Bibliographic record
Abstract
In low-income and middle-income countries, access to dialysis is hindered by poor resources, and 75% of patients with end-stage kidney disease die for not affording dialysis.1Thurlow J.S. Joshi M. Yan G. et al.Global epidemiology of end-stage kidney disease and disparities in kidney replacement therapy.Am J Nephrol. 2021; 52: 98-107https://doi.org/10.1159/000514550Crossref PubMed Scopus (59) Google Scholar Lebanon has been a middle-income country where access to dialysis is universal. The quality of dialysis has reached its peak by implementing ultrapure fluids, mandatory thrice-weekly dialysis, and monthly laboratory tests.2Aoun M. Makkouk J. Ammar W. UltraPure water in haemodialysis: a step towards better quality in Lebanon.East Mediterr Health J. 2019; 25: 134-141https://doi.org/10.26719/emhj.18.032Crossref PubMed Scopus (3) Google Scholar Recently, this country has been facing a catastrophic inflation. Dialysis fees’ reimbursement became insufficient to cover costs. A shortage in laboratory kits prevented routine testing. The unaffordable price of fuel made transportation to units difficult. In response to this conundrum, dialysis units were challenged to adapt and improvise the best balance to sustain treatment and preserve quality. This letter summarizes the outcomes of a cost-saving scheme in a sample of hemodialysis patients. This scheme consists of reducing dialysis sessions and blood tests (Supplementary Methods).A total of 76 patients were included (Supplementary Table S1). There were 24 patients shifted to twice-weekly dialysis, but 5 developed hyperkalemia and returned to thrice weekly. Table 1 illustrates a significant difference between the medians of interdialytic weight gain preimplementation and postimplementation of the cost-saving scheme. This difference is driven by those shifted to twice-weekly dialysis. A significant difference was noted in hemoglobin before and after but not driven by patients shifted to twice-weekly dialysis. The decrease in hemoglobin level was found significant in patients who had erythropoiesis-stimulating agent dose reduced >25% and left 2 months without testing (P = 0.041; Wilcoxon test). Patients who had the same or increase in erythropoiesis-stimulating agent dose had no significant difference in hemoglobin (P = 0.247; Wilcoxon test).Table 1Clinical outcomes pre–cost-saving and post–cost-saving scheme implementationVariablePre(n = 76)Post(n = 76)P valueHemoglobin, median (IQR)10.7 (10.0–11.7)10.5 (9.87–11.7)0.080Hb in patients on thrice weekly11 (10–12)10.6 (9.9–11.7)0.017Hb in patients on twice weekly10.3 (9.5–10.7)10.3 (8.8–11.7)0.679Serum potassium, median (IQR)5.1 (4.6–5.7)5.15 (4.6–5.6)0.621Predialysis SBP, median (IQR)140 (130–150)140 (130–150)0.925IDW, median (IQR)2 (1.5–3)2 (1.62–3)0.009IDW in patients on thrice weekly2 (2.3)2 (2.3)0.131IDW in patients on twice weekly2 (1.2)2 (1.3)0.023At least 1 hospitalization, n (%)21 (27.6)11 (14.5)0.137Hb, hemoglobin; IDW, interdialytic weight gain; IQR, interquartile range; SBP, systolic blood pressure.Wilcoxon test was used to compare the pre- and post-results. Open table in a new tab In summary, shifting patients with residual diuresis to twice-weekly dialysis is safe. Incremental hemodialysis was found to be cost-effective in incident dialysis patients; trials are ongoing to clarify its long-term effects.3Murea M. Moossavi S. Fletcher A.J. et al.Renal replacement treatment initiation with twice-weekly versus thrice-weekly haemodialysis in patients with incident dialysis-dependent kidney disease: rationale and design of the TWOPLUS pilot clinical trial.BMJ Open. 2021; 11e047596https://doi.org/10.1136/bmjopen-2020-047596Crossref PubMed Scopus (8) Google Scholar Anemia did not worsen in our patients shifted to twice-weekly dialysis. Increasing the interval between 2 blood tests seemed safe in patients who had no significant reduction in their erythropoiesis-stimulating agent dose. Testing every 6 weeks was suggested by a Canadian study.4Silver S.A. Alaryni A. Alghamdi A. Digby G. Wald R. Iliescu E. Routine laboratory testing every 4 versus every 6 weeks for patients on maintenance hemodialysis: a quality improvement project.Am J Kidney Dis. 2019; 73: 496-503https://doi.org/10.1053/j.ajkd.2018.10.008Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar In conclusion, a personalized approach to the management of hemodialysis patients can be cost-saving without jeopardizing the patients’ safety on the short term. Each country has its specificities and necessitates a different cost-effective hemodialysis program.5Ball J.T. Establishing a cost-effective hemodialysis program in the developing world.Clin Nephrol. 