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

Exploring the factors affecting home dialysis patients' participation in telehealth-assisted home visits: A mixed-methods study

BACKGROUND

Technology, such as telehealth, is increasingly used to support home dialysis patients. The challenges patients and carers face when home dialysis nursing visits are provided via telehealth have yet to be explored.

OBJECTIVES

To explore patients' and carers' perspectives as they transition to telehealth-assisted home visits and identify the factors influencing their engagement in this modality.

DESIGN

A mixed-methods approach, guideed by the behaviour change wheel using the capability, opportunity, motivation-behaviour model to explore individual's perceptions of telehealth.

PARTCIPANTS

Home dialysis patients and their carers.

MEASURUEMENTS

Suveys and qualitative interviews.

METHODS

A mixed-methods approach was undertaken, combining surveys and qualitative interviews. It was guided by the Behaviour Change Wheel using the Capability, Opportunity, Motivation- Behaviour model to explore individuals' perceptions of telehealth.

RESULTS

Thirty-four surveys and 21 interviews were completed. Of 34 survey participants, 24 (70%) preferred face-to-face home visits and 23 (68%) had previously engaged in telehealth. The main perceived barrier identified in the surveys was knowledge of telehealth, but participants believed there were opportunities for them to use telehealth. Interview results revealed that the convenience and flexibility of telehealth were perceived as the main advantages of telehealth. However, challenges such as the ability to conduct virtual assessments and to communicate effectively between clinicians and patients were identified. Patients from non-English speaking backgrounds and those with disabilities were particularly vulnerable because of the many barriers they faced. These challenges may further entrench the negative view regarding technology, as discussed by interview participants.

CONCLUSION

This study suggested that a blended model combining telehealth and face-to-face services would allow patient choice and is important to facilitate equity of care, particularly for those patients who were unwilling or had difficulty adopting technology.

Towards a better uptake of home dialysis in Europe: understanding the present and looking to the future

Use of peritoneal dialysis and home haemodialysis remains low in Europe, with the highest use in Scandinavian countries and the lowest in Eastern and Central Europe despite the advantages for people on dialysis and economic advantages for healthcare systems. This is partly due to the impact of the haemodialysis industry resulting in proliferation of haemodialysis units and nephrologist reimbursement related to use of haemodialysis. Equally important is the bias against home dialysis at both clinician and healthcare system levels. The underlying causes of this bias are discussed in relation to a mechanistic view of the human body, lack of compassion, failure to adjust dialysis provision for older age and frailty, proliferation of small dialysis centres, and complexity of decision-making and clinical care. For home dialysis to flourish, we need to foster a change in attitude to and vision of the aims of healthcare so that enabling meaningful activities of people requiring dialysis, as explored in the Standardized Outcomes in Nephrology initiative, rather than achieving biological numbers become the focus of care delivery.

Advances in Human-Centered Care to Address Contemporary Unmet Needs in Chronic Dialysis

Advances in the treatment of kidney failure with chronic dialysis have stagnated over the past three decades, with over 50% of patients still managed by conventional in-hospital haemodialysis. In parallel, the demands of chronic dialysis medical care have changed and evolved due to a growing population that has higher frailty and multimorbidity. Thus, the gap between the needs of kidney failure patients and the healthcare capability to provide effective overall management has widened. To address this problem, healthcare policy has increasingly aligned towards a human-centred approach. The paradigm shift of human-centred approach places patients at the forefront of decision-making processes, ensuring that specific needs are understood and prioritised. Integration of human-centred approaches with patient care has been shown to improve satisfaction and quality of life. The aim of this narrative is to evaluate the current clinical challenges for managing kidney failure for dialysis providers; summarise current experiences and unmet needs of chronic dialysis patients; and finally emphasise how human-centred care has advanced chronic dialysis care. Specific incremental advances include implementation of renal supportive care; home-assisted dialysis; hybrid dialysis; refinements to dialysis methods; whereas emerging advances include portable and wearable dialysis devices and the potential for the integration of artificial intelligence in clinical practice.

Centre variation in home dialysis uptake: A survey of kidney centre practice in relation to home dialysis organisation and delivery in England

BACKGROUND

Disparities in home dialysis uptake across England suggest inequity and unexplained variation in access. We surveyed staff at all English kidney centres to identify patterns in service organisation/delivery and explore correlations with home therapy uptake, as part of a larger study ('Inter-CEPt'), which aims to identify potentially modifiable factors to address observed variations.

