Time to Expand Access and Utilization of Home Dialysis: Lessons From the COVID-19 Pandemic

The Use of a Novel Virtual Reality Training Tool for Peritoneal Dialysis: Qualitative Assessment Among Health Care Professionals

BACKGROUND

Effective peritoneal dialysis (PD) training is essential for performing dialysis at home and reducing the risk of peritonitis and other PD-related infections. Virtual reality (VR) is an innovative learning tool that is able to combine theoretical information, interactivity, and behavioral instructions while offering a playful learning environment. To improve patient training for PD, Fresenius Medical Care launched the stay•safe MyTraining VR, a novel educational program based on the use of a VR headset and a handheld controller.

OBJECTIVE

This qualitative assessment aims to investigate opinions toward the new tool among the health care professionals (HCPs) who were responsible for implementing the VR application.

METHODS

We recruited nursing staff and nephrologists who have gained practical experience with the stay•safe MyTraining VR within pilot dialysis centers. Predetermined open-ended questions were administered during individual and group video interviews.

RESULTS

We interviewed 7 HCPs who have 2 to 20 years of experience in PD training. The number of patients trained with the stay•safe MyTraining VR ranged from 2 to 5 for each professional. The stay•safe MyTraining VR was well accepted and perceived as a valuable supplementary tool for PD training. From the respondents' perspective, the technology improved patients' learning experience by facilitating the internalization of both medical information and procedural skills. HCPs highlighted that the opportunity offered by VR to reiterate training activities in a positive and safe learning environment, according to each patient's needs, can facilitate error correction and implement a standardized training curriculum. However, VR had limited use in the final phase of the patient PD training program, where learners need to get familiar with the handling of the materials. Moreover, the traditional PD training was still considered essential to manage the emotional and motivational aspects and address any patient-specific application-oriented questions. In addition to its use within PD training, VR was perceived as a useful tool to support the decision-making process of patients and train other HCPs. Moreover, VR introduction was associated with increased efficiency and productivity of HCPs because it enabled them to perform other activities while the patient was practicing with the device. As for patients' acceptance of the new tool, interviewees reported positive feedback, including that of older adults. Limited use with patients experiencing dementia or severe visual impairment or lacking sensomotoric competence was mentioned.

CONCLUSIONS

The stay•safe MyTraining VR is suggested to improve training efficiency and efficacy and thus could have a positive impact in the PD training scenario. Our study offers a process proposal that can serve as a guide to the implementation of a VR-based PD training program within other dialysis centers. Dedicated research is needed to assess the operational benefits and the consequences on patient management.

Image-guided tunneled peritoneal dialysis catheter placement

Patients with end-stage renal disease (ESRD) often will ultimately require dialysis to survive. One type of dialysis is peritoneal dialysis (PD), which utilizes the vessel-rich peritoneum as a semi-permeable membrane to filter blood. In order to perform PD, a tunneled catheter must be placed through the abdominal wall and into the peritoneal space, with ideal positioning of the catheter within the most dependent portion of the pelvis, represented by the rectouterine or rectovesical space in women and men, respectively. There are several approaches to PD catheter insertion, including open surgical, laparoscopic surgical, blind percutaneous, and image-guided with the use of fluoroscopy techniques. Interventional radiology (through the use of image-guided percutaneous techniques) is an infrequently utilized resource to place PD catheters, and offers real-time imaging confirmation of catheter positioning with similar outcomes to more invasive surgical catheter insertion approaches. Although the vast majority of dialysis patients receive hemodialysis instead of peritoneal dialysis in the United States, some countries have moved towards a "Peritoneal Dialysis First" initiative, prioritizing initial PD, as it is less burdensome on healthcare facilities as it can be performed at home. In addition, the outbreak of the COVID-19 pandemic has produced shortages of medical supplies and delays in care delivery worldwide, while simultaneously generating a shift away from in-person medical visits and appointments. This shift may be met with more frequent utilization of imaged-guided PD catheter placement, reserving surgical and laparoscopic placement for complex patients who may require omental periprocedural revisions. This literature review outlines a brief history of PD, the various techniques of PD catheter insertion, patient selection criteria, and new COVID-19 considerations, in anticipation for the increased demand for PD in the United States.

