Dialysis: It's a Partnership - Part I

Are Kidney Dietitians the Diet Police?

Medications While on Dialysis: Helping Improve Your Treatment Goals

Good Access = Good Dialysis

The Importance of Good Water for Good Dialysis

Quality Assessment and Process Improvement in Dialysis

Providing Quality Care and The New Rules Under Medicare: What You Should Know

Dialysis: It's a Partnership - Part I
Anastasia Korbitz, Editor

Can we talk? I hope so, as this is a lot of what we all do at WDI when you become a dialysis patient. Talk-talk-talk, but that's a good thing! This is how we both know how well you are eating, dialyzing, feeling and coping.

The staff at WDI really appreciates it when you talk with us about your well-being, tell us your concerns, and ask questions and inform us of your goals and how you want to meet them. We strive to make all this talking a two-way street. WDI tells YOU how you are doing and YOU tell WDI how you are doing. See how this works?

I think we have an excellent team at WDI. I may be biased, but it's true. They are a dedicated team of professionals, but there is one thing they cannot do…wonder what that is? Well, they cannot read your mind! We all took that class on mind-reading and it just didn't work. So, you have to tell us what's on your mind.

Part I of this newsletter focuses on talking about the role of WDI in your care. Do you ever wonder why dialysis is done the way it is or the reason for our recommendations? Well, we don't just make stuff up, although we need to be able to think on our feet! Decisions are based on training, research and guidance.

By training, I mean that each discipline on a dialysis unit has to undergo education and training to provide you with the best care currently available. Your team must do annual and biannual training of current issues to help you have the best outcomes.

You may not be aware, but dialysis has changed over its long history. Your care is based on years of research to address the best ways of delivering care. Research is ongoing and its outcomes often lead to more questions and the need for more answers, ultimately leads to the need for more research. Think of it as a very long, long discussion.

Guidance regarding dialysis care comes from all levels from the Medical Director, physician, administration and Medicare. Indeed Medicare closely monitors dialysis unit outcomes and sets expectations for care in a dialysis facility.

So, Part I will provide you with information on some aspects of the dialysis process you may not know about. Consider this a "behind-the-scenes-tour". You will hear from experts about how their involvement helps provide you with the best possible care. Finally, you will have the opportunity to learn more about the changes as established by Medicare.

Part I will focus on "what WDI does to ensure good dialysis" for YOU. The next edition, Part II, will discuss what YOU can do to obtain good dialysis and the best outcomes for yourself. You didn't think you would just sit back and not be involved in this whole dialysis process, did you?

Read on and then if you like, we can talk...

Are Kidney Dietitians the Diet Police?
Fran Kittell, RD

When you see the dietitian approaching your chair, do you begin to think, "Oh, no!"  Do you feel trapped in your chair and want to flee?

Do you consider the dietitian the "food police"? What is the role of the kidney dietitian? Hopefully you don't feel like fleeing, but instead realize you can use your dietitian as a great resource for feeling good while on dialysis.

The diet suggested for someone on dialysis is not easy. It can be confusing and appear to be just the opposite of what you may hear on T.V or even what your neighbor says they eat.

Who is your kidney dietitian? Did you know your dietitian went to college for four years? Not only that but, your dietitian interned for about a year before having to take a national examination for their registration. It does not stop there. To be a kidney dietitian, a little more advanced, your dietitian likely trained additionally on a kidney unit before qualifying as a kidney dietitian. Furthermore, at WDI, both Ann and I have taken and passed a renal specialty nutrition examination to qualify as specialists in this area of dietetics. So, you have an invaluable resource readily available at your nutritional request!

And why is that so important? To do well on dialysis, in fact, survive longer, you need to eat well. This is not always so easily achieved! The diet suggestions often can be conflicting and confusing. Eating too much or too little potassium can be fatal. Eating too much phosphorus can make your bones frail. Not eating enough protein can shorten your life expectancy while on dialysis. We realize how hard it can be to find the appropriate levels of these dietary variables in what you eat. That is what your dietitian is for. Use this person.

We want eating to continue to be an enjoyable experience; not frightening or necessarily too restrictive. Your dietitian may be able to fit your favorite foods into your meal plan. Your dietitian understands your monthly lab values and how they can reflect what you can eat. Your dietitian enables you to make good food choices, perhaps enabling you to include a favorite high potassium containing food into your meals. Your dietitian has many tricks-up-the-sleeve, such as using nondairy creamer as a substitute for milk on cereal or freezing grapes to help control thirst.

So, next time the dietitian approaches your chair, ask them to stop and answer your diet questions. We love it when you have diet questions! Keep an ongoing list of questions. For example, what can you eat to feel better? Another example, ask how you can fit chocolate into your life without getting too high a potassium level in your blood. More often than not, your dietitian will have all kinds of diet ideas that will help you feel better about what you eat while on dialysis.