METHODS

Between June and September 2022, staff working at English kidney centres were surveyed and individual responses combined into one centre-level response per question using predetermined data aggregation rules. Descriptive analysis described centre practices and their correlation with home dialysis uptake (proportion of new home dialysis starters) using 2019 UK Renal Registry 12-month home dialysis incidence data.

RESULTS

In total, 180 responses were received (50/51 centres, 98.0%). Despite varied organisation of home dialysis services, most components of service delivery and practice had minimal or weak correlations with home dialysis uptake apart from offering assisted peritoneal dialysis and 'promoting flexible decision-making about dialysis modality'. Moderate to strong correlations were identified between home dialysis uptake and centres reporting supportive clinical leadership (correlation 0.32, 95% Confidence Interval (CI): 0.05-0.55), an organisational culture that values trying new initiatives (0.57, 95% CI: 0.34-0.73); support for reflective practice (0.38, 95% CI: 0.11-0.60), facilitating research engagement (0.39, 95% CI: 0.13-0.61) and promoting continuous quality improvement (0.29, 95% CI: 0.01-0.53).

CONCLUSIONS

Uptake of home dialysis is likely to be driven by organisational culture, leadership and staff attitudes, which provide a supportive clinical environment within which specific components of service organisation and delivery can be effective.

System-Level Strategies to Improve Home Dialysis: Policy Levers and Quality Initiatives

Advocacy and policy change are powerful levers to improve quality of care and better support patients on home dialysis. While the kidney community increasingly recognizes the value of home dialysis as an option for patients who prioritize independence and flexibility, only a minority of patients dialyze at home in the United States. Complex system-level factors have restricted further growth in home dialysis modalities, including limited infrastructure, insufficient staff for patient education and training, patient-specific barriers, and suboptimal physician expertise. In this article, we outline trends in home dialysis use, review our evolving understanding of what constitutes high-quality care for the home dialysis population (as well as how this can be measured), and discuss policy and advocacy efforts that continue to shape the care of US patients and compare them with experiences in other countries. We conclude by discussing future directions for quality and advocacy efforts.

Assisted PD throughout Europe: advantages, inequities, and solution proposals

BACKGROUND

Peritoneal dialysis provides several benefits for patients and should be offered as first line kidney replacement therapy, particularly for fragile patients. Limitation to self-care drove assisted peritoneal dialysis to evolve from family-based care to institutional programs, with specialized care givers. Some European countries have mastered this, while others are still bound by the availability of a volunteer to become responsible for treatment.

METHODS

A group of leading nephrologists from 13 European countries integrated real-life application of such therapy, highlighting barriers, lessons learned and practical solutions. The objective of this work is to share and summarize several different approaches, with their intrinsic difficulties and solutions, which might helpperitoneal dialysis units to develop and offer assisted peritoneal dialysis.

RESULTS

Assisted peritoneal dialysis does not mean 4 continuous ambulatory peritoneal dialysis exchanges, 7 days/week, nor does it exclude cycler. Many different prescriptions might work for our patients. Tailoring PD prescription to residual kidney function, thereby maintaining small solute clearance, reduces dialysis burden and is associated with higher technique survival. Assisted peritoneal dialysis does not mean assistance will be needed permanently, it can be a transitional stage towards individual or caregiver autonomy. Private care agencies can be used to provide assistance; other options may involve implementing PD training programs for the staff of nursing homes or convalescence units. Social partners may be interested in participating in smaller initiatives or for limited time periods.

CONCLUSION

Assisted peritoneal dialysis is a valid technique, which should be expanded. In countries without structural models of assisted peritoneal dialysis, active involvement by the nephrologist is needed in order for it to become a reality.

Inequities in kidney health and kidney care

Health inequity refers to the existence of unnecessary and unfair differences in the ability of an individual or community to achieve optimal health and access appropriate care. Kidney diseases, including acute kidney injury and chronic kidney disease, are the epitome of health inequity. Kidney disease risk and outcomes are strongly associated with inequities that occur across the entire clinical course of disease. Insufficient investment across the spectrum of kidney health and kidney care is a fundamental source of inequity. In addition, social and structural inequities, including inequities in access to primary health care, education and preventative strategies, are major risk factors for, and contribute to, poorer outcomes for individuals living with kidney diseases. Access to affordable kidney care is also highly inequitable, resulting in financial hardship and catastrophic health expenditure for the most vulnerable. Solutions to these injustices require leadership and political will. The nephrology community has an important role in advocacy and in identifying and implementing solutions to dismantle inequities that affect kidney health.