Main Barriers to the Introduction of a Home Haemodialysis Programme in Poland: A Review of the Challenges for Implementation and Criteria for a Successful Programme

Introduction: Home dialysis in Poland is restricted to the peritoneal dialysis (PD) modality, with the majority of dialysis patients treated using in-centre haemodialysis (ICHD). Home haemodialysis (HHD) is an additional home therapy to PD and provides an attractive alternative to ICHD that combines dialysis with social distancing; eliminates transportation needs; and offers clinical, economic, and quality of life benefits. However, HHD is not currently provided in Poland. This review was performed to provide an overview of the main barriers to the introduction of a HHD programme in Poland. Main findings: The main high-level barrier to introducing HHD in Poland is the absence of specific health legislation required for clinician prescribing of HHD. Other barriers to overcome include clear definition of reimbursement, patient training and education (including infrastructure and experienced personnel), organisation of logistics, and management of complications. Partnering with a large care network for HHD represents an alternative option to payers for the provision of a new HHD service. This may reduce some of the barriers which need to be overcome when compared with the creation of a new HHD service and its supporting network due to the pre-existing infrastructure, processes, and staff of a large care network. Conclusions: Provision of HHD is not solely about the provision of home treatment, but also the organisation and definition of a range of support services that are required to deliver the service. HHD should be viewed as an additional, complementary option to existing dialysis modalities which enables choice of modality best suited to a patient’s needs.

Treatment Decision Making for Older Kidney Patients during COVID-19

BACKGROUND AND OBJECTIVES

Coronavirus disease 2019 (COVID-19) disrupted medical care across health care settings for older patients with advanced CKD. Understanding how shared decision making for kidney treatment decisions was influenced by the uncertainty of an evolving pandemic can provide insights for supporting shared decision making through the current and future public health crises.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed thematic and narrative analyses of semistructured interviews with patients (CKD stages 4 and 5, age 70+), care partners, and clinicians from Boston, Portland (Maine), San Diego, and Chicago from August to December 2020.

RESULTS

We interviewed 76 participants (39 patients, 17 care partners, and 20 clinicians). Among patient participants, 13 (33%) patients identified as Black, and seven (18%) had initiated dialysis. Four themes with corresponding subthemes emerged related to treatment decision making and the COVID-19 pandemic: (1) adapting to changed educational and patient engagement practices (patient barriers to care and new opportunities for telemedicine); (2) reconceptualizing vulnerability (clinician awareness of illness severity increased and limited discussions of patient COVID-19 vulnerability); (3) embracing home-based dialysis but not conservative management (openness to home-based modalities and limited discussion of conservative management and advanced care planning); and (4) satisfaction and safety with treatment decisions despite conditions of uncertainty.

CONCLUSIONS

Although clinicians perceived greater vulnerability among older patients CKD and more readily encouraged home-based modalities during the COVID-19 pandemic, their discussions of vulnerability, advance care planning, and conservative management remained limited, suggesting areas for improvement. Clinicians reported burnout caused by the pandemic, increased time demands, and workforce limitations, whereas patients remained satisfied with their treatment choices despite uncertainty.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Decision Aid for Renal Therapy (DART), NCT03522740.

Clinical presentation and outcomes of chronic dialysis patients with COVID-19: A single center experience from Greece

BACKGROUND

Coronavirus disease 2019 (COVID-19) is still a menacing pandemic, especially in vulnerable patients. Morbidity and mortality from COVID-19 in maintenance hemodialysis (MHD) patients are considered worse than those in the general population, but vary across continents and countries in Europe.

AIM

To describe the clinical course and outcomes of hospitalized MHD patients with COVID-19 in a retrospective observational single center study in Greece.

