Adapting the dialysis unit to increased hematocrit levels.
Recombinant human erythropoietin (epoetin) therapy had a significant impact on the practice of nephrology before its widespread use in the dialysis arena. Since then, a number of long-term studies have provided physicians with parameters for optimizing therapeutic response and patient outcomes with epoetin therapy. Fears of accelerated hypertension syndromes or increased fistula clotting are recognized as largely unfounded. There is a marked improvement in well-being, as measured by both subjective and objective parameters, as the level of anemia is reduced. Fortunately, epoetin was recognized early as essential therapy in patients on dialysis and thus was reimbursed by the Health Care Financing Administration (HCFA) and other payers, albeit through various methods of payment. Why is it, then, that hematocrit levels are still averaging approximately 30%? Perhaps the basic concern that all practitioners share is the potential for increased morbidity at "higher" hematocrit levels. Increased access clotting was not reported in the recently completed Epogen (Epoetin alfa; Amgen Inc, Thousand Oaks, CA) phase IV postmarketing study. Needle size, however, needs to be considered, because higher blood flow rates accompanied by higher hematocrit levels may lead to increased hemolysis. The venous needle size is especially important in patients who experience large weight gains. It is important to keep these issues in mind as one decides on an appropriate hematocrit level for a given patient. Hull and Eschbach reviewed postdialysis data from patients with naturally occurring high hematocrit levels and found no major changes in hematocrit level, thus alleviating the concern of significant postdialysis inspissation as a common cause for fistula clotting.
Paganini
E P
EP
Department of Hypertension/Nephrology, Cleveland Clinic Foundation, OH 44195, USA.
D000328:Adult; D000740:Anemia / Q000209:etiology / Q000517:prevention & control; D001166:Arteriovenous Shunt, Surgical; D001783:Blood Flow Velocity; D001794:Blood Pressure; D004921:Erythropoietin / Q000009:adverse effects / Q000627:therapeutic use*; D006400:Hematocrit; D006801:Humans; D007676:Kidney Failure, Chronic / Q000097:blood* / Q000628:therapy; D009339:Needles; D006435:Renal Dialysis; D013927:Thrombosis / Q000503:physiopathology
D004921:Erythropoietin