Home care assistance and the utilization of peritoneal dialysis

Chronic kidney disease and support provided by home care services: a systematic review

BACKGROUND

Chronic diseases, such as chronic kidney disease (CKD), are growing in incidence and prevalence, in part due to an aging population. Support provided through home care services may be useful in attaining a more efficient and higher quality care for CKD patients.

METHODS

A systematic review was performed to identify studies examining home care interventions among adult CKD patients incorporating all outcomes. Studies examining home care services as an alternative to acute, post-acute or hospice care and those for long-term maintenance in patients' homes were included. Studies with only a home training intervention and those without an applied research component were excluded.

RESULTS

Seventeen studies (10 cohort, 4 non-comparative, 2 cross-sectional, 1 randomized) examined the support provided by home care services in 15,058 CKD patients. Fourteen studies included peritoneal dialysis (PD), two incorporated hemodialysis (HD) and one included both PD and HD patients in their treatment groups. Sixteen studies focused on the dialysis phase of care in their study samples and one study included information from both the dialysis and pre-dialysis phases of care. Study settings included nine single hospital/dialysis centers and three regional/metropolitan areas and five were at the national level. Studies primarily focused on nurse assisted home care patients and mostly examined PD related clinical outcomes. In PD studies with comparators, peritonitis risks and technique survival rates were similar across home care assisted patients and comparators. The risk of mortality, however, was higher for home care assisted PD patients. While most studies adjusted for age and comorbidities, information about multidimensional prognostic indices that take into account physical, psychological, cognitive, functional and social factors among CKD patients was not easily available.

CONCLUSIONS

Most studies focused on nurse assisted home care patients on dialysis. The majority were single site studies incorporating small patient populations. There are gaps in the literature regarding the utility of providing home care to CKD patients and the impact this has on healthcare resources.

Functional Disability in Older Adults Maintained on Peritoneal Dialysis Therapy

♦

BACKGROUND

Older in-center hemodialysis patients have a high burden of functional disability. However, little is known about patients on home chronic peritoneal dialysis (PD). As patients opting for home dialysis are expected to play a greater role in their own dialysis care, we hypothesized that a relatively low number of PD patients would require help with basic self-care tasks (ADL) and instrumental activities of daily living (IADL). ♦

METHODS

We used a cross-sectional study design to measure the proportion of patients aged 65 years and older undergoing outpatient PD who needed help with day-to-day activities. Patients living in nursing homes were excluded from the study. Functional dependence in ADL and IADL tasks were measured by the Barthel and Lawton Scales. Physical performance measures used included the timed up-and-go (TUG) test, chair stands and Folstein mini-mental score (MMSE). ♦

RESULTS

A total of 74 of 76 (97%) eligible PD patients participated. Patients had a mean age of 76.2 ± 7.5 years. Thirty-six percent had impaired MMSE scores, 69% were unable to stand from a chair without the use of their arms and 51% had abnormal TUG scores. Only 8 patients (11%) were fully independent for both ADL and IADL activities. Dependence in one or more ADL activity was reported by 64% of participants, while 89% reported dependence in one or more IADL. ♦

CONCLUSIONS

Impaired physical and functional performance is common in older patients maintained on PD. Collaborative geriatric-renal programs may be beneficial within the dialysis community.

Dialysis modality decision-making for older adults with chronic kidney disease

AIMS AND OBJECTIVES

To examine the personal and structural facilitators and barriers for home-dialysis decision-making for older adults with chronic kidney disease.

BACKGROUND

Chronic illness is a global problem. Older adults with chronic kidney disease form a large and growing segment of the dialysis population in many high-income countries but are less likely to uptake home-dialysis despite its benefits.

DESIGN

This qualitative ethnography framed in social theory took place in Canada and included adults with chronic kidney disease not on dialysis, older than 65 years of age.

METHODS

Thirteen people (seven men and six women, aged 65-83 years of age) who received care in a team chronic kidney disease clinic took part. Persons with chronic kidney disease were interviewed and group interviews were conducted with four of their chronic kidney disease clinic healthcare professionals. Content analysis was used for data analysis.

RESULTS

The factors influencing older adults' chronic kidney disease modality decisions are similar to younger adults. However, older adults with chronic kidney disease are in a precarious state with persistent uncertainty. Age imposes some limitations on modality options and transplantation. Modality decisions were influenced by health status, gender, knowledge, values, beliefs, past experience, preferences, lifestyle and resources. Support from family and healthcare professionals was the largest determinant to home-dialysis selection.

CONCLUSION

The social and contextual factors associated with age influenced home-dialysis decision-making. Adequate social support, functional status and resources enabled home-dialysis selection.

RELEVANCE TO CLINICAL PRACTICE

Understanding more about the decision-making processes for older adults with chronic kidney disease is important for quality interventions and the economic sustainability of dialysis services.

Dialysis therapies in older patients with end-stage renal disease

Each year a large number of older individuals with advanced renal disease are started on chronic dialysis therapy. Life expectancy is estimated at between 2 and 4 years depending on age, comorbidity, and intensity of medical care required in the weeks around the dialysis start time. Survivors remain at high risk of ongoing morbidity. Regarding quality of life, many older patients express regret over having opted for chronic dialysis therapy and subsequently choose to withdraw from treatment, whereas many others maintain a quality of life similar to that of age-matched peers. Early assessment and ongoing comprehensive geriatric assessment is recommended.

