Journal of the American Society of Nephrology, Vol 4, 1004-1020, Copyright © 1993 by American Society of Nephrology

REVIEWS

The hemodialysis prescription and quality-adjusted life expectancy. Renal Physicians Association Working Committee on Clinical Guidelines

JC Hornberger
Department of Health Research & Policy, Stanford University School of Medicine, CA 94305-5093.

What comprises an optimal prescription for uremictoxin clearance in the chronic hemodialysis setting is a much disputed issue. The dispute is underscored by the rise in mortality of the U.S. dialysis population during the 1980s and reports of significant noncompliance with minimal treatment standards recommended from the National Cooperative Dialysis Study. A decision model was developed to summarize and test assumptions about the effect of various dialytic-treatment options on patient outcomes. Treatment options included delivered fractional urea clearance (Kt/V), dialysis-treatment duration, dialysis membrane (high flux versus conventional), dialysate (bicarbonate versus acetate), and ultrafiltration (controlled versus uncontrolled). The expected outcome for any set of treatment options was calculated as a function of a representative patient's life expectancy, adjusted for the probability and assumed importance of avoiding uremia- and treatment-related complications, referred to as quality-adjusted life expectancy (QALE). QALE increased by 59 days for each 0.1-U increase in Kt/V and by 187 days with high-flux dialysis. Controlled ultrafiltration with bicarbonate dialysis increased QALE by 30 days compared with uncontrolled ultrafiltration with acetate dialysis. Sensitivity analyses showed that, under conservative assumptions, QALE increased 11 days for every 0.1 increment in Kt/V. The model afforded a framework for reviewing the literature and testing assumptions about the expected benefits of dialytic-treatment options for the development of a clinical guideline on the adequacy of dialysis.

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