Analysis and outcome of 1063 patients trained for home hemodialysis

Dialysis after kidney transplant failure: how to deal with this daunting task?

The best treatment for patients with end-stage kidney disease is kidney transplantation, which, if successful provides both a reduction in mortality and a better quality of life compared to dialysis. Although there has been significant improvement in short-term outcomes after kidney transplantation, long-term graft survival still remains insufficient. As a result, there has been an increase in the number of individuals who need dialysis again after kidney transplant failure, and increasingly contribute to kidney transplant waiting lists. Starting dialysis after graft failure is a difficult task not only for the patients, but also for the nephrologists and the care team. Furthermore, recommendations for management of dialysis after kidney graft loss are lacking. Aim of this narrative review is to provide a perspective on the role of dialysis in the management of patients with failed kidney allograft. Although numerous studies have reported higher mortality in patients undergoing dialysis following kidney allograft failure, reports are contrasting. A patient-centered, individualized approach should drive the choices of initiating dialysis, dialysis modality, maintenance of immunosuppressive drugs and vascular access.

Intelligent "Internet Plus" services in the first case of home hemodialysis in mainland China

BACKGROUND

Many studies have shown that compared with those who use other dialysis modalities, patients using home hemodialysis (HHD) have an increased rate of survival and better quality of life. It was noted in 2006 that there was opportunity for significant expansion of the use of HHD in many countries. China covers a vast area and has a large amount of end-stage renal failure patients. But in mainland China, all dialysis treatments are in-center, and the number of HHD patients is zero. In 2018, our hospital received the permission of the Shanghai government to carry out HHD.

CASE PRESENTATION

We initiated four incident hemodialysis patients on an HHD regimen, one patient has been dialyzed in the home safely for 8 months. The biochemical parameters of the first patient remained stable on the regimen and he achieved standard Kt/V urea targets. Treatment-related adverse events were not reported during the follow-up. We combined HHD with intelligent "Internet Plus" real-time remote monitoring and introduced the Internet, especially visualization software, to replace traditional telephone and home visit methods. It is more intuitive and quicker to assist patients in performing home hemodialysis and improve the safety of treatment.

CONCLUSIONS

HHD can be performed by selected trained patients in mainland China. Combined with the internet, visualization software, and traditional telephone and home visits, it is intuitive and quick to assist patients in carrying out HHD and improve the safety of treatment. HHD broadens the choices for uremia patients in China.

Progressive survival improvement of incident dialysis patients in a tertiary center, Ireland

BACKGROUND

The survival of incident dialysis patients' end-stage kidney disease in some European and American has been reported to improve in modern era compared to earlier periods. However, in Ireland, this has not been well documented.

AIM

To investigate the survival outcomes of incident end-stage kidney failure dialysis patients in a tertiary center over a 24-year period, 1993-2017.

METHODS

A retrospective analysis was carried out utilizing the Beaumont Hospital Renal Database. Consecutive adults with incident dialysis were analyzed. Kaplan-Meier methods and the estimated mean survival times were used to evaluate survival at successive 4-year periods of time.

RESULTS

In total, 2106 patients were included, of whom 830 underwent subsequent renal transplantation during follow-up. During the study period, from 1993 up to 2017, the mean patients' age increased from 56.3 ± 17.4 in 1993-1996 to 60.6 ± 18.3 in 2014-2017. There was an overall decrement in mortality over successive time intervals which were mirrored by the improvements in median survival after commencement of dialysis treatment from 6.14 years during 1993-1996 to 8.01 years during 2009-2012. Patients' survival has steadily improved, with the 5-year survival has risen over time, by almost 15%. This positive signal persisted and became more pronounced after adjusting Kaplan-Meier curve to age, where the 5-year survival estimates were exceeding 80% in 2014-2017.

CONCLUSION

Survival rates among incident dialysis patients have improved progressively between 1993 and 2017 in Beaumont Hospital in Dublin, Ireland. The factors which led to this improvement are not entirely clear, but likely to be multifactorial.