Peritoneal dialysis and the process of modality selection

The process of modality selection and how it works is a critical determinant of peritoneal dialysis (PD) utilization. This very complex process has not been well analyzed. Here, we break it down into 6 steps and point out how problems at each step can significantly reduce the proportion of endstage renal disease patients initiating PD. It is important that any program wishing it to grow its use of PD understand the steps and the points at which problems may be arising. Examples are presented.

Neighborhood socioeconomic status and barriers to peritoneal dialysis: a mixed methods study

BACKGROUND AND OBJECTIVES

The objective of this study was to evaluate the association between neighborhood socioeconomic status and barriers to peritoneal dialysis eligibility and choice.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study was a mixed methods parallel design study using quantitative and qualitative data from a prospective clinical database of ESRD patients. The eligibility and choice cohorts were assembled from consecutive incident chronic dialysis patients entering one of five renal programs in the province of Ontario, Canada, between January 1, 2004 and December 31, 2010. Socioeconomic status was measured as median household income and percentage of residents with at least a high school education using Statistics Canada dissemination area-level data. Multivariable models described the relationship between socioeconomic status and likelihood of peritoneal dialysis eligibility and choice. Barriers to peritoneal dialysis eligibility and choice were classified into qualitative categories using the thematic constant comparative approach.

RESULTS

The peritoneal dialysis eligibility and choice cohorts had 1314 and 857 patients, respectively; 65% of patients were deemed eligible for peritoneal dialysis, and 46% of eligible patients chose peritoneal dialysis. Socioeconomic status was not a significant predictor of peritoneal dialysis eligibility or choice in this study. Qualitative analyses identified 16 barriers to peritoneal dialysis choice. Patients in lower- versus higher-income Statistics Canada dissemination areas cited built environment or space barriers to peritoneal dialysis (4.6% versus 2.7%) and family or social support barriers (8.3% versus 3.5%) more frequently.

CONCLUSIONS

Peritoneal dialysis eligibility and choice were not associated with socioeconomic status. However, socioeconomic status may influence specific barriers to peritoneal dialysis choice. Additional studies to determine the effect of targeting interventions to specific barriers to peritoneal dialysis choice in low socioeconomic status patients on peritoneal dialysis use are needed.

The role of peritoneal dialysis in modern renal replacement therapy

Most patients starting dialysis can choose between peritoneal dialysis and haemodialysis. There is little evidence proving that one form of dialysis is better than the other; although there may be an early advantage to peritoneal dialysis (PD) in young patients with residual function this effect is short-lived. Technique failure develops after years on PD so dialysis modality will often change during a long dialysis career. Quality of life studies, which must be interpreted carefully, indicate that patients require information about the impact of dialysis on their lifestyle as well as health-related outcomes so that they can choose the most suitable dialysis modality. Increasing numbers of frail elderly patients are starting dialysis; support in the home by nursing staff may facilitate the use of PD in this group. In the UK guidelines prioritise the patient's choice of dialysis modality (where feasible) based on good quality predialysis education. Cost of treatment is generally lower on PD, which is particularly recommended for patients with residual renal function and few comorbidities.

[Assisted peritoneal dialysis: home-based renal replacement therapy for the elderly patient]

The number of elderly patients with end stage renal disease is constantly increasing. Conventional hämodiaylsis as the mainstay of renal replacement therapy is often poorly tolerated by frail eldery patients with multiple comorbidities. Although many of these patients would prefer a home based dialysis treatment, the number of elderly patients using peritoneal dialysis (PD) is still low. Impaired physical and cognitive function often generates insurmountable barriers for self care peritoneal dialysis. Assisted peritoneal dialysis can overcome many of these barriers and give elderly patients the ability of a renal replacement therapy in their own homes respecting their needs.

Peritoneal dialysis--current status and future challenges

Peritoneal dialysis is now a well established, mature treatment modality for advanced chronic kidney disease. The medium term (at least 5 year) survival of patients on peritoneal dialysis is currently equivalent to that of those on haemodialysis, and is particularly good in patients who are new to renal replacement therapy and have less comorbidity. Nevertheless the modality needs to keep pace with the constantly evolving challenges associated with the provision and delivery of health care. These challenges, which are gradually converging at a global level, include ageing of the population, multimorbidity of patients, containment of cost, increasing self care and environmental issues. In this context, peritoneal dialysis faces particular challenges that include multiple barriers to the therapy and unsatisfactory and poorly defined technique survival as well as limitations relating to intrinsic aspects of the therapy, such as peritoneal membrane longevity and hypoalbuminaemia. To move the therapy forward and favourably influence health-care policy, the peritoneal dialysis community needs to integrate their research effort more effectively by undertaking clinically meaningful studies-with a strong focus on technique survival--that are supported by multidisciplinary expertise in patient-centred outcomes, study design and analysis.