2020; 93: 17-20https://doi.org/10.5414/CNP92S103Crossref PubMed Google Scholar In low-income and middle-income countries, access to dialysis is hindered by poor resources, and 75% of patients with end-stage kidney disease die for not affording dialysis.1Thurlow J.S. Joshi M. Yan G. et al.Global epidemiology of end-stage kidney disease and disparities in kidney replacement therapy.Am J Nephrol. 2021; 52: 98-107https://doi.org/10.1159/000514550Crossref PubMed Scopus (59) Google Scholar Lebanon has been a middle-income country where access to dialysis is universal. The quality of dialysis has reached its peak by implementing ultrapure fluids, mandatory thrice-weekly dialysis, and monthly laboratory tests.2Aoun M. Makkouk J. Ammar W. UltraPure water in haemodialysis: a step towards better quality in Lebanon.East Mediterr Health J. 2019; 25: 134-141https://doi.org/10.26719/emhj.18.032Crossref PubMed Scopus (3) Google Scholar Recently, this country has been facing a catastrophic inflation. Dialysis fees’ reimbursement became insufficient to cover costs. A shortage in laboratory kits prevented routine testing. The unaffordable price of fuel made transportation to units difficult. In response to this conundrum, dialysis units were challenged to adapt and improvise the best balance to sustain treatment and preserve quality. This letter summarizes the outcomes of a cost-saving scheme in a sample of hemodialysis patients. This scheme consists of reducing dialysis sessions and blood tests (Supplementary Methods). A total of 76 patients were included (Supplementary Table S1). There were 24 patients shifted to twice-weekly dialysis, but 5 developed hyperkalemia and returned to thrice weekly. Table 1 illustrates a significant difference between the medians of interdialytic weight gain preimplementation and postimplementation of the cost-saving scheme. This difference is driven by those shifted to twice-weekly dialysis. A significant difference was noted in hemoglobin before and after but not driven by patients shifted to twice-weekly dialysis. The decrease in hemoglobin level was found significant in patients who had erythropoiesis-stimulating agent dose reduced >25% and left 2 months without testing (P = 0.041; Wilcoxon test). Patients who had the same or increase in erythropoiesis-stimulating agent dose had no significant difference in hemoglobin (P = 0.247; Wilcoxon test). Hb, hemoglobin; IDW, interdialytic weight gain; IQR, interquartile range; SBP, systolic blood pressure. Wilcoxon test was used to compare the pre- and post-results. In summary, shifting patients with residual diuresis to twice-weekly dialysis is safe. Incremental hemodialysis was found to be cost-effective in incident dialysis patients; trials are ongoing to clarify its long-term effects.3Murea M. Moossavi S. Fletcher A.J. et al.Renal replacement treatment initiation with twice-weekly versus thrice-weekly haemodialysis in patients with incident dialysis-dependent kidney disease: rationale and design of the TWOPLUS pilot clinical trial.BMJ Open. 2021; 11e047596https://doi.org/10.1136/bmjopen-2020-047596Crossref PubMed Scopus (8) Google Scholar Anemia did not worsen in our patients shifted to twice-weekly dialysis. Increasing the interval between 2 blood tests seemed safe in patients who had no significant reduction in their erythropoiesis-stimulating agent dose. Testing every 6 weeks was suggested by a Canadian study.4Silver S.A. Alaryni A. Alghamdi A. Digby G. Wald R. Iliescu E. Routine laboratory testing every 4 versus every 6 weeks for patients on maintenance hemodialysis: a quality improvement project.Am J Kidney Dis. 2019; 73: 496-503https://doi.org/10.1053/j.ajkd.2018.10.008Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar In conclusion, a personalized approach to the management of hemodialysis patients can be cost-saving without jeopardizing the patients’ safety on the short term. Each country has its specificities and necessitates a different cost-effective hemodialysis program.5Ball J.T. Establishing a cost-effective hemodialysis program in the developing world.Clin Nephrol. 2020; 93: 17-20https://doi.org/10.5414/CNP92S103Crossref PubMed Google Scholar Supplementary Material Download .pdf (.06 MB) Help with pdf files Supplementary File (PDF)Supplementary Methods.Table S1. Comparison between the thrice-weekly and the twice-weekly dialysis patients. Download .pdf (.06 MB) Help with pdf files Supplementary File (PDF) Supplementary Methods. Table S1. Comparison between the thrice-weekly and the twice-weekly dialysis patients.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.001 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".