Excellent long time survival for Swedish patients starting home-hemodialysis with and without subsequent renal transplantations

Survival for patients on dialysis is poor. Earlier reports have indicated that home-hemodialysis is associated with improved survival but most of the studies are old and report only short-time survival. The characteristics of patient populations are often incompletely described. In this study, we report long-term survival for patients starting home-hemodialysis as first treatment and estimate the impact on survival of age, comorbidity, decade of start of home-hemodialysis, sex, primary renal disease and subsequent renal transplantation. One hundred twenty-eight patients starting home-hemodialysis as first renal replacement therapy 1971-1998 in Lund were included. Data were collected from patient files, the Swedish Renal Registry and Swedish census. Survival analysis was made as intention-to-treat analysis (including survival after transplantation) and on-dialysis-treatment analysis with patients censored at the day of transplantation. Ten-, twenty- and thirty-year survival were 68%, 36% and 18%. Survival was significantly affected by comorbidity, age and what decade the patients started home-hemodialysis. For patients younger than 60 years and with no comorbidities, the corresponding figures were 75%, 47% and 23% and a subsequent renal transplantation did not significantly influence survival. Long-term survival for patients starting home-hemodialysis is good, and improves decade by decade. Survival is significantly affected by patient age and comorbidity, but the contribution of subsequent renal transplantation was not significant for younger patients without comorbidities.

How to overcome barriers and establish a successful home HD program

Home hemodialysis (HD) is an underused dialysis modality in the United States, even though it provides an efficient and probably cost-effective way to provide more frequent or longer dialysis. With the advent of newer home HD systems that are easier for patients to learn, use, and maintain, patient and provider interest in home HD is increasing. Although barriers for providers are similar to those for peritoneal dialysis, home HD requires more extensive patient training, nursing education, and infrastructure support in order to maintain a successful program. In addition, because many physicians and patients do not have experience with home HD, reluctance to start home HD programs is widespread. This in-depth review describes barriers to home HD, focusing on patients, individual physicians and practices, and dialysis facilities, and offers suggestions for how to overcome these barriers and establish a successful home HD program.

Outcome of home haemodialysis patients: a case-cohort study

BACKGROUND

Randomized, controlled comparisons between home haemodialysis (HHD) and centre haemodialysis (CHD) have not been performed to date. Reported survival benefits of HHD as compared with CHD from uncontrolled studies have been attributed largely to patient selection.

METHODS

In order to minimize a selection bias, we have compared the outcome of our HHD and CHD patients with a nested case-cohort study. For each patient trained for HHD at our dialysis centre between 1970 and 1995 (n=103), a corresponding match was searched from the CHD patients by retrospective chart analysis. The pairs were matched for sex, age (+/-5 years), time of dialysis therapy onset (+/-2 years) and renal disease category. For 58 of the 103 HHD patients, a corresponding matched CHD patient was identified. Both treatment groups had the same mean age (50+/-13 years) at dialysis onset and were comparable with respect to the Khan comorbidity index, prevalence and duration of hypertension, smoking habits, history of myocardial infarction, stroke and peripheral vascular disease. In both groups, approximately 50% of the patients were transplanted during the observation period.

RESULTS

HHD patients were hospitalized less often and tended to have fewer operations as compared with CHD patients. Survival was significantly longer in HHD as compared with CHD. Five, 10 and 20 year survival rates were 93 (n=55 patients at risk), 72 (41) and 34% (11) with HHD and 64 (38), 48 (26) and 23% (4) with CHD, respectively. This survival difference persisted after adjusting for predictors of mortality, i.e. age at onset of dialysis, year of start of dialysis therapy and Khan comorbidity index.

CONCLUSIONS

HHD offers a cheap and valuable alternative to CHD, with no apparent disadvantages.

Home hemodialysis: survival, quality of life, and rehabilitation

Choice of treatment modality for patients with end-stage renal disease ideally should not only increase the chances of survival but also improve quality of life and facilitate rehabilitation goals. These goals include employment, enhanced physical functioning, improved understanding of dialysis, increased control, and resumption of activities enjoyed before dialysis. Home hemodialysis has been consistently associated with improved long-term patient survival and quality of life compared with patients treated with in-center hemodialysis or peritoneal dialysis. Home hemodialysis is also well suited to rehabilitation. Home hemodialysis training programs educate patients and partners to become responsible for dialysis treatments, thus encouraging independence and permitting flexible scheduling, which promotes greater participation in exercise and employment. Further information about modality choice and rehabilitation outcomes could be obtained by systematic data collection to enable comparisons between modalities. Patients should have the opportunity to choose from among all modalities, including home hemodialysis.