A Brazilian experience in assisted automated peritoneal dialysis: a reliable and effective home care approach

INTRODUCTION

Automated assisted peritoneal dialysis (AAPD) has been shown to be successful as renal replacement therapy for elderly and physically incapable end-stage renal disease (ESRD) patients. In early 2003, a pioneer AAPD program was initiated at GAMEN Renal Clinic in Rio de Janeiro, Brazil. ♢

OBJECTIVE

We evaluated the results of an AAPD program offered as an option to elderly ESRD patients with physical or cognitive debilities or as last resort to patients with vascular access failure or hemodynamic instability during hemodialysis. ♢

METHODS

A cohort of 30 consecutive patients started AAPD from January 2003 to March 2008 and was followed to July 2009. Demographics, clinical and laboratory parameters, causes of death, and patient and technique survival were analyzed. ♢

RESULTS

Median age of the patients was 72 years (range: 47 - 93 years), with 60% being older than 65. The Davies score was greater than 2 in 73% of patients, and the Karnofsky index was less than 70 in 40%. The overall peritonitis rate was 1 episode in 37 patient-months. The total duration of AAPD ranged from 3 to 72 months. Patient survival was 80% at 12 months, 60% at 24 months, and 23.3% at 48 months. The most common cause of death was cardiovascular problems (70%). ♢

CONCLUSIONS

In this clinical observational study, AAPD fulfilled its expected role, offering an opportune, reliable, and effective homecare alternative for ESRD patients with no other renal replacement therapy options.

Determinants of training and technique failure in home hemodialysis

Home hemodialysis (HHD) has clinical and economic advantages compared with in-center conventional hemodialysis. Many health systems wish to broaden the population to which this modality can be successfully offered. However, determinants of successful HHD training and technique survival are unknown. We hypothesize that both medical and social factors play a role when patients fail to successfully adopt HHD. We examined characteristics of consecutive patients who initiated training for HHD between 2003 and 2011. Patients were classified as "failure" if they failed to complete HHD training or experienced technique failure (TF) within the first year of treatment. Remaining patients were classified as "success." One hundred seventy-seven patients initiated HHD training. In the "failure" group (n = 32), 24 did not finish training and 8 had TF. In the "success" group (n = 145), 65 (45%) patients remained on NHD, 49 (34%) discontinued HHD because of renal transplantation and 21 (14%) because of death, while only 10 (7%) eventually transferred to another dialysis modality. In a multivariable logistic regression analysis, the strongest predictors of "failure" were end-stage renal disease because of diabetes (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.4-10.3, P = 0.008) and use of rental housing (OR 3.1, 95% CI 1.3-6.0, P = 0.01). Both medical and social factors are associated with failure to adopt HHD. Enhanced supports or a customized education strategy for these vulnerable patients should be considered.

Population-based home care services in breast cancer: utilization and costs

OBJECTIVE

To determine utilization and costs of home care services (hcs) for individuals with a diagnosis of breast cancer (bc).

METHODS

Incident cases of invasive bc in women were extracted from the Ontario Cancer Registry (2005-2009) and linked with other Ontario health care administrative databases. Control patients were selected from the population of women never diagnosed with any type of cancer. The types and proportions of hcs used were determined and stratified by disease stage. Attributable home care utilization and costs for bc patients were determined. Factors associated with hcs costs were assessed using regression analysis.

RESULTS

Among the 39,656 bc and 198,280 control patients identified (median age: 61.6 years for both), 75.4% of bc patients used hcs (62.1% stage i; 85.7% stage ii; 94.6% stage iii; 79.1% stage iv) compared with 14.6% of control patients. The number of hcs used per patient-year were significantly higher for the bc patients than for the control patients (14.97 vs. 6.13, p < 0.01), resulting in higher costs per patient-year ($1,210 vs. $325; $885 attributable cost to bc, p < 0.01). The number of hcs utilized and the associated costs increased as the bc stage increased. In contrast, hcs costs decreased as income increased and as previous health care exposure decreased.

INTERPRETATION

Patients with bc used twice as many hcs, resulting in costs that were almost 4 times those observed in a matched control group. Less than an additional $1000 per bc patient per year were spent on hcs utilization in the study population.

Impact of individual and environmental socioeconomic status on peritoneal dialysis outcomes: a retrospective multicenter cohort study

OBJECTIVES

We aimed to explore the impacts of individual and environmental socioeconomic status (SES) on the outcome of peritoneal dialysis (PD) in regions with significant SES disparity, through a retrospective multicenter cohort in China.

METHODS

Overall, 2,171 incident patients from seven PD centers were included. Individual SES was evaluated from yearly household income per person and education level. Environmental SES was represented by regional gross domestic product (GDP) per capita and medical resources. Undeveloped regions were defined as those with regional GDP lower than the median. All-cause and cardiovascular death and initial peritonitis were recorded as outcome events.

RESULTS

Poorer PD patients or those who lived in undeveloped areas were younger and less-educated and bore a heavier burden of medical expenses. They had lower hemoglobin and serum albumin at baseline. Low income independently predicted the highest risks for all-cause or cardiovascular death and initial peritonitis compared with medium and high income. The interaction effect between individual education and regional GDP was determined. In undeveloped regions, patients with an elementary school education or lower were at significantly higher risk for all-cause death but not cardiovascular death or initial peritonitis compared with those who attended high school or had a higher diploma. Regional GDP was not associated with any outcome events.

CONCLUSION

Low personal income independently influenced all-cause and cardiovascular death, and initial peritonitis in PD patients. Education level predicted all-cause death only for patients in undeveloped regions. For PD patients in these high risk situations, integrated care before dialysis and well-constructed PD training programs might be helpful.

