Background¡GThe study found patients of end stage renal disease(ESRD) may have various comorbidities, and recently many studied showed ESRD patients with dementia were gradually diagnosed by clinical physicians, in particular of Alzheimer¡¦s disease. This becomes a very important issue because it often occurs in elderly and may increase the utilization of health care and motality. Objectives¡GThis study explores the prevelance of ESRD with dementia and finds out if there are any significant difference upon demography status, comorbodities, dialysis therapy, utilization of health care between ESRD with dementia and without dementia. As well as we will discuss the risk factors of ESRD patient with dementia. Methods¡GWe conducted secondary data analysis with admnstrative data of National Health Insurance between 2000, 2002, 2004 and 2006. We firstly seleced the patients diagnosed as ESRD and dementia, and merged the data set and other related variables.The data was analyzed by Chi-square test, t-test and logistic regression. Result¡GThe prevelance of ESRD with dementia were 0.35%(2000), 0.46%(2002), 0.89%(2004), 1.08%(2008)¡FESRD patients with and without dementia was significant difference (p < 0.0001) between sex, dialysis therapy, dialysis duration, and the regions of hospital organizations, class of hospital organizations, specialty,except the region of hospital organization in 2002¡F ESRD patients with and without dementia was significant difference (p < 0.0001) between age, comorbidities, outpatient visits and expenditures. Finally we found age, sex, hemodialysis therapy, outpatient visits were the risk factors of ESRD with dementia. Conclusion¡GThe study was benefited by large sample of adminstative data, but there were some limitation of precision of diagnoses and payment issue of health care system, therefore, we strongly suggested further study could be conducted by research questionnaires to make up the weakness of adminstatrative data.

Background: The prevalence of patients with end stage renal disease (ESRD) in Taiwan has risen to the first in the world in recent years. Non-traumatic lower extremity lesion is a common disease of diabetic and ESRD patients. Many studies have found that the prevalence of non-traumatic lower extremity lesion in diabetic patients with ESRD is higher than normal diabetic patients. Prevention the incidence of lower extremity lesions in patients with ESRD may prevent patients from further amputation. Objectives: This study explored the prevalence of ESRD with Non-traumatic lower extremity lesion. We focused on demography status, comorbidities, dialysis therapies and utilization of health care to define the risk factors of disease. Methods: This study conducted secondary data analysis with administrative data from Bureau of National Health Insurance (HV_CD data) for four years (2000, 2002, 2004 and 2006). In total, there were 57021, 75711, 76750, and 86902 for years 2000, 2002, 2004, and 2006, respectively. To attain the research purposes, descriptive analyses and logistic regression were performed. Result: The prevalence of ESRD with non-traumatic lower extremity lesion for the four years were 1.30%, 1.44%, 2.71% and 2.45%, respectively. ESRD patients with and without non-traumatic lower extremity lesion were significant difference between comorbidities (OR for the four years were 2.06, 1.98, 1.86 and 1.83), dialysis therapies (hemodialysis / peritoneal dialysis, OR for the four years were 17.1, 16.79, 15.12 and 9.23) and duration of dialysis (1-5 years / 5 years and more, OR was 1.39 in 2002).There were significant differences in regions of hospital organizations (compared with the north, OR were 0.67 in the center in 2000, 1.47 in the east in 2002 and 0.87 in the center in 2006), class of hospital organizations (compared with Academic Medical Centers, OR were 1.40 in Regional Hospitals, 1.50 in District Hospitals and 0.36 in Physician Clinics in 2000, 0.18 in Physician Clinics in 2002, 0.76 in Regional Hospitals, 0.78 in District Hospitals and 0.23 in Physician Clinics in 2004, 0.66 in Regional Hospitals, 0.75 in District Hospitals and 0.26 in Physician Clinics in 2006 ) and outpatient visits ( positive correlation in all years except 2000). Conclusion: The risk factors of suffering non-traumatic lower extremity lesion in ESRD patients are comorbidities, dialysis therapies and duration of dialysis. In the part of regions of hospital organizations, the east region has higher and the center region has lower probability of suffering the disease, comparing with the north region. Academic Medical Centers has the highest probability to find ESRD patients with non-traumatic lower extremity lesion. We also found the numbers of outpatient visits were increasing with the disease. Based on the results, we highly suggest that caregivers from dialysis units have to pay great attention in taking care of the ESRD patients with non-traumatic lower extremity lesion to prevent from the further amputation.