METHODS

We correlated clinical, laboratory, and radiological data with the clinical outcomes of MHD patients hospitalized with COVID-19 during the pandemic. The diagnosis was confirmed by real-time polymerase chain reaction. Outcome was determined as survivors vs non-survivors and “progressors” (those requiring oxygen supplementation because of COVID-19 pneumonia worsening) vs “non-progressors”.

RESULTS

We studied 32 patients (17 males), with a median age of 75.5 (IQR: 58.5-82) years old. Of those, 12 were diagnosed upon screening and 20 with related symptoms. According to the World Health Organization (WHO) score, the severity on admission was mild disease in 16, moderate in 13, and severe in 3 cases. Chest computed tomography (CT) showed 1-10% infiltrates in 24 patients. Thirteen “progressors” were recorded among included patients. The case fatality rate was 5/32 (15.6%). Three deaths occurred among “progressors” and two in “non-progressors”, irrespective of co-morbidities and gender. Predictors of mortality on admission included frailty index, chest CT findings, WHO severity score, and thereafter the increasing values of serum LDH and D-dimers and decreasing serum albumin. Predictors of becoming a “progressor” included increasing number of neutrophils and neutrophils/lymphocytes ratio.

CONCLUSION

Patients on MHD seem to be at higher risk of COVID-19 mortality, distinct from the general population. Certain laboratory parameters on admission and during follow-up may be helpful in risk stratification and management of patients.

Expanding Utilization of Home Dialysis: An Action Agenda From the First International Home Dialysis Roundtable

In a groundbreaking meeting, leading global kidney disease organizations came together in the fall of 2020 as an International Home Dialysis Roundtable (IHDR) to address strategies to increase access to and uptake of home dialysis, both peritoneal dialysis and home hemodialysis. This challenge has become urgent in the wake of the coronavirus disease 2019 (COVID-19) pandemic, during which patients with advanced kidney disease, who are more susceptible to viral infections and severe complications, must be able to safely physically distance at home. To boost access to home dialysis on a global scale, IHDR members committed to collaborate, through the COVID-19 public health emergency and beyond, to promote uptake of home dialysis on a broad scale. Their commitments included increasing the reach and influence of key stakeholders with policy makers, building a cooperative of advocates and champions for home dialysis, working together to increase patient engagement and empowerment, and sharing intelligence about policy, education, and other programs so that such efforts can be operationalized globally. In the spirit of international cooperation, IHDR members agreed to document, amplify, and replicate established efforts shown to improve access to home dialysis and support new policies that facilitate access through procedures, innovation, and reimbursement.

Is home hemodialysis a practical option for older people?

An increasing demand for in-center dialysis services has been largely driven by a rapid growth of the older population progressing to end-stage kidney disease. Since the onset of the COVID-19 pandemic, efforts to encourage home-based dialysis options have increased due to risks of infective transmission for patients receiving hemodialysis in center-based units. There are various practical and clinical advantages for patients receiving hemodialysis at home. However, the lack of caregiver support, cognitive and physical impairment, challenges of vascular access, and preparation and training for home hemodialysis (HHD) initiation may present as barriers to successful implementation of HHD in the older dialysis population. Assessment of an older patient's frailty status may help clinicians guide patients when making decisions about HHD. The development of an assisted HHD care delivery model and advancement of telehealth and technology in provision of HHD care may increase accessibility of HHD services for older patients. This review examines these factors and explores current unmet needs and barriers to increasing access, inclusion, and opportunities of HHD for the older dialysis population.

Covid-19 epidemic in the dialysis units of the french speaking part of Belgium : special insight into patients on home dialysis

In the French-speaking part of Belgium, between march and end of may 2020, 284 patients have suffered a Covid-19 infection, 7,9% of the prevalent dialysis population. Some of them have been  diagnosed through rt-PCT as they were symptomatic, others, asymptomatic,  being diagnosed by swab viral culture. Fifty two patients died (18% of the positive patients). The vast majority of them were patients on hemodialysis, only ten cases have been observed in patients on home dialysis techniques. Primary renal disease were diabetes or renal hypertensive disease in more than 50% of the patients and the most important comorbidities were cardiac ischemic or congestive disease, autonomy problems, cancer and smoking habits.