Good Dialysis Index

The Good Dialysis Index

Introduction to the Good Dialysis Index

At a pre-conference session of the Annual Dialysis Conference, Seattle, Washington, 6^th March 2010 – ‘Successful Home Haemodialysis’ – I presented a concept that I had been working on for some time … the ‘Good Dialysis Index’ (GDI). This was the first public presentation of the GDI. I have since been asked to present the same talk at the Asian Pacific Congree Seoul (2010), the Annual Australian Amgen Nephrology Symposium in Melbourne (2011) and the Australian and New Zealand Home Therapies Conference in Sydney (2012) – along with a number of other local or institution-specific presentations of the concept.

A GDI is not really a novel or new approach. I am aware that others before me (including Bob Lindsay in the British Medical Journal in the late 1960s!), and many who likely will follow, have played around with dialysis ‘scoring systems’. Perhaps it is a reflection of the dissatisfaction of some – myself clearly included – with the blinkered mathematics of dialysis ‘adequacy’ … Kt/V … that has prompted different thinking on what should and does constitute … good dialysis.

While the interest shown from many at the conference has been both heartening and gratifying, it remains a ‘work-in-progress’ and may continue to evolve over time. However, I have decided to add it to this site for comment, trial application and consideration by any who may chance upon it here.

I would welcome feed-back … positive or negative … through the ‘Contact Us’ option at this site.

While some may wish to bring it to the attention of their dialysis teams, it remains to be validated. However, there has been sufficient interest at the Seattle ADC from dialysis systems and groups with very large patient numbers against whom it can be tested that a more rigorous evaluation may yet prove possible. Meanwhile, it is just an idea, a proposal, an untested hypothesis – and any who might apply it to themselves or their patients must be mindful of that.

I do not pretend it to be perfect, but it is an attempt to ‘hear the patient speak’ …

Why, then, the need for a GDI?

I believe we need additional factors, beyond Kt/V and beyond small molecular clearance, to properly evaluate ‘good dialysis’.

We need to value-add to dialysis while Kt/V stays as a ‘lowest common denominator’.

Good dialysis, for each patient, should ensure the best of:

• Fluid, salt, volume and blood pressure control

• The prevention or regression of LV hypertrophy and the maintenance of good LV function

• Simple, balanced iron and anemia management

• The control and normalization of calcium, phosphate, the Ca⁺⁺ x PO₄^≡ product and PTH

• An unrestricted, palatable, healthy diet and fluid intake

• Optimal middle molecule clearance

• Down-regulation of inflammatory stimuli and the markers of inflammation – albumin and CRP

• Removal of protein-bound uremic toxins (eg: p-cresol) which, though not currently removed by standard, non-protein-leaky hemodialysis membranes, will become a ‘future factor’

Good patient management must also ensure:

• The abolition of dialysis related symptoms

• Medication simplicity

• And an acknowledgement that patients have

• Lives to live

• Families to enjoy

• Jobs to (hopefully) return to

• A rehabilitation road to tread

Good health-management principles should also aim for:

• Minimization of patient co-morbidity

• Reduction in hospitalization

• Control/reduction in burgeoning health-care expenditure

If we want to achieve ‘Good Dialysis’, we must:

1. Let the patient ‘speak’

2. Be mindful of the patients’ desired outcomes

3. Include a balance of patient-derived information

4. Use empathetic as well as systematic evaluation

At the end of the day, we must intend:

• Patient survival … but a ‘good’ survival which is patient-goaled

and ..

• If and when the end is close, sensitively-managed dialysis withdrawal, palliation and as ‘good’ a death as possible

ALL these – and more – are the stuff of good dialysis

How, then, should we ‘express’ good dialysis?

• By more mathematical formulae?

… I don’t think so

• If naiveté was good enough for Scribner

… I can accept that

• Maybe some ‘touchy-feely’ stuff isn’t so bad

… Medicine is still ‘an art’

What follows should underpin the review of EVERY patient at EVERY clinic visit

The GDI ‘score’ permits the serial monitoring of ‘good dialysis’ in each patient

Each parameter scores an equal ‘1’

· There is, intentionally, no ‘weighting’ factor

· This ensures maximum simplicity.

· Though some favor relative ‘weighting’

And … if all factors matter, then each factor matters, independent of a ‘weighting’

The potential advantages of the Good Dialysis Index include:

1. Serial follow-up may allow earlier identification of patient deterioration

2. Dialysis patient review is standardized

3. With long-term follow-up, there is a potential for:

• Cross-modality benchmarking of ‘modality effect’

• Cross-unit benchmarking of ‘unit effect’

	Dialysis Key Performance Indicators (KPI)	Points	Score	If ‘0’, what intervention best addresses this

	Patient-Directed Questions
1	Are you currently feeling ‘pretty good’ about things?	1
2	Are your diet and fluid intake free of major restrictions?	1
3	Is your blood access is a native arteriovenous fistula?	1
4	Is your dialysis free of cramp, nausea and headache … etc?	1
5	Are you part or full-time employed or retired by choice?	1
6	Have you remained out of hospital for the last 3 months?	1
	Process-directed Questions
7	≥7 sessions/each 2 wks … (all inter-dialytic breaks <48hrs)	1
8	≥18 total hrs /each wk … (within any frequency regimen)	1
9	2 mth Kt/V ≥1.3 or PRU ≥70% (or PRU ≥50% if ≥5 x HD/wk)	1
10	Mean inter-dialytic weight gains ≤2.5% dry weight	1
11	Mean pre-HD systolic BPs ≥105 and ≤150	1
12	No intra-dialytic saline has been used in last 4 wks	1
	Laboratory-directed Questions
13	2 mth Hb ≥110 and ≤125 g/L	1
14	2 mth T’Sat ≥20% and ≤45% ± Ferritin ≥300 and ≤500 µg/L	1
15	2 mth pre-HD Ca x PO₄ product ≤4.0 (if SI) or ≤50 (if US)	1
16	2 mth calcium in normal range and PTH ≥2 to ≤4 x normal	1
17	2 mth albumin ≥35 g/L	1
18	2 mth CRP is normal for the local laboratory	1
	Chart-directed Questions
19	No anti-hypertensive medications are necessary	1
20	No phosphate binder medications are necessary	1

MAXIMUM SCORE	20
16-20 = good dialysis
10-16 = can significantly improve dialysis
<10 = poor or unacceptable dialysis

Click here for an easy to print version of the GDI

***Hint: Select "Fit to Page" in the Page Layout section of Printing Preferences***

Note:

This sheet is designed to be filled in at each clinic visit and will serve:

1. As part of the Patient Medical Record

2. As a serial reflection of patient progress, service performance and interventional identification

It remains un-validated … but ongoing application may help serve as that validation over time