Intensive hemodialysis in the (nursing) home: the bright side of geriatric ESRD care?

Elderly ESRD patients often lose functionality when they start dialysis, which may be due to a variety of clinical problems. We recently postulated that intensive (longer and/or more frequent) hemodialysis (HD) may be the ideal strategy to try to prevent these ESRD- and dialysis-related complications, including dialysis-induced hypotension, cardiac and cerebral events, malnutrition, infections, sleep problems, and psychological issues. The feasibility of home dialysis therapies has been demonstrated in observational studies. As self-care dialysis is often a challenge in the elderly patient, assisted intensive home HD may facilitate the long-term continuation of this modality. Intensive nursing home HD seems to be an attractive goal for the future because many elderly ESRD patients reside in an extended care facility. Combination with rehabilitation and support by social worker and psychologist remains crucial in the holistic approach toward the elderly ESRD patient. Further studies are required to test the potential protective effects of intensive HD on functionality and quality of life in elderly ESRD patients, and to elucidate the mechanisms underlying frailty and other geriatric syndromes in this highly vulnerable patient population.

Determinants of peritoneal dialysis technique failure in incident US patients

OBJECTIVES

Switching from peritoneal dialysis (PD) to hemodialysis (HD) is undesirable, because of complications from temporary vascular access, disruption of daily routine, and higher costs. Little is known about the role that social factors play in technique failure.

DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS

We followed for 3 years a nationally representative cohort of US patients who initiated PD in 1996 - 1997. Technique failure was defined as any switch from PD to HD for 30 days or more. We used Cox regression to examine associations between technique failure and demographic, medical, social, and pre-dialysis factors. We estimated hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

We identified an inception cohort of 1587 patients undergoing PD. In multivariate analysis, female sex (HR: 0.78; 95% CI: 0.64 to 0.95) was associated with lower rates of technique failure, and black race [compared with white race (HR: 1.48; 95% CI: 1.20 to 1.82)] and receiving Medicaid (HR: 1.48; 95% CI: 1.17 to 1.86) were associated with higher rates. Compared with patients who worked full-time, those who were retired (HR: 1.49; 95% CI: 1.07 to 2.08) or disabled (HR: 1.38; 95% CI: 1.01 to 1.88) had higher rates of failure. Patients with a systolic blood pressure of 140 - 160 mmHg had a higher rate of failure than did those with a pressure of 120 - 140 mmHg (HR: 1.24; 95% CI: 1.00 to 1.52). Earlier referral to a nephrologist (>3 months before dialysis initiation) and the primary decision-maker for the dialysis modality (physician vs patient vs shared) were not associated with technique failure.

CONCLUSIONS

This study confirms that several socio-demographic factors are associated with technique failure, emphasizing the potential importance of social and financial support in maintaining PD.

Changes in patient and technique survival over time among incident peritoneal dialysis patients in Canada

BACKGROUND AND OBJECTIVES

In the last 15 years in Canada, there have been less stringent guidelines for peritoneal dialysis (PD) adequacy, availability of novel PD solutions, and lower PD-related peritonitis rates. Effects of these changes on outcomes of incident patients treated with PD during this period are unknown.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Risk of PD technique failure and mortality were compared among three incident cohorts of PD patients who initiated dialysis during the following periods: 1995-2000, 2001-2005, and 2006-2009. A multivariable model was used to evaluate time to PD technique failure using inverse probability of treatment and censoring weights accounting for changing survival and transplantation rates.

RESULTS

Between 1995 and 2009,13,120 incident adult PD patients were identified from the Canadian Organ Replacement Register. Compared with the 1995-2000 cohort (n=5183), the risk of PD technique failure was lower among patients between 2001 and 2005 (n=4316) but similar among incident patients between 2006 and 2009 (n=3621). Cause-specific PD technique failure revealed no difference in PD peritonitis-related technique failure over time. PD technique failure due to inadequate PD was initially higher in the 2001-2005 cohort but lower in the 2006-2009 cohort compared with the 1995-2000 cohort. Relative to incident patients between 1995 and 2000, adjusted mortality was lower among incident patients between 2001 and 2005 and 2006 and 2009.

CONCLUSIONS

Survival on PD continues to improve with only modest changes in PD technique failure. Peritonitis remains an ongoing and modifiable source of PD technique failure.

Renal replacement therapy in the elderly population

ESRD has become an important problem for elderly patients. The segment of the ESRD population age 65 years or older has grown considerably, and this growth is expected to accelerate in coming years. Nephrologists caring for the elderly with advanced kidney disease will encounter patients with comorbid conditions common in younger patients, as well as physical, psychological, and social challenges that occur with increased frequency in the aging population. These challenging factors must be addressed to help inform decisions regarding the option to initiate dialysis, the choice of dialysis modality, whether to pursue kidney transplantation, and end-of-life care. This article will highlight some common problems encountered by elderly patients with ESRD and review data on the clinical outcomes of elderly patients treated with different modalities of dialysis, outcomes of kidney transplantation in the elderly, and nondialytic management of CKD stage 5.