Medications While on Dialysis: Helping Improve Your Treatment Goals
Kim Holdener, PharmD

There are three main medications that are routinely given to patients while on dialysis at WDI. Two of these, darbepoetin (Aranesp) and iron sucrose (Venofer), are used to treat anemia or low red blood cells. The third medication, paricalcitol (Zemplar), is a vitamin D supplement that is given to help with bone health. All three of these medications are important for your overall health and well-being while on dialysis.

People with kidney disease often develop anemia which means you have low red blood cell counts. This is because your kidneys produce a hormone erythropoietin (EPO) that tells your body to make red blood cells. When your kidneys do not work well, they do not make enough of this hormone and, therefore, your body does not have enough red blood cells.

Red blood cells are important because they carry oxygen around to different parts of your body and give you the energy you need for daily activities. Symptoms of anemia include feeling tired, shortness of breath, looking pale, fatigue, and having trouble concentrating. These symptoms can directly affect your quality of life. Anemia is also associated with increased risk of death and hospitalization for people with kidney disease.

You may receive two medications while on dialysis that help to treat anemia, darbepoetin and/or iron sucrose. Darbepoetin is a man-made form of EPO that is used to treat anemia. It is given intravenously (IV) once a week during hemodialysis treatments or as a subcutaneous (under the skin) injection every one to four weeks for people on peritoneal dialysis. Iron is also an important part of anemia treatment. This is because iron in your body is used to make new red blood cells.

If you do not have enough iron your body can not make red blood cells no matter how much darbepoetin you receive. For people on peritoneal dialysis, an oral iron supplement is often adequate. However, people on hemodialysis need intravenous iron because oral iron will not provide enough iron to keep iron levels where they should be. When iron levels are low, a "load" of IV iron is given in ten doses over ten dialysis sessions. When iron levels are normal, patients often receive a "maintenance" dose of iron once a week.

The third medication that may be given on dialysis at WDI is called paricalcitol and is used to treat bone disease associated with kidney disease. Paricalcitol is a vitamin D supplement. It is given to help lower parathyroid hormone (PTH) levels. PTH levels are part of the balance of phosphorus and calcium levels in your body. When these levels become abnormal, it affects your bone health and can cause osteoporosis-like symptoms. People who are on peritoneal dialysis often take this medication, or one like it, in a pill form.

All three of these medications that are given during dialysis treatments help to improve your health and quality of life. Your monthly lab report card has the results of your anemia and bone health labs. You can discuss these results with your nurse, nurse practitioner, dietitian, pharmacist or physician to see if they are meeting our treatment goals, and how these medications are adjusted to give you the best outcomes.

Good Access = Good Dialysis
Xinliu Meyer

If you receive hemodialysis four hours per treatment, three times weekly, then you spend a total of 78 days in a year on dialysis. Since dialysis consumes this big chunk of your time, you want to make sure that you are receiving good dialysis every time.

How do you know you are getting good dialysis? The effectiveness of hemodialysis treatment is measured by waste removal ratio during one given dialysis treatment, which is called URR (Urea Reduction Ratio). The more waste removal during dialysis treatment, the higher URR you will get and the better your dialysis is. URR is the measure for dialysis adequacy.

Multiple factors can contribute to how good of a dialysis you may receive or the adequacy of your dialysis. However, having a good functioning hemodialysis access is one of the crucial steps toward getting good dialysis.

An arterial venous fistula is the gold standard access for patients on long term hemodialysis. It is recommended by KDOQI (Kidney Disease Outcomes Quality Initiative) and Fistula First Coalition as the preferred permanent access for dialysis.

A fistula is a surgical connection between an artery to a vein, usually in the forearm or an upper arm. A fistula is superior to a catheter. Patients with a fistula have few infections (2008 USRDS Annual Data Report, Volume II ESRD Emerging Issues), less hospitalizations (Seminars in Dialysis, Vol. 21. 2008) and lower death rates (International Society of Nephrology, 2001, Vol. 60) than those with catheters. Patients who use a fistula are able to achieve better adequacy of dialysis and consequently, they report greater physical activity, energy, emotional and social well-being compared to patients using a catheter. (2008 USRDS Annual Data Report, Volume II ESRD Emerging Issues).

The Importance of Good Water for Good Dialysis
Emily Reitz, PCT Manager

Did you know that the average person consumes about 3.7 gallons of water per week while the dialysis patient is exposed to 95 gallons of water per week? This is the reason why very high water quality is so important in the dialysis unit.

All hemodialysis treatments require the use of purified water. Purification starts with the incoming water source in whichever town or city your unit is in. From there our equipment goes to work removing inorganic materials like trace minerals and heavy metals, and organic materials like bacteria, viruses, and endotoxins. Healthy kidneys would normally excrete these toxic substances into the urine. The main piece of equipment that removes toxins from the water is known as the "RO" or the reverse osmosis system.

Dialysis has very strict standards for water quality which are set by AAMI, (Association for the Advancement of Medical Instrumentation) which requires many different tests on the water. Here at WDI you may have seen some of our staff collecting samples from different stations.

We test several outlets per month both in the unit and in the water room and monitor results closely. We also monitor our water quality starting first thing in the morning and periodically throughout the day.