Background:Various amalgamation diseases which the ESRD patient of may suffer from have already had quite a lot of research to latter stage abroad .Recently, Abroad research find The ESRD patient in carry on extended dialysis can exert an influence or appear melancholy mood to psychological condition their treat .Extended dialysis may influence its medical resource to use or increase mortality.It gradually become to a topic. Objectives¡GThis study explores the prevelance of ESRD with melancholia and finds out if there are any significant difference upon demography status, comorbodities, dialysis therapy, utilization of health care between ESRD with melancholia and without melancholia.As well as we will discuss the risk factors of ESRD patient with melancholia. Methods¡GWe conducted secondary data analysis with admnstrative data of National Health Insurance between 2000, 2002, 2004 and 2006. We firstly seleced the patients diagnosed as ESRD and melancholia, and merged the data set and other related variables.The data was analyzed by Chi-square test, t-test and logistic regression. Result¡GThe prevelance of ESRD with melancholia were 0.47%(2000), 0.73%(2002),1.27%(2004), 1.34%(2008)¡FESRD patients with and without melancholia was significant difference (p < 0.0001) between sex, dialysis therapy, dialysis duration, and the regions of hospital organizations, class of hospital organizations. ESRD patients with and without melancholia was significant difference (p < 0.0001) between age, comorbidities, dialysis duration, outpatient visits and expenditures. Conclusion¡GThe study was benefited by large sample of adminstative data, but there were some limitation of precision of diagnoses and payment issue of health care system, therefore, we strongly suggested further study could be conducted by research questionnaires to make up the weakness of adminstatrative data.

Background: According to 2010 U.S. Renal Data System 2010Annual Data Report, the incidence and prevalence of End-Stage Renal Disease is the worst of the world in Taiwan. Sleep complaints are common in dialysis patients, and impacts negatively on health. It has become highly important issue. Objectives: This study explored the prevalence of ESRD with sleep disorder. We focused on demography status, comorbidities, dialysis therapies and utilization of health care to define the risk factors of disease. Methods: We conducted secondary data analysis with admnstrative data of National Health Insurance between 2000, 2002, 2004 and 2006. We firstly seleced the patients diagnosed as ESRD and Dyssomnia, and merged the data set and other related variables.The data was analyzed by Chi-square test, t-test and logistic regression. Result: The prevalence of ESRD with sleep disorder for the four years were 2.1%¡B2.7%¡B6.4% and 7.3%, respectively. Female patient has higher risk than male .Higher comorbidity score also lead to higher risk, dialysis therapies in hemodialysis/peritoneal were 16.45¡B16.48¡B8.23 and 7.91 in OR. There were significant differences in regions of hospital organizations (northern compared with the eastern, OR were 3.47, 2.73, 1.94 and 2.29, class of hospital organizations (compared with Physician Clinics), there are more cases in Regional Hospitals, except 2006. Outpatient expenses and visits are both positive correlation in all years. Conclusion: The risk factors of suffering sleep disorder in ESRD patients are sex, comorbidities and dialysis therapies. It is a relatively common but frequently unrecognized, therefore, we strongly suggested further study could be conducted by research questionnaires to make up the weakness of adminstatrative data.

Chronic inflammation is considered strongly influence the morbidity and mortality of patients with end-stage renal disease (ESRD) through its multiple pathogenic roles, in association with oxidative stress, accelerated aging, endothelial dysfunction and atherosclerosis, malnutrition, dialysis-related amyloidosis, anaemia, and immune dysfunction . Hemodialysis ¡]HD¡^ is widely used for kidney failure patients,it is a method for removing waste products such as creatinine and urea. However, at present it is well known the course of hemodialysis can create obvious inflammation condition and oxidation pressure. The oxidation stress of HD can arise from the osmosis pressure and oxidative environment of dialysis tube. The oxidative stresses will finally modify proteins which turn out initiate the short term and long term complications related to renal diseases of HD patients. We identified oxidated proteins in the hemodialysis tube of 16 HD patients. The protein oxidation level was determined by Oxyblot assay. The oxidation proteins were further identified by LC/MS detection. Many serum proteins were detected to be oxidized including albumin, apoA, immunoglobin,beta-globin, hemoglobin, etc. It has been well documented that albumin is quite vulnerable to ROS and elevated levels of carbonyl groups of albumin have been reported in plasma of dialysis patients. Inflammatory effects were further tested. The oxidation proteins of HD patients induce pro-inflammatory factor TNF-alpha expression of HEK293T and HEK293 cells. These results indicate HD induce protein oxidation, and inflammatory response which may responsible for complications of End-stage kidney disease (ESRD). Keywords¡GHemodialysis, oxidative stress, ESRD, HEK293, inflammatory