End-Stage Renal Disease and Renal Replacement Therapy in older Patients

As the world’s population continues to age, practitioners encounter increasing numbers of older patients with end-stage renal disease (ESRD) who require renal replacement therapy (RRT). Conservative management may be considered in older patients and has been shown to offer comparable survival rates and hospital-free days to RRT patients. At present, for those who choose RRT, hemodialysis is the most commonly used modality. Many practitioners believe that peritoneal dialysis (PD), including assisted peritoneal dialysis, can be used safely in this population. Age is not a contra-indication to peritoneal dialysis, and a choice of modality should be offered to older patients. Assisted peritoneal dialysis has been used successfully in multiple regions without an increase in complication rates. Quality of life is an important issue for older patients with ESRD, and studies such as Broadening options for long-term Dialysis in the Elderly support the use of PD in older patients as it is associated with fewer fluctuations in symptoms of ESRD and less intrusion into people’s lives. This review discusses the appropriateness of initiating RRT in older patients, choices of modality, underutilization of PD in older patients, use of assisted PD, complication rates, and quality of life in these patients. overall, PD seems to be a safe and effective modality of RRT in older patients, and assisted PD can be used in patients with limited functional impairment.

Chronic kidney disease stressors influence choice of dialysis modality

AIM

  This article is a report of a study examining the relationships between chronic kidney disease stressors and coping strategies with dialysis modality.

BACKGROUND

  People with chronic kidney disease are given information to enable dialysis modality choice. This education increases awareness and may alleviate concerns and stress. Disease-related stressors and coping may affect dialysis selection. Understanding the influence of stress and coping on dialysis choices will assist in providing responsive programmes. Reducing stress and encouraging coping may increase home dialysis which, despite economic and patient benefits, remains underused.

DESIGN

  A prospective correlational design was used.

METHODS

  Information was obtained from the Chronic Kidney Disease Stress Inventory and the Jalowiec Coping Scale in 223 individuals not on dialysis between the years 2005-2007. Data were recorded with respect to modality at dialysis initiation (n = 76) from 2005-2010. The effects of stress, coping and patient parameters on modality selection were compared using bivariate and multivariate analyses.

RESULTS

  Individuals on home dialysis vs. in-centre haemodialysis reported significantly fewer pre-dialysis stressors. Coping was not associated with dialysis modality. Individuals on in-centre haemodialysis had a lower serum creatinine, less advanced kidney disease and weighed more than those who started on a home therapy. Physiological stressors were most common and are amenable to interventions.

CONCLUSION

  Pre-dialysis stress levels predicted dialysis modality. Interventional studies are recommended to address chronic kidney disease stressors with the outcome of improving home-dialysis usage.

How to address barriers to peritoneal dialysis in the elderly

Older patients on dialysis have unique needs and characteristics and their outcomes vary from that of their younger counterparts. Comparatively fewer will start or be maintained on peritoneal dialysis (PD) compared to younger patients, despite the fact that hemodialysis is often poorly tolerated. Barriers to PD for older patients include poor vision, frailty, cognitive dysfunction, accommodation issues, and a bias from renal teams that older patients cannot do PD. The development of assisted PD can overcome many of these barriers. The ability of older patients to use PD as their dialysis modality should not be determined by whether they live in an area where the nephrologist is a PD enthusiast. All patients should be given nonbiased information so they can choose the dialysis modality that gives them the best quality of life and suits their and their family's lifestyle.

Systematic barriers to the effective delivery of home dialysis in the United States: a report from the Public Policy/Advocacy Committee of the North American Chapter of the International Society for Peritoneal Dialysis

Home dialysis, currently underused in the United States compared with other industrialized countries, likely will benefit from the newly implemented US prospective payment system. Not only is home dialysis less expensive from the standpoint of pure dialysis costs, but overall health system costs may be decreased by more subtle benefits, such as reduced transportation. However, many systematic barriers exist to the successful delivery of home dialysis. We organized these barriers into the categories of educational barriers (patient and providers), governmental/regulatory barriers (state and federal), and barriers specifically related to the philosophies and business practices of dialysis providers (eg, staffing, pharmacies, supplies, space, continuous quality improvement practices, and independence). All stakeholders share the goal of delivering home dialysis therapies in the most cost- and clinically effective and least problematic manner. Identification and recognition of such barriers is the first step. In addition, we have suggested action plans to stimulate the kidney community to find even better solutions so that collectively we may overcome these barriers.

What influences patient choice of treatment modality at the pre-dialysis stage?

BACKGROUND

There is little information on factors influencing patient choice of renal replacement modality (RRM) in the UK. Pre-dialysis education programmes have been associated with increased uptake of peritoneal dialysis (PD) in other countries but their relevance in informing patient choice within UK centres has not been extensively studied. In this study, we examined how patient choice of different treatment modalities [haemodialysis (HD), PD and conservative management (CM)] is influenced by personal and demographic parameters.

METHODS

Questionnaires were sent to 242 pre-dialysis patients from a single centre. Patients were asked to rate factors affecting their treatment choice. Demographics, functional status, educational day attendance and Charlson index (CI) scores were also collected.