Quality Assessment and Process Improvement in Dialysis
Michelle Krueger, RN, Clinic Nurse Manager

Q.A.P.I – This stands for Quality Assessment and Performance Improvement. This is a very important part of the background workings here at Wisconsin Dialysis. There are many individuals involved in the ongoing assessment of quality at WDI.

Who are they? These individuals include:  our Medical Director, Dr. Paul Kellerman; our Facility Administrator, John Hensey, myself, the Clinical Nurse Manager, Michelle Krueger; our Clinical Nurse Specialist, Xinliu Meyer; our Nurse Care Team Leaders, Cheryl Bass and Carla Campbell; our Renal Dietitians, Fran Kittell and Ann Mader; our Social Workers, Anastasia Korbitz and Deb Parker; our Nurse Practitioner, Deb Krembs; our pharmacist, Kim Holdener, and several nurses in the in-center hemodialysis unit who work on our anemia management protocol (Lila Jorgensen and Casey Dathan), bone health protocol (Kathleen Bendewald), hepatitis vaccinations and monitoring (Jackie Simmons), and dialysis adequacy monitoring (Kelly Coloso).

Our Home Dialysis program also includes each of the home dialysis nurses and our Associate Medical Director, Dr. Lisa Nanovic. Our Senior Executive Assistants, Kris Kappel and Tricia Borgrud assist with the all important record keeping of the efforts of this large group of individuals. The final individual, and perhaps the most important part of the group, is each of you, our dialysis patients.

Now that you know who the members of the team are, what exactly are they doing?  There are many parameters and core indicators that we look at that tell us about the quality of the dialysis treatments we are providing and the therapeutic environment we maintain in the clinic.

Remember the report card that you receive each month? This information is important to us too. The labs on the report card sum up what we call the "core indicators". This includes hemoglobins, ferritin or iron levels, Transferritin saturation, albumin or blood protein levels, phosphorus, PTH or parathyroid hormone, URRs or Urea Reduction Ratio and Kt/V or dialysis clearance . There are goals that we strive to meet among all of our dialysis patients to ensure that we are providing the best dialysis, good anemia management practices, good bone health practices, and all patients are maintaining good nutritional status.

The next items that we look at do not depend on your lab data. We also look at our mortality data which reviews those patients that have gone before us. We review our dialysis access types to ensure we are working as partners with each of you to obtain and maintain the best access for you. Once you have had a fistula or graft placed, we try to have the catheter removed within 90 days. This is an effort to lower infection risks, provide better dialysis treatments and encourage the use of the new permanent access.

We look at water chemistry and microbiology results. In other words, we make sure our water used in dialysis is kept ultra pure. We look at trends in infection control and hospitalization rates to ensure we continue below the national averages. We do chart audits to ensure our documentation is thorough. We look at trends in occurrence screens, infectious waste data, and review our patients on the transplant waiting list.

Providing Quality Care and The New Rules Under Medicare: What You Should Know
Anastasia Korbitz

You may not be aware of it, but there is a lot of "behind the scenes" activity at WDI to keep our dialysis program going strong. The goal, since our inception, is to provide the best treatment currently available. How do we do it? Well, first and foremost we are committed to quality care. Also, WDI, like all other dialysis programs, is closely monitored by Medicare to ensure we meet specific quality of care guidelines. Dialysis programs are reviewed at regular intervals, on-site, by a Medicare surveyor.

In October of 2008, Medicare provided updated regulations for the delivery of dialysis that all units must follow. The new guidelines build on an already standardized program by asking more of dialysis units and of you!

Much of the new guidelines are devoted to involving you even more in education, treatment choice and participation in your own care. Patients are not the only ones affected by the new regulations, the staff and dialysis organizations are too.

Here are some highlights regarding the new regulations from Medicare that you should know:

• Facilities must maintain a comfortable temperature and make "reasonable accommodations" for patients who are not comfortable at that temperature.
• Facilities must provide patient privacy during physical examination or exposure of private body parts.
• Patients must be informed about what to do during emergencies and how to plan for them.
• Patients have the right to receive information about their care in ways that they can understand.
• Patients have the right to expect that their facility staff will: 1) Treat them with respect, dignity, and sensitivity; 2) Take into consideration their physical condition, emotional state, and cultural background; and 3) Not retaliate against those who question staff procedure or staff performance.
• Patients have the right to be informed about all treatment modalities (not just those offered by a facility).
• Patients have the right to participate in their care to the extent that they desire and have the right to refuse any aspect of treatment.
• Patients have the right to privacy and confidentiality in all aspects of treatment, including their medical records.
• Patients have the right to be informed regarding patient care policies, facility rules and expectations of patient conduct, the facility complaint process and patient transfer and discharge policies.
• Patients have the right to file a complaint against facilities without punishment or any form of retaliation for doing so.
• Patients have the right to receive a 30 day advance written notice of a facility discharge, when done against the patient's will except in the case of an immediate threat to the health and safety of others).
• The facility must include the patient in the development of the Patient Assessment and Plan of Care.