An improved understanding of the costs of diseases is obtained by conducting a case study of the costs associated with end stage renal disease (ESRD). In estimating the costs of ESRD, the costs incurred by both patients and their primary unpaid caregivers are calculated. Most economic studies of the costs of diseases ignore either the patients’ or unpaid caregiver side, focusing on one or the other. From a theoretical standpoint, it is shown unpaid caregiving lowers the costs of diseases to society. Unpaid caregiver lowers the cost, because for unpaid caregiving to occur, the net benefits of unpaid caregiving must be lower than the net benefits of hiring a paid caregiver. Using patients and their primary caregivers at the Gambro Dialysis Center in College Station, Texas as a case study, estimated total ESRD costs range from $84,000 to $121,000 / year / case. The distribution of these costs is positively skewed. Of the total costs, approximately 2% to 25% can be attributed to unpaid caregiving. Excluding direct medical costs in total ESRD costs, unpaid caregiving is 14% to 65% of total ESRD costs. Consideration of unpaid caregiving costs is, therefore, an important component of the costs of diseases. These estimates are conservative as the costs associated with lifestyle changes and health effects are noted, but no monetary value is placed on them. Results also indicate the patients’ and caregivers’ perception of the quantity of caregiving varies. An alternative water supply system to improve the efficiency of water supply systems taking into account water pricing, marketing, and treatment costs is proposed. This system treats and supplies water differently depending on the source of the water and if the end-use of the water is a potable or non-potable use, then may reduce treatment costs. Decreased treatment costs may make more stringent water standards more affordable. More stringent water standards may cause a decrease in the risk of water-related diseases including ESRD induced by water-borne toxins. Reducing the risk of ESRD will reduce society’s costs associated with chronic illnesses. Possible benefits and costs of the proposed system are discussed, but not calculated.

Background: End-stage renal disease (ESRD) is a chronic medical condition where 90% or more of the kidneys are nonfunctional (Doig & Huether, 2014). The current treatment for ESRD is Hemodialysis [HD] (National Institute of Diabetes and Digestive and Kidney Disease [NIDDK], 2013). Individuals who have ESRD who undergo HD suffer from tremendous symptom and treatment burden that affects various facets of life (Axelsson, Klang, Hagelin, Jacobson, & Gleissman, 2014; Axelsson et al., 2012; Tamura & Cohen, 2010). Unfortunately, the symptom and treatment burden associated with ESRD are underrecognized and undertreated (Feely et al., 2016; Gelfman & Meyer, 2012; Murtagh, Addington-Hall, & Higginson, 2007; Russon & Mooney, 2010; Tamura & Meier, 2013). Purpose: The purpose of this quality improvement project is to explore if ESRD patients in Davita Desert Dialysis are knowledgeable about palliative care and if providing education might change their behavior. The primary aim is to create awareness in patients about PC services in an effort to improve their quality of care through education. Design: A quantitative pre- and post survey approach using qualtrics software was utilized to assess the baseline and post-education knowledge of patients who met the inclusion criteria. Setting: DaVita Desert Dialysis, Sun City, AZ. Intervention: The educational intervention is the viewing of a three-minute voice over presentation about palliative care. Limitations: The sample size was small and exposes this study to marked bias and non-generalizability due to the limited number of recruited individuals. Results: One hundred percent of the individuals in the posttest had better awareness about and knowledge about PC. Conclusion: PC can improve the quality of life of patients that suffer from the undertreated and underrecognized symptom and treatment burden (Tamura & Meier, 2013). Further data and studies will be needed to establish PC in the field of nephrology as it relates to the ESRD population undergoing HD. However, the quality improvement focus of increasing PC awareness among ESRD patients undergoing HD has shown great promise as all participants had increased awareness, knowledge availability, and readiness for PC services.

