ESRD Clinical Performance Indicators (CPM)

End Stage Kidney Disease (ESRD) Clinical Performance Measures are indicators of care that measure how well established targets (or thresholds) of care for dialysis patients are met (compliance to clinical guidelines). The measure can be applied at the dialysis facility level. The measures were developed from clinical practice guidelines established by a study conducted by the National Kidney Foundation Inc., called K/DOQI.

K/DOQI
The National Kidney Foundation's initiative to assemble kidney disease experts who look at all the research done about various aspects of kidney disease and make decisions or recommendations as to the most appropriate care for patients with kidney disease. Some of the guidelines already developed for patients with ESRD include:

• Adequacy of hemodialysis
• Adequacy of peritoneal dialysis
• Management of vascular access
• Management of anemia
• Nutrition
• Chronic Kidney Disease: Evaluation, Classification, and Stratification
• Dyslipidemia
• Bone Metabolism and Disease in Chronic Kidney Disease
• Bone Metabolism and Disease in Chronic Kidney Disease in Children
• Hypertension and Antihypertensive Agents in Chronic Kidney Disease.
• Cardiovascular Disease in Dialysis Patients

Some useful information:

What is anemia?

Anemia means you do not have enough red blood cells. Healthy red blood cells are manufactured in the bone marrow and they carry oxygen throughout the body. If you do not have enough red blood cells, the body does not get enough oxygen. Patients with anemia may look pale, feel tired, cold, and have muscle weakness or impotence. Anemia is common in people with Chronic Kidney Disease and people on Dialysis. This is due to the fact that. Kidneys produce an important hormone which aids manufacture red blood cells and this hormone is lacking in kidney disease.

What is adequacy of dialysis?

Adequacy of dialysis is a number that measures how well wastes were removed from your body during dialysis treatment. A common measurement of adequacy in hemodialysis is the "Kt/V". This measurement takes into account your size and weight, the type of dialyzer (artificial kidney) that is being used, the total treatment time, and the total volume of urea in the body (using blood samples from before and after the hemodialysis treatment to measure the blood urea nitrogen (BUN). The Kt/V is then figured using a mathematical formula. The adequacy of dialysis for Peritoneal Dialysis can be measured in several different ways.

Research has shown that patients who do not have a Kt/V of 1.2 or more are likely to have symptoms such as nausea, vomiting, loss of appetite, weakness, or mental confusion. Having a Kt/V of 1.2 or more helps prevent these symptoms and helps prevent other health issues resulting from not receiving enough hemodialysis. A Kt/V of 1.2 or more is considered that you are getting adequate hemodialysis. If your facility uses Kt/V for the measurement of hemodialysis or if you are on peritoneal dialysis, it is advised that you discuss the adequacy of dialysis with your doctor or dialysis facility.

What is vascular access?

All patients who are on hemodialysis need a "connection" that allows blood to flow from the patient's artery to a dialysis machine that cleans the blood and then returns the blood to the patient through a vein. A fistula is a surgical connection of an artery to a vein in the forearm. When an arteriovenous fistula (AVF) is created, the vein enlarges and creates the safest, most reliable, and effective access, or way to remove, clean and return a dialysis patient's blood to them. AVFs are usually considered the best type of access for dialysis patients because they cause fewer infections, hospitalizations, clotting problems, as well as improving blood flow for better treatment. AVFs also usually last for years, compared to weeks or months for other access types.

KNOWLEDGE ZONE

Finding Ways To Get Fit - Getting Fit Outside Getting Fit Inside

Building Strength
- Walk wearing wrist weights
- Push your child in a stroller around your neighborhood
- Explore the surrounding areas on your bike
- Exercise on an elliptical trainer
- Use free weights or machines at the local gym
- Jump rope to increase upper body strength

Building Endurance
- Go for a hike through the local park
- Develop a daily walking/running routine with a neighbor
- Go swimming at the local pool
- Walk/run using a treadmill
- Play basketball
- Enroll in an aerobics class

Building Flexibility
- Play tennis or badminton
- Wash your car by hand
- Play nine holes of golf
- Take a yoga class
- Stretch during TV commercials
- When cleaning your home, place emphasis on stretching to get hard
  to reach areas

Healthy Lifestyle Tip
Checklist for Losing Weight by the Singapore Heart Foundation .