RESULTS

One hundred and eighteen replies were received. Seventy per cent of patients had chosen HD, 20% PD and 10% had opted for CM. There was a clear association between age and modality choice. Mean age of patients choosing PD was 55 years compared to 68 years for HD and 84 years for CM (P<0.001). Similarly, the degree of co-morbidity was linked with treatment choice, with patients choosing PD having a mean CI score of 4.1 compared to 5.8 among HD patients and 7.7 for CM (P<0.001). Factors rated as important by all three groups were: the ability to cope, fitting modality with lifestyle, distance to centre and verbal and written information about modality. Conversely, factors rated as not important by all groups were: use of internet, religious beliefs and friends' views. Using analysis of variance, there was a statistically significant variance between the HD and the PD group responses in the following factors: provision of written information (P=0.048), fitting modality with lifestyle (P=0.025), family/home/work circumstances (P=0.003) and past medical history (P=0.018). Fifty per cent of patients who chose PD attended a formal education day compared to 32.9% that chose HD and 0% that chose CM (P=0.011). The following demographic factors were crucial in predicting RRM choice: being married (PD 95.7%, HD 53.8%, CM 41.7%; P<0.001), being employed (PD 33.3%, HD 11.5%, CM 0%; P=0.015) and having another person living at home (PD 100%, HD 69.5%, CM 50%; P=0.003). Patients who have had a social services assessment in the last 12 months or received private care services or disability allowance were more likely to choose CM.

CONCLUSIONS

This study highlights important factors influencing patient choice of end-stage renal disease treatment modality including CM. While some of these are non-modifiable, such as age and degree of co-morbidity, others draw attention to the importance of good information provision and pre-dialysis education in empowering socially able patients to choose self-care therapies. Furthermore, the overwhelming association of having a strong social support network and being functionally able with choosing PD emphasizes the need for assisted PD.

Dialysis options for end-stage renal disease in older people

The numbers of older patients requiring dialysis therapy is rising, reflecting the ageing of the general population. Older dialysis patients have a tendency to present later for dialysis, have a higher number of comorbid conditions, are at higher risk of cognitive dysfunction and have increased levels of frailty. These are all barriers to home dialysis therapy so hospital haemodialysis (HD) is the predominant dialysis modality for older patients. Evidence suggests, however, that home treatment with peritoneal dialysis (PD) intrudes less into the life of older patients than hospital HD. Assisted PD is available in some countries and this enables more older patients to be treated in their own homes. Adjustments to patient education also need to be made to accommodate the barriers to learning and decision-making that often exist in older people.

Effects of a nationwide predialysis educational program on modality choice, vascular access, and patient outcomes

BACKGROUND

Patients' education about transplant, hemodialysis (HD), peritoneal dialysis (PD), and conservative care often is provided by nephrologists as needed and occurs as time allows.

STUDY DESIGN

Quality improvement report.

SETTING & PARTICIPANTS

Attendees of a national treatment options program (TOPs) who initiated long-term dialysis therapy (median, 3.4 months) at Fresenius Medical Care, North America facilities throughout 2008 were compared with period-prevalent incident patients receiving usual care.

QUALITY IMPROVEMENT PLAN

Standardized predialysis treatment options education.

OUTCOMES

Rates of opting for PD modality, arteriovenous HD access at initiation, and early (90-day) mortality risk.

MEASUREMENTS

Logistic regression (for choice of PD and HD access type) and Cox models (for early mortality) were constructed, including a 1:1 matched cohort. A post hoc sensitivity analysis also compared a propensity score-matched cohort.

RESULTS

3,165 TOPs attendees (10.5% of 30,217 incident patients admitted between January 1 and December 31, 2008), were younger, more likely to be white, and had slightly larger body surface area. The unadjusted OR for TOPs attendees for selecting PD therapy was 8.45 (95% CI, 7.63-9.37) with a case-mix plus laboratory-adjusted OR of 5.13 (95% CI, 3.58-7.35). For patients who opted for in-center HD therapy, the OR was 2.14 (95% CI, 1.96-2.33) and adjusted OR was 2.06 (95% CI, 1.88-2.26) for starting with a fistula or graft. The unadjusted early mortality HR was 0.51 (95% CI, 0.43-0.60) and case-mix plus laboratory-adjusted adjusted HR was 0.61 (95% CI, 0.50-0.74) for TOPs attendees (all outcomes, P < 0.001). These results were consistent in the 1:1 matched analysis and propensity score-matched analysis.

LIMITATIONS

It is possible that physicians who referred to these programs were more likely to prescribe PD therapy or place arteriovenous accesses. Motivated, treatment-adherent patients (who would have better outcomes) may have self-selected to attend education sessions.

CONCLUSION

Attending an options class predialysis was associated with more frequent selection of home dialysis, fewer tunneled HD catheters, and lower mortality risk during the first 90 days of dialysis therapy.

Compared with younger peritoneal dialysis patients, elderly patients have similar peritonitis-free survival and lower risk of technique failure, but higher risk of peritonitis-related mortality

BACKGROUND

The number of elderly patients with end-stage kidney disease (ESKD) is increasing worldwide, but the proportion of elderly patients commencing peritoneal dialysis (PD) is falling. The reluctance of elderly ESKD patients to consider PD may be related to a perception that PD is associated with greater rates of complications. In the present study, we compared outcomes between younger and older PD patients.

METHODS

Using Australia and New Zealand Dialysis Registry data, all adult ESKD patients commencing PD between 1991 and 2007 were categorized into under 50, 50 - 64.9, and 65 years of age or older groups. Time to first peritonitis, death-censored technique failure, and peritonitis-associated and all-cause mortality were evaluated by multivariate Cox proportional hazards model analysis.

