: LV Disease LV mass illness advances as CKD advances (not unavoidably) Increased LV Mass is extremely common in the occurrence ESRD persistent (70%), with just insignificant to unassuming change with ordinary in-focus HD (somewhat better with PD) Non regressors have an exceptionally poor guess Glassock

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Three of each four passings and hospitalizations in dialysis patients can be connected to sudden demise or CHF Left Ventricular in Origin Glassock

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Leading Causes of LV Muscle and Fibrotic Disease Hypervolemia "dry weight" is a "scalawag" Whatever happened to euvolemia or standardized extracellular volume? Hypertension Inflammation (likely brought about by hypervolemia) Cardiac shocking amid excessively forceful ultrafiltration due to abbreviated dialysis

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Volume Overload and LVH In test unconstrained hypertension, LV Mass increment is connected to volume extension and salt admission, not to pulse Salt-stacking may build LV mass through nearby impacts (increase of An II impacts and TGF β ) (Varagic J. et al Am J Physiol Heart Circ Physiol 290:Hi503, 2006; Wu HCM, et al Circulation 98:2621, 1998) )

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Consequences of LVH and cardiovascular fibrosis CHF Difficulty accomplishing euvolemia with short Rx time Because of progressing hypervolemia, it is the main source of hospitalizations and demise, particularly in the primary year, however continuous. High reason for re-hospitalization Arrhythmias Fibrous tissue enclosing myocytes with high electrical resistance; nearby deferral of the spreading front of the activity potential Favors "reentry" kind of atrial and ventricular ARRYTHMIAS with high hospitalization and passing

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LVH and Dialysis mode and Prescription Conventional 3x/wk dialysis redresses under 40% of LVH Observational (cross-sectional) concentrates on demonstrate a lower commonness of LVH in PD contrasted with routine HD patients Emerging information: More continuous/longer HD sessions: emphatically connected with a much lower pervasiveness, even inversion of LVH contrasted with customary HD (Awaiting FHN thinks about) It is exceptionally hard to accomplish euvolemia with the ebb and flow model of care

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What has not worked so far in ordinary hemodialysis to determine cardiovascular malady? Statins have not been viable 4D and Aurora ESA treatment of iron deficiency has not salutarily affected mortality Attempting to accomplish euvolemia with ordinary HD Traditional result appraisals arranged towards ASCVD Sodium demonstrating and control

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LVH in ESRD: Effect of EPO treatment Seven (7) RCT have been led that analyze the impact of EPO treatment on LVH in CKD/ESRD All yet one have neglected to demonstrate any advantageous impact on LVH of EPO treatment and amendment of hemoglobin to typical or close typical levels

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Harmful Effect of Dialysis (after McIntyre CW, et al CJASN, 4:914,2009) Myocardial "Staggering" (transient local divider movement variation from the norm) grows regularly (65%) amid hemodialysis, particularly in nearness of basic CHD as well as Diabetes High UF volumes increment hazard Repeated scenes bargain heart work, prompt to LV fibrosis and improve mortality chance

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Sodium Known consequences for pulse and hypervolemia (between dialytic weight picks up) Blood weight free target organ harm Vasculature changes Minor increments of sodium in CSF or serum expands pressor systems and increments cardiotonic steroids – sodium displaying And we stack our patients with sodium Hypertonic Saline bolus for hypotension Saline bolus in the wash back (hypertonic) and preparing Sodium displaying Dialysate sodium (hypertonic to common serum sodium)

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A New Paradigm Adding control of LVH to Clinical Performance Guidelines will accomplish healthy impacts on grimness and mortality in ESRD treatment

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Cardiovascular Disease in ESRD: Boston Conclusions This is an issue of the left ventricle, not ASCVD It is an issue of hypervolemia The new worldview of ESRD treatment must incorporate adjustment of LVH a