Calciphylaxis is a late complication of end-stage renal disease (ESRD) affecting ~1–4% patients on hemodialysis, with a mortality rate of >50%. Cutaneous manifestations include necrotic, non-healing ulcers most commonly in the lower extremities. Visceral organ vasculopathy often occurs as well. Warfarin is a possible risk factor due to its effect on the inhibition of Matrix GLa protein. Under the influence of hyperphosphatemia, vascular smooth muscle cells can undergo ectopic calcification in absence of the MGLa protein. The issue of anticoagulation in dialysis patients has therefore been debated, as Warfarin may potentially induce vasculopathy and increase risk of bleeding, such as hemorrhagic strokes and GI bleeds. A 64-year-old male with ESRD, non-compliant with dialysis, presented with lower extremity pain. Patient was noted to have large, malodorous, bilateral lower extremity ulcers with necrosis and eschars. Punch biopsy of the ulcers demonstrated acute inflammation with calcium deposits and thrombi within the blood vessels, suggestive of Calciphylaxis. Patient was started on Sodium Thiosulfate and Sevelamer for hyperphosphatemia. Atrial fibrillation was incidentally found on EKG, and due to high risk of stroke based on the CHA2DS-VASc score, patient was started on Heparin and bridged to Warfarin on discharge. Patient was readmitted 3 months later to the ICU with septic shock. Lower extremity ulcers appeared to be healing, but he reported several episodes of hematochezia (INR=2.0, hemoglobin=5.2). Warfarin was therefore held and patient was transfused. EGD showed no evidence of upper GI bleed, however patient refused colonoscopy. Patients on dialysis are at increased risk of bleeding due to defective primary hemostasis. The most serious source of bleeding is gastrointestinal, which accounts for 3–7% of all deaths in the dialysis population. Current guidelines for management of atrial fibrillation by the American Heart Association recommend warfarin for oral anticoagulation in patients with ESRD who have a CHA2DS2-VASc score of 2 or greater to prevent thromboembolic events. Our patient with ESRD and Calciphylaxis presented with new-onset atrial fibrillation and therefore started on Warfarin due to high CHA2DS2-VASc score. However patient developed a GI bleed with worsening anemia requiring transfusion, prompting discontinuation of Warfarin. It is therefore questionable whether the risk-benefit assessment based on CHA2DS2-VASc is appropriate for dialysis patients. Unfortunately, all the data available on the subject of Warfarin in ESRD patients are observational without any randomized-clinical trials. Therefore no objective criteria exist to modify the anticoagulation guidelines in dialysis patients.

Local context should be considered a significant social determinant of health for immigrant communities, particularly those with precarious legal status. In this thesis I use a study done by Lilia Cervantes, MD and collegeaues of undocumented immigrants with end-stage renal disease attempting to access healthcare in three different US states to expand on my argument. Due to the lack of comprehensive federal immigration reform since 1986, many immigrants depend on the Emergency Medical and Active Labor Treatment Act (EMTALA) to access healthcare, which provides emergency-only care. Without federal mandates, further healthcare for this population is dependent on local laws and/or safety-net services. As a result, this local context impacts their medical outcomes, healthcare utilization and economic costs and acts as a potential moral hazard to family, patients and providers of and serving immigrant communities. / Urban Bioethics

Despite best available care, uncontrolled chronic kidney disease (CKD) - a complex disease that impacts millions in the United States, will eventually progress to end stage renal disease which is associated with high morbidity and mortality. New evidence suggests management of earlier stages of CKD is effective in delaying disease progression. This project evaluated the impact of a CKD class, led by a nephrology nurse practitioner, on preventing disease progression in advanced CKD patients with diabetes and hypertension. The purpose of the class was to validate the need for the advanced practice nurse (APN) in the care continuum of CKD. CKD education is a quality improvement project based on the chronic illness trajectory nursing model by Corbin and Strauss. Using a case-control method and a simple descriptive statistic to compare the mean values, retrospective data from 52 patients were analyzed. Twelve non-participating patients had a mean 7% increase in serum creatinine levels at the 1-year mark. Forty participating patients saw a mean decrease of 30% serum creatinine. With significant evidence suggesting that disease progression is delayed and renal function is improved in all study markers for patients who participated in a CKD education class led by a nephrology nurse practitioner and who received usual care - an argument can be made for updating the APN role in the continuum of care for those with CKD. The results may contribute to social change by providing improved access to quality care that addresses the socioeconomic devastation of end stage renal disease.