Regular Walking Can Decrease the following potential Health Problems
- Anxiety
- Blood pressure
- Blood triglycerides
- Body fat
- Bone loss
- Constipation
- Depression
- Falls & fractures
- Glucose
- Mobility limitations
- Pain
- Risk of some cancers
- Risk of heart attack, hypertension and stroke
- Risk of diabetes
- Stress
- Weight

Regular Walking Improves Your Health , both mentally and physically
which include:
- Ability to regulate body temperature
- Aerobic capacity
- Balance
- Blood sugar
- Bone density
- Cartilage and joint health
- Circulation
- Energy level and endurance
- Flexibility/range of motion
- HDL (good) cholesterol
- Heart health
- Joint Mobility
- Life span
- Mental Capacity
- Metabolic Rate
- Mood
- Muscle mass and tone
- Overall general health
- Quality of life and sleep
- Reaction time
- Feeling of accomplishment
- Self-esteem
- Strength

Six Steps to Healthy Living

Stay Physically Active
- People often have misconceptions about the intensity and type of
  exercise needed to produce healthy benefits. The best way to become
  physically active is to find something you enjoy doing when it's
  convenient for you.

Eat more vegetables and fruits
- You should consume at least two portions of each of these everyday. It
   provides you with lot of different vitamins and much needed fiber in the
   diet

Eat Foods Low In Saturated Fats and Cholesterol
- The American Heart Association recommends that you limit your
   average daily cholesterol intake to less than 300 milligrams.

Maintain Proper Weight
- Measurement of body fat composition is the key to long-term success.
  Have Regular Medical Checkups. You and your doctor must work
  together to keep your health in check.

Don't Smoke or Use Other Tobacco Products
- As soon as you stop smoking, your risk of heart disease and stroke
  starts to drop.

Have Your Blood Pressure Checked Regularly
- High blood pressure makes your heart work harder, which may add
  strain on the heart and arteries. If you have high blood pressure, follow
  your doctor's advice about changing your diet and lifestyle habits.


BLOOD PRESSURE

Understanding Why High Blood Pressure Is A ProblemGenerally, normotension (normal blood pressure) is defined as less than 130mmHg for systolic value (SBP) and less than 80mmHg for diastolic value (DBP).

The higher the blood pressure, the more load on the blood vessels and this can damage the vessels. In the worst case, blood vessels can rupture causing internal bleeding. When this happens in the brain, it is called a stroke. In addition, high blood pressure increases the myocardial( heart muscle) workload so that the heart must work harder to maintain adequate blood flow to the body.

This causes ischemic heart disease (IHD) resulting in heart attack (myocardial infarction) and angina. People with hypertension have increased risk of suffering from of having a stroke. Conversely, it is also known that those with normal blood pressure have a lesser risk of ischemic heart disease (myocardial infarction and angina) and stroke.

Thus, it can be concluded that keeping blood pressure within a normal range to prevent these occurrences is of utmost importance.

Helpful Blood Pressure Reminders
- Have your blood pressure checked by your doctor.
- If you have high blood pressure, follow your doctor's advice about
  changing your diet and lifestyle habits.
- If your doctor has prescribed medication for your high blood pressure,
  it is very important to take it regularly. If you have any new symptoms
  call your doctor.
- Measure and record your blood pressure at home regularly.
  This information may be valuable to your doctor in evaluating your
   condition
- Cooperate. You and your doctor must work together in order to keep
   your blood pressure and your diabetes under control.

Dietary Keys To Reducing High Blood Pressure

Fruits and Juices : Increased consumption of juices and fruits (especially bananas) provide high levels of potassium which is beneficial.

Monounsaturated Fats : Increased consumption of products with monounsaturated fats, such as olive oil, in your diet can greatly diminish your risk of high blood pressure and may even eliminate the need to take medication to control the situation.

Omega-3 Fatty Acids : Increased consumption of omega-3 fatty acids that are commonly found in cold-water fish. These acids are proven to reduce high-blood pressure as well as lower your cholesterol.

Whole Oats : Increased consumption of whole oats may help control your high blood pressure. Additionally, they also have positive affects on cholesterol and blood sugar levels.

Vitamin C : Increased consumption of products containing Vitamin C to battle high blood pressure. This may mean a daily vitamin supplement or be part of an increased consumption of fruits, such as oranges

OBESITY

- Health Risks of Obesity
- Overweight and Obesity - Health Consequences

The primary concern of overweight and obesity is one of health and not appearance. Obesity is a serious disease with serious health risks.

Obesity Health Risks - Premature Death
An estimated 300,000 deaths per year may be attributable to obesity.

The risk of death rises with increasing weight. Even moderate weight excess (10 to 20 pounds for a person of average height) increases the risk of death, particularly among adults aged 30 to 64 years.

Individuals who are obese (BMI > 30) have a 50 to 100% increased risk of premature death from all causes, compared to individuals with a healthy weight.

Obesity Health Risks - Heart Disease
The incidence of heart disease (heart attack, congestive heart failure, sudden cardiac death, angina or chest pain, and abnormal heart rhythm) is increased in persons who are overweight or obese (BMI > 25). High blood pressure is twice as common in adults who are obese than in those who are at a healthy weight. Obesity is associated with elevated triglycerides (blood fat) and decreased HDL cholesterol ("good cholesterol").