RESULTS

Of the 12 932 PD patients included in the study, 3370 (26%) were under 50 years of age, 4386 (34%) were 50 - 64.9 years of age, and 5176 (40%) were 65 years of age or older. Compared with younger patients (<50 years), elderly patients (≥ 65 years) had a similar peritonitis-free survival and a lower risk of death-censored technique failure [hazard ratio (HR): 0.85; 95% confidence interval (CI): 0.79 to 0.93], but they had higher peritonitis-related (HR: 2.31; 95% CI: 1.68 to 3.18) and all-cause mortality (HR: 2.90; 95% CI: 2.60 to 3.23).

CONCLUSIONS

Not unexpectedly, elderly patients have higher peritonitis-related and all-cause mortality, which is likely a consequence of a greater prevalence of comorbid disease. However, compared with younger patients, elderly patients have superior technique survival and similar peritonitis-free survival, suggesting that PD is a viable renal replacement therapy in this group of patients.

Effect of an in-hospital chronic kidney disease education program among patients with unplanned urgent-start dialysis

BACKGROUND AND OBJECTIVES

The effect of in-hospital education on the adoption of home dialysis (peritoneal dialysis [PD] and home hemodialysis [HHD]) after an unplanned dialysis start is unknown.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Clinical demographics of consecutive patients acutely initiating hemodialysis (HD) from January 2005 to December 2009 were abstracted using institutional electronic records. All patients received multimedia chronic kidney disease education by the same advanced care nurse practitioner before discharge from the hospital. Clinical characteristics of patients choosing home dialysis or staying on in-center HD were compared.

RESULTS

Between 2005 and 2009, 228 patients acutely started renal replacement therapy (RRT) at the center. Seventy-one patients chose home dialysis (49 patients adopted PD and 22 adopted HHD), 132 chose to remain on in-center HD, and 25 died before discharge from the hospital. Patients adopting home dialysis tended to be younger than in-center HD patients (55 ± 18 [home dialysis] versus 59 ± 16 [in center] years; P=0.09) and were similar in gender distribution (49% [home dialysis] versus 56% [in center] male; P=0.2). Patients adopting home dialysis were more likely to have a failed kidney transplant (24% [home dialysis] versus 12% [in center]; P=0.045) and less likely to have ischemic nephropathy (9% [home dialysis] versus 21% [in center]; P=0.03). The distribution of comorbid conditions was different between patients adopting home dialysis and in-center HD.

CONCLUSIONS

Home dialysis is feasible after urgent dialysis start. Education should be promoted among patient experiencing acute-start dialysis.

The impact of type of assistance on characteristics of peritonitis in elderly peritoneal dialysis patients

BACKGROUND

The elderly patients are the fastest-growing end-stage renal disease (ESRD) population in Taiwan. Assisted peritoneal dialysis (PD) has been employed to overcome the barriers to PD. The aim of this retrospective, single-center study was to describe the status of assisted PD and the impact of type of assistance on peritonitis in elderly patients in Taiwan.

METHODS

One hundred and two patients initiated PD at the age of 65 or older between 2000 and 2008; 79 episodes of peritonitis occurred during the follow-ups. The patients and episodes of peritonitis were divided into three groups based on the type of assistance: (1) self-care: patients performing dialysis independently, (2) family: patients whose dialysis was performed by family, (3) caregiver: patients whose dialysis was performed by a private caregiver. Patient characteristics and incidence, etiology and outcomes of peritonitis were compared.

RESULTS

There were 26 (25.5%), 44 (43.1%), and 32 (31.4%) patients in the self-care, family, and caregiver groups, respectively. The overall peritonitis rate was 1/33 patient-months. Patients in the caregiver group were older and had more comorbidities than the self-care group. They had a trend of higher overall peritonitis rate (1/24 patient-months, P = 0.077) and fungal peritonitis rate (P = 0.060) compared to the self-care and family groups, but this was statistically non-significant.

CONCLUSIONS

Three-fourths of elderly PD patients in the present study required assistance from family members or private caregivers. Caregiver-assisted patients were significantly older and had more comorbidities. Also, a non-significant trend of higher peritonitis incidence was observed in these patients.

The impact of treatment modality on infection-related hospitalization rates in peritoneal dialysis and hemodialysis patients

BACKGROUND AND OBJECTIVES

Infection is a major cause of morbidity and mortality in the dialysis population. This study compares the rates of infection-related hospitalization (IRH) in incident chronic dialysis patients initiating outpatient peritoneal dialysis (PD) and hemodialysis (HD).

METHODS AND PATIENTS

This was a retrospective cohort study at the dialysis program of a tertiary-care center in Toronto, Canada. Incident chronic dialysis patients that were eligible for both PD and HD and started outpatient dialysis between 1 January 2004 and 31 August 2008 were included. Dialysis modality was assigned at the start of outpatient dialysis treatment. All hospital admissions were reviewed and incidence of IRH was compared between PD and HD using Poisson regression.