Growing a peritoneal dialysis program in Palestine from zero to 178 patients in 5 years: a single-center experience

INTRODUCTION

Kidney failure is rapidly rising in Palestine, as the number of patients receiving maintenance dialysis has quadrupled in the last 15 years. In this study, we share an overview of our experience growing a peritoneal dialysis (PD) program from zero to 178 patients in 5 years at An-Najah National University Hospital in Palestine, presenting some challenges and ways to overcome them.

METHODS

This was a single-center retrospective study of patients treated with PD from November 2016 to December 2021. Demographic and clinical data were obtained for each patient. In addition, PD discontinuation, peritonitis, and mortality rates were calculated and presented as the primary patient outcomes.

RESULTS

A total of 158 patients were eligible for the study. The mean age was 51.8 ± 16.4 years, and 53.8% of patients were male. Diabetic nephropathy was the most common cause of kidney failure. 63 episodes of peritonitis were diagnosed in 48 patients (30.4%) for a rate of 1 episode/ 38.2 patient-months (0.31 episodes/ patient-years). 20 patients had their PD treatment discontinued, mainly due to psychosocial reasons and infectious and mechanical complications. Death was the fate of 27 patients, with cardiovascular disease and COVID-19 being the two main causes.

CONCLUSION

The outcomes of this experience proved favorable and showed that PD could serve as a viable option for kidney failure patients in Palestine. Moreover, this study can serve as an example for other places where circumstances are challenging to take the initiative of starting their PD programs.

A Survey of Environmental Sustainability Practices in Dialysis Facilities in Australia and New Zealand

BACKGROUND AND OBJECTIVES

Climate change is the biggest global health threat of the twenty-first century. Health care itself is a significant contributor to greenhouse gas emissions, and dialysis programs contribute disproportionately. Nephrology societies have called for increased recognition and action to minimize the environmental effect of dialysis care, but little data exist regarding environmental sustainability practices within dialysis facilities worldwide. This survey reports a baseline of environmental sustainability practices of dialysis facilities in Australia and New Zealand.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

An online survey was used to collect data regarding key areas of environmental sustainability practices within dialysis facilities between November 2019 and December 2020. An invitation to complete the survey was sent to the heads of all dialysis facilities in Australia and New Zealand.

RESULTS

Responses were received from 132 dialysis facilities, representing 33% (122 of 365) of dialysis services within Australia and New Zealand. Most responses were from public satellite facilities (53 of 132; 40%), in-center dialysis facilities (33 of 132; 25%), and co-located dialysis and home therapies facilities (28 of 132; 21%). Opportunities for improvement in environmental sustainability practices were identified in three domains. (1) Culture. A minority of facilities reported having an environmental sustainability strategy in place (44 of 132; 33%) or undertaking sustainability audits (27 of 132; 20%). Only 7% (nine of 132) reported the inclusion of environmental training in staff induction programs. (2) Building design, infrastructure, and energy use. Few facilities reported the use of renewable energy (18 of 132; 14%), reclaiming reverse osmosis reject water (16 of 126; 13%), or the use of motion-sensor light switches (58 of 131; 44%). (3) Operations. A minority of facilities reported waste management education (47 of 131; 36%), auditing waste generation (23 of 132; 17%), or that environmental sustainability was considered in procurement decisions (33 of 132; 25%).

CONCLUSIONS

Environmental sustainability is not currently prioritized in clinical practice, building design and infrastructure, or management systems in Australian and New Zealand dialysis facilities responding to this survey.

The vulnerability of maintenance dialysis patients with COVID-19: mortality and risk factors from a developing country

Patients on maintenance dialysis therapy are especially vulnerable to COVID-19 and its complications. This study aimed to assess the incidence, epidemiological characteristics, and mortality rate of COVID-19 among maintenance dialysis patients. This retrospective observational chart review study included 548 patients from all dialysis units in the West Bank of Palestine who acquired COVID-19 between 5 March 2020, and 11 August 2021. We collected data on patients' demographics, clinical features, and outcomes. A multivariable logistic regression model was used to assess independent risk factors for COVID-19-related mortality. The incidence of COVID-19 among maintenance dialysis patients was 35.3%, as 548 out of 1554 patients have tested positive during the study period. Patients on haemodialysis were three times riskier to get infected than those on peritoneal dialysis (37% vs 11.3%). Half (50.2%) of infected patients required hospitalisation, and 24.5% were admitted to an intensive care unit, while the mortality rate stood at 26.8%. Old age, male sex, central venous catheter use, comorbid diabetes, smoking, and having an RH negative blood group type were determined to be significantly associated with increased risk of mortality. In conclusion, the incidence of COVID-19 among Palestinian maintenance dialysis patients was notably high, especially among haemodialysis patients. High rates of hospitalisation, ICU admission, intubation and death were observed, and predictive factors for COVID-19-related mortality were identified. Therefore, the implementation of strict infection control measures and promotion of home dialysis are warranted to reduce the infection rate.KEY MESSAGESThe incidence of COVID-19 among Palestinian maintenance dialysis patients was notably high; more than one-third of the total dialysis population acquired COVID-19, with haemodialysis patients being three times more likely to get infected compared to their peritoneal dialysis counterparts.The mortality rate among maintenance dialysis patients was 26.8%, more than 25 times higher than that of the general population. The risk of mortality was significantly increased with age, male sex, smoking, diabetes, and having central venous catheter as vascular access for haemodialysis.Strict infection control measures, as well as the promotion of home dialysis, are necessary to reduce the risk of infection.

