New adequacy calculation
- 0Oct 29, '11 by just keep swimmingWe recently began using URR's as the measure of adequacy along with the KT/V. I have always tracked both on my patients, so no big deal. What I don't understand is that residual renal function is no longer calculated into any measurement of adequacy. This doesn't make sense to me...if someone has residual function, they need less HD, right? I have found that we are now increasing DFR, BFR, and times to make up for this function not being calculated in. Could someone expla8in to me why residual function shouldn't be a factor in calculation of adequacy?
- 1Oct 30, '11 by traumaRUs, MSN, APRN, CNS AdminResidual function only allows the pt to be a little looser with fluid. It has no effect on the filtering of toxins. CMS has decided that a URR of 65 is adequate. That's actualy barely adequate. The higher the kT/V is (>1.4) the better for the pt.
Any pt on HD has a GFR of <12 and usually below 10.
- 0Oct 30, '11 by just keep swimmingQuote from traumaRUsThank you for your response but i guess I'm still confused about something...if residual function only allows the patient to be looser with fluids, what about those patients who only run once or twice a week because they still have some function? I understand KT/V and URR and the implications of poor results, just wasn't sure where residual function came in. If I'm not mistaken, it was calculated into the KT/V and produced a higher number. Should this not be part of the KT/V?Residual function only allows the pt to be a little looser with fluid. It has no effect on the filtering of toxins. CMS has decided that a URR of 65 is adequate. That's actualy barely adequate. The higher the kT/V is (>1.4) the better for the pt.
Any pt on HD has a GFR of <12 and usually below 10.
- 0Oct 31, '11 by traumaRUs, MSN, APRN, CNS AdminHmm - I'm with a large nephrology practice and we have no one running once/twice/week. If they only need dialysis once per week, they don't need dialysis.
Wonder what their GFR is? CMS is coming down hard on providers that try to do HD for other than ESRD.
- 0Oct 31, '11 by just keep swimmingI have patients who only come a couple times each month and we have no record of them going to any ER in the area to dialyze. Those who are only scheduled once/twice/week are usually expected to regain function but are going to need dialysis too long to be considered acute (one lost function while on chemo but regained it within a few months). As for the patients who are non compliant, they must have a significant amount of residual function to be able to come so infrequently. Some do not even reach a KT/V of 1.2 because their pre BUN is not high enough. Do you think that maybe these people are being started too early? Eventually, they almost all end up 3/week or very ill, however I have some who have been doing it for many months, some close to a year.
I work in a very large, inner city unit. We get all the difficult patients and all of the non compliant patients...
- 0Nov 1, '11 by traumaRUs, MSN, APRN, CNS Adminlol - my biggest clinic is 130 pts of noncompliant, inner city, tough as nails pts.
I too have several that only come intermittently, they haven't urinated in years! Don't know why they survive.
My own theory is that they have lived very hard lives and have had to survive many difficulties so surviving w/o working kidneys isn't so bad.
My other thought is that they have been so sick for so long that they don't realize what feeling good is anymore.
- 0Nov 1, '11 by just keep swimmingSounds like you work in my world! I love it but it sure is challenging sometimes. I hope you don't mind me picking your brain...I'm always looking for new things to learn and unfortunately, the NP I work with has been there 3 years and is still asking about when to schedule a fistulogram or how we know when to adjust EDW.....grrrrr! But I'll save that rant for another day. Luckily, I have some great docs who are great teachers! I'm in school for my BSN right now and hope to continue to be a NP eventually (when my kids give me time that is). I read your thread about "how much do you want to take off today". What do you do with those patients who chronically put on 8 or more kg and then crash when trying to pull the fluid, especially with those whose cardiac function is poor?
- 0Nov 3, '11 by traumaRUs, MSN, APRN, CNS AdminWell, I refuse to allow >6% EDW (not the weight they come in at) to be pulled.
The other issue is that I work for 17 docs and they all have their own way of managing pts. I always error on the safe side and the newest literature says that removing 11ml/kg/hr is the best way to decrease the cardiac stress.
So, I've been using that. I provide lots of education to my pts. Plus, the one unit, where the most noncompliant pts are, have seen pts die in the chair and that scares them....usually.
- 0Nov 3, '11 by msnmbahcmI am a traveler and am currently in Arizona. It has been my experience that using PUF (sequential dialysis) for the 1st hour, to take off 2L has been positive, no cardiac issues nor any b/p issues. I worked in an acute setting where we did CRRT, PUF, SLED, etc and I have conferenced with docs all over and they like the fact we can decrease EDWs effectively with this mode in the OP setting.