DFC Dialysis Facility Compare g/dl UPR65% UPR BUN BUN/ BUN NEJM, March10,2005 Anemia of C

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1 HemodialysisReview Article: Medical ProgressNEJM, Nov.4, 2010 H Dialyser NEJM AV fistula Kt/V urea Vml t DFC: Dialysis Facility Compare

2 DFC Dialysis Facility Compare g/dl UPR65% UPR BUN BUN/ BUN NEJM, March10,2005 Anemia of Chronic Disease TFC: Hb odds Ht Hb Hb erythropoietin 25 Brookline Dialysis Massachusetts General Hospital 10 3 Massachusetts General Hospital 17 Brookline Dialysis Massachusetts General Hospital 0 % Brookline Dialysis 4 UPR65

3 96 Massachusetts General Hospital 100% Brookline Dialysis Massachusetts General Hospital Brookline Dialysis NEJM MIPPA: Medicare improvements for Patients and Providers Act bundled payment 2011 erythropoietin cherry-picking : NEJM 16

4 NEJM ml 400ml/ ml/kg/h 6. Kt/V urea Hb Kt/V urea Hemodialysis Review Article: Medical Progress NEJM, Nov.4, 2010 H23.1 Jonathan Himmelfarb, M.D. T.Alp Ikizler, M.D. Vanderbilt 50 Belding Scribner blood-access Scribner AV fistula 100

5 dialysatebicarbonate compartmentalized 2microglobulin p-cresol ultrafiltration 10ml/kg/h sorbent Dialyzer: hollow-fiber dialyzer High-flux membrane low-flux membrane 4 3 QOL 200ml 400ml/ blood-access dialysate 2

6 Ultrafiltration 10ml/kg/h Nasodium mmol/L Na Kpotassium 2 3mmol/L K K K 30 Ca mmol/L Ca Ca Mg 0.5mmol/LMg Mg flux Alkaline buffers 30 40mmol/L. Chloride alkaline buffer Glucose mg/dl D

7 single-pool Kt/Vurea>1.4 5 ultrapure 10 12g/dl AV fistula() Ca mg/dlP mg/dl Intact PTH 2 D phosphate binder PTH 4.0g /dl PKNa LDL 100mg/dl Quantifying the dose and adequacy of dialysis Kt/V urea K 1 mlt V urea Kt/Vurea Vml t high-flux

8 2microglobulin high-flux CaP QOL 1972 ESRD: End-Stage Renal Disease 1972

9 MIPPA: Medicare improvements for Patients and Providers Act (ESRD) bundled payment 2011 cherry-picking : 2003 CMSCenters for Medicare and Medicaid Services arteriovenous fistulas Fistula First fistula CMS DFC (Dialysis Facility Compare) Dialysis Facility Compare / 1 /

10 AV fistule() tunneled catheter 1970 NCDSthe National Cooperative Dialysis Study single-pool Kt/V urea V ml t higher permeability characteristics Kt/V urea 1.4 Homocysteine erythropoietin p-cresol sulfateindoxyl sulfate phosphate

11 NEJM ml 400ml/ ml/kg/h 6. Kt/V urea Hb Kt/V urea

125 2 P 1st washout 2 PB P mg/dL nd washout 2 P 5.5mg/dL< mg/dL <2.5mg/dL P P 2 D D 3 Ca 10

125 2 P 1st washout 2 PB P mg/dL nd washout 2 P 5.5mg/dL< mg/dL <2.5mg/dL P P 2 D D 3 Ca 10 . (1) 125 1 125 Renagel PB-94 P intact-pth P 1 b c a b 1 18 2 3 3 3 1 P 4 D 1 5 6 7 2 1HIV 2 3 4 5Hb 8.0g/dL ALT 48IU/L 6 7 PB-94 440mg 403mg 1-196 125 2 P 1st washout 2 PB-94 1 2 4 4 P 2.5 5.5mg/dL 1

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