RESULTS

Of 264 incident chronic dialysis patients, 168 (64%) were eligible for both treatment modalities: 71 (42%) started outpatient PD and 97 (58%) started outpatient HD. The unadjusted and adjusted incidence rate ratios (IRR) of IRH did not differ significantly between PD and HD: 1.23 [95% confidence interval (CI) 0.65-2.32, p=0.37] and 1.14 (95% CI 0.58-2.23, p=0.71) respectively. There was no difference between PD and HD in the risk of access loss (28% vs 35%, p=0.73), modality change (22% vs 0%, p=0.10), or death (17% vs 6%, p=0.60) following hospitalization for infection. Patients starting outpatient treatment on PD versus HD were more likely to be hospitalized for peritonitis (IRR 3.20, 95% CI 1.16-9.09; p=0.029) and there was a trend for fewer hospitalizations for bacteremia (IRR 0.19, 95% CI 0.028-1.30; p=0.091). The risk of IRH did not differ between PD and HD in the subgroup of patients that received adequate predialysis care (IRR 1.16, 95% CI 0.59-2.27; p=0.67) or when patients starting outpatient HD with a central venous catheter were excluded (IRR 1.52, 95% CI 0.53-4.37; p=0.44).

CONCLUSIONS

Patients that initiate outpatient peritoneal dialysis do not have a significantly increased risk of infection-related hospitalization compared to those that initiate outpatient hemodialysis.

Dialysis modality choices among chronic kidney disease patients: identifying the gaps to support patients on home-based therapies

BACKGROUND

Home dialysis is a cost-effective renal replacement strategy, which provides improved quality of life compared to conventional in-center hemodialysis (CHD). To date, most studies support the use of multidisciplinary chronic kidney disease (CKD) clinics to facilitate timely initiation of dialysis. This is an observational cohort study examining 486 patients with CKD over the period of 2001-2007 to ascertain potential demographic differences among patients transitioned to in-center versus home dialysis.

SUBJECTS AND METHODS

From January 2001 to December 2007, 486 patients with CKD attended the multidisciplinary renal management clinic at the University Health Network in Toronto.

RESULTS

One hundred and fifty-three of the 486 patients were initiated on renal replacement therapy [59 to center hemodialysis (CHD), 15 to home hemodialysis (HHD) and 79 to home peritoneal dialysis (PD)]. HHD patients were younger (48 ± 15 years) than those who selected CHD (62 ± 16 years) or PD (64 ± 16 years). Although the gender distribution was similar overall, the percentage of single males was higher in CHD versus home dialysis patients (29 vs. 15%, P < 0.05). There were no significant differences in other demographic, clinical and biochemical parameters at the time of dialysis initiation. Disinterest in home dialysis by patients and their families (25.4%) and lack of social support (12.1%) constituted the main barriers to home dialysis. Medical contraindications for home dialysis were present among 11% of the patients. Other less frequent barriers were inadequate space, communication barrier and inability to perform their own dialysis.

CONCLUSIONS

Sixty-one percent of patients requiring dialysis chose a home dialysis modality. Patients' and their families' disinterest in home dialysis and lack of support (either perceived or actual) represented the major overall barriers to adoption of home dialysis.

Broadening Options for Long-term Dialysis in the Elderly (BOLDE): differences in quality of life on peritoneal dialysis compared to haemodialysis for older patients

Background. Health-related quality of life (QOL) is an important outcome for older people who are often on dialysis for life. Little is, however, known about differences in QOL on haemodialysis (HD) and peritoneal dialysis (PD) in older age groups. Randomising patients to either modality to assess outcomes is not feasible.

Methods. In this cross-sectional, multi-centred study we conducted QOL assessments (Short Form-12 Mental and Physical Component Summary scales, Hospital Anxiety and Depression Scale and Illness Intrusiveness Ratings Scale) in 140 people (aged 65 years or older) on PD and HD.

Results. The groups were similar in age, gender, time on dialysis, ethnicity, Index of Deprivation (based on postcode), dialysis adequacy, cognitive function (Mini-Mental State Exam and Trail-Making Test B), nutritional status (Subjective Global Assessment) and social networks. There was a higher comorbidity score in the HD group. Regression analyses were undertaken to ascertain which variables significantly influence each QOL assessment. All were influenced by symptom count highlighting that the patient’s perception of their symptoms is a critical determinant of their mental and physical well being. Modality was found to be an independent predictor of illness intrusion with greater intrusion felt in those on HD.

Conclusions. Overall, in two closely matched demographic groups of older dialysis patients, QOL was similar, if not better, in those on PD. This study strongly supports offering PD to all suitable older people.

Dialysis delivery in Canada and the United States: a view from the trenches

Although the general framework for health care delivery is vastly different in Canada and the United States, the framework for dialysis delivery is less divergent. However, the 2 systems have evolved very differently. Examined during the past 20 years, it is apparent that the dialysis system in the United States has undergone profound change, whereas the system in Canada is relatively stagnant. Most of the change in the United States has been positive, and this evolutionary change is expected to continue. In Canada, a system that historically has worked reasonably well is now showing severe signs of suboptimal performance that would be expected to get worse if no effort is made to improve it. This article, written from the perspective of 2 academic clinicians, tries to describe similarities and differences, identify strengths and weaknesses, and serve as a catalyst for discussions about improving both systems. Just as no dialysis treatment modality is perfect, the same can be said for dialysis delivery systems. Empirical methods to objectively evaluate the impact of change must be included in the design and implementation of new initiatives in the United States and Canada.