Hierarchically structural layered double oxides with stretchable nanopores for highly effective removal of protein-bound uremic toxins

The global outbreak and prevalence of coronavirus disease 2019 (COVID-19) has triggered an urgent demand for family hemodialysis equipment. It is particularly vital to design and apply superior adsorbents to adsorb toxins for reducing the usage of dialysate. In this work, hierarchically structural MgAl layered double oxides (LDO) with stretchable nanopores were exploited through a facile one-pot trisodium citrate (TSC) assistant hydrothermal reaction followed by calcination treatment for effectively adsorbing protein-bound uremic toxins such as hippuric acid (HA) or indoxyl sulfate (IS). The optimized MgAl LDO possessed flower-like spherical morphology, ultrahigh specific surface area (187.3 m²/g) and uniquely stretchable nanopores, which were more conducive to incorporating anions due to their unique memory effect endowing them with promising adsorption capacities for HA or IS. And the adsorption data could be better conformed to pseudo-second-order kinetic model and Langmuir isotherm determining that the maximum adsorption capacity of HA and IS was 129.8 mg/g and 63.1 mg/g, respectively. Furthermore, the computation of molecular size paired with the analysis of adsorption mechanism accurately revealed that high-efficiency toxin capture was mainly attributed to electrostatic interaction for internal intercalation and surface adsorption. Therefore, the application of such delicate LDO as new premium adsorbent would facilitate the development and popularization of family hemodialysis equipment.

The European Kidney Health Alliance (EKHA) and the Decade of the KidneyTM

The European Kidney Health Alliance (EKHA) is an advocacy organization that defends the case of the kidney patients and the nephrological community at the level of the European Union (EU), and from there, top to bottom, also at the national level of the EU member states and the EU-associated countries. The Decade of the KidneyTM is a global initiative launched by the American Association of Kidney Patients (AAKP) to create greater awareness and organize patient demands for long overdue innovation in kidney care. This article describes the medical and patient burden of kidney disease, the history of EKHA, its major activities and tools for policy action and the need for innovation. We then describe the Decade of the KidneyTM initiative, the rationale why EKHA joined this activity to emanate parallel action at the European side, the novel professionalized structure of EKHA, and its immediate targets. The final aim is to align all major stakeholders for an action plan on kidney disease comparable to Europe's successful Beating Cancer Plan, with the additional intent that the EKHA model is applied also by the respective national kidney-related societies to create a broad mobilization at all levels. The ultimate aims are that the EU considers chronic kidney disease (CKD) as a major health and health-economic problem, to consequently have CKD included as a key health research target by the European Commission, and to improve quality of life and outcomes for all kidney patients.

Peritoneal catheter insertion: combating barriers through policy change

Barriers to accessing home dialysis became a matter of life and death for many patients with kidney failure during the coronavirus disease 2019 (COVID-19) pandemic. Peritoneal dialysis (PD) is the more commonly used home therapy option. This article provides a comprehensive analysis of PD catheter insertion procedures as performed around the world today, barriers impacting timely access to the procedure, the impact of COVID-19 and a roadmap of potential policy solutions. To substantiate the analysis, the article includes a survey of institutions across the world, with questions designed to get a sense of the regulatory frameworks, barriers to conducting the procedure and impacts of the pandemic on capability and outcomes. Based on our research, we found that improving patient selection processes, determining and implementing correct insertion techniques, creating multidisciplinary teams, providing appropriate training and sharing decision making among stakeholders will improve access to PD catheter insertion and facilitate greater uptake of home dialysis. Additionally, on a policy level, we recommend efforts to improve the awareness and feasibility of PD among patients and the healthcare workforce, enhance and promulgate training for clinicians—both surgical and medical—to insert PD catheters and fund personnel, pathways and physical facilities for PD catheter insertion.