Obesity Health Risks - Diabetes
A weight gain of 11 to 18 pounds increases a person's risk of developing type 2 diabetes to twice that of individuals who have not gained weight. Over 80% of people with diabetes are overweight or obese.

Obesity Health Risks - Cancer
Overweight and obesity are associated with an increased risk for some types of cancer including endometrial (cancer of the lining of the uterus), colon, gall bladder, prostate, kidney, and postmenopausal breast cancer.

Women gain of more than 20 pounds from age 18 to midlife double their risk of postmenopausal breast cancer, compared to women whose weight remains stable.

Obesity Health Risks - Breathing Problems
Sleep apnea (interrupted breathing while sleeping) is more common in obese persons. Obesity is associated with a higher prevalence of asthma.

Obesity Health Risks - Arthritis
For every 2-pound increase in weight, the risk of arthritis increases by 9 to 13%. Symptoms
of arthritis can improve with weight loss.

Obesity Health Risks - Reproductive Complications & Complications of Pregnancy
Obesity during pregnancy is associated with increased risk of death in both the baby and the mother and increases the risk of maternal high blood pressure by 10 times.

In addition to many other complications, women who are obese during pregnancy are more likely to have gestational diabetes (diabetes developing during pregnancy) and problems with labour and delivery.

Infants born to women who are obese during pregnancy are more likely to be high birth weight and, therefore, may face a higher rate of Cesarean section delivery and low blood sugar in the baby(which can be associated with brain damage and seizures).

Obesity during pregnancy is associated with an increased risk of birth defects, particularly neural tube defects, such as spinal bifida. Obesity in premenopausal women is associated with irregular menstrual cycles and infertility.

Obesity Health Risks - Additional Health Consequences
Overweight and obesity are associated with increased risks of gall bladder disease, incontinence of urine, increased surgical risk, and depression. Obesity can affect the quality of life through limited mobility and decreased physical endurance as well as through social, academic, and job discrimination.

Obesity Health Risks - Children & Adolescents
Risk factors for heart disease, such as high cholesterol and high blood pressure, occur with increased frequency in overweight children and adolescents compared to those with a healthy weight.

Type 2 diabetes, previously considered an adult disease, has increased dramatically in children and adolescents. Overweight and obesity are closely linked to type 2 diabetes.

Overweight adolescents have a 70% chance of becoming overweight or obese adults. This increases to 80% if one or more parent is overweight or obese.

Visceral Fat Reduction - Metabolic & Respiratory Improvements

Visceral Fat Reduction Study Results
A modest weight loss of 5-10 percent of body weight improved the metabolic profile in overweight and simple obesity. Recent weight loss data showed that a moderate weight loss of about 15-20 percent of baseline body weight was associated with improved respiratory function and metabolic profile in patients with severe obesity.

Visceral Fat Reduction Study Conclusion
It may be suggested that a preferential visceral fat mobilisation could at least in part explain these observations and that the association between visceral fat loss and metabolic improvements could be mediated by a reduction in liver fat infiltration. Reduction of visceral fat accumulation should be a major goal of any treatment of obesity.
Source: 2003 Elsevier Science.

FEVER

What You Need To Know About Fevers
- A fever is when the body's temperature is higher than normal due to
  an infection.
- Fever is usually caused by a virus or bacteria. It is a way in which the
  body fights infection.
- A fever is not dangerous, and does not always mean that a person has
  a serious illness.

Treatment:
The prevailing idea seems to be that high fevers cause brain damage. This is essentially untrue. The truth is that the brain is able to act like a thermostat and keep the temperature from going beyond a safe range; i.e. about 106.2 degrees. The only exceptions are devastating infections of the brain itself, as in bacterial meningitis, most of which are now prevented by immunization. Use a thermometer as a guide for temperature measurement.

Usually, the infection is caused by a virus, and antibiotics do not help viral infections. If the infection is bacterial it can be treated with antibiotics prescribed by your doctor. While waiting for the medication to take effect, the temperature can be brought down by warm water baths; cold water or ice water is not recommended as they can cause the blood vessels in the skin to constrict, and decrease the body's ability to get rid of extra heat.

Also, cold or chilly water will cause a child to shiver, which will increase the body's internal heat. Additionally, you should do the following to provide extra comfort:

1. Drink plenty of clear fluid.
2. Dress as lightly as possible.
3. Keep the child cool.
4. NEVER use alcohol

Additional helpful hints:
1. Ibuprofen (Advil, Motrin) is gradually replacing
   acetaminophen(Tylenol) as the of choice because it lasts longer
   and is anti-inflammatory as well.
2. Aspirin is NOT recommended for children under 18 years of age due
    to the risk of Reyes syndrome, a liver disorder associated with the
    use of aspirin and certain viral infections.
3. When in doubt, call your pediatrician or doctor.