Survival on dialysis therapy: one center's experience

Patient survival while undergoing renal replacement therapy was evaluated from January 1, 1967, through June 15, 1986. There were 1,216 patients, of which 230 were treated by continuous ambulatory peritoneal dialysis (CAPD), 150 by home hemodialysis (HHD), and the remainder by dialysis in a free-standing dialysis facility (LCD). Covariate analysis found that patient survival on dialysis therapy was not influenced by race, sex, or marital status. Patients more than 60 years of age and patients with renal failure secondary to diabetes mellitus or hypertension had the worst survival on dialysis. Patients entering into CAPD were associated with diminished survival when compared to HHD but not to LCD. The ability of the initial dialysis technique to maintain a person on dialysis was not different when patients were matched for age, race, and etiology of renal failure. Only a randomized prospective trial will answer the question as to whether continuous ambulatory peritoneal dialysis can maintain a patient at home as long as home hemodialysis.

Predictors of survival in patients undergoing dialysis

Survival and risk analyses were performed on all 532 patients in whom long-term dialysis was started from 1970 through 1985. During this 16-year period, starting age increased from 47 to 60 years (p less than 0.001), and the incidence of diabetes mellitus and renal vascular disease increased. Survival analysis showed age, renal diagnosis, type of dialysis, and year starting dialysis to be important predictors of survival. There was a fourfold rise in the risk ratio as starting age increased from 25 to 65 years. The risk was 1.5 times higher for those patients who did not start dialysis in 1978 through 1981 than for those who did. Risk decreased fivefold for patients choosing home hemodialysis. Home hemodialysis patients survived longer compared with patients utilizing other dialysis modalities, possibly because of a younger average age and a lower incidence of diabetes mellitus and renal vascular disease. There was greater than a threefold rise in risk ratio with the diagnosis of diabetes mellitus compared with either chronic glomerulonephritis or polycystic kidney disease. Older patients and those with diabetes mellitus formed the high-risk group; these two characteristics have been increasing during the last eight years of the study. It is concluded that although patients with high risk have an increased and a high mortality, overall survival has improved.

Results of treatment in patients with end-stage renal disease: a multivariate analysis of risk factors and survival in 341 successive patients

Factors that affect survival in patients with end-stage renal disease (ESRD) are still only partially understood. We report an analysis on a cohort of 341 successive patients who started ESRD treatment in one institution. Survival was calculated from the start of ESRD treatment, whether initial treatment was by dialysis (335 patients) or transplantation (6 patients). Analysis of factors affecting survival was done using the Cox multivariate hazard analysis. Relative risks were calculated for several demographic factors, the primary renal disease, the presence or absence of various high-risk co-morbid factors, and for a first transplant from a living-related or cadaver donor. Older patients, patients with no prior health insurance, those with diabetic nephropathy, and those with small kidneys of unknown cause had statistically significantly higher risks of dying. The risk of dying decreased by year of start of ESRD treatment. Living related donor transplantation was associated with a decreased hazard to age 45 years and older; whereas cadaver donor transplantation was associated with a hazard that increased with age and was significantly increased by age 45.

Results of treatment of renal failure by means of home hemodialysis

Of 630 patients who began hemodialysis treatment for chronic renal failure between 1965 and 1977, 147 successfully completed training for home hemodialysis. Patient compliance was satisfactory, as reflected by the results of monthly blood chemical values, hematocrits, and weight gain between dialysis. Although only 15 patients had previous myocardial infarctions and 4 had had strokes before beginning dialysis, 9 patients subsequently experienced acute myocardial infarctions and 14 had strokes. Of the 45 patients who died while being maintained by hemodialysis, 24 had cardiopulmonary complications and 6 had strokes. Despite such complications, 70 patients were gainfully employed and 32 were active at home or at school, whereas 29 were totally disabled. At last follow-up, 74 remained on home hemodialysis, 53 had functioning renal allografts, and the rest of the patients were being maintained in our dialysis center, had transferred elsewhere, or were being maintained by peritoneal dialysis. The overall estimated 5-year survival rate was 56%, whereas the estimated 5-year survival rate for those maintained by home hemodialysis alone was 52%.

Treatment bias in the management of end-stage renal disease

A study was conducted of 419 patients with end-stage renal disease (ESRD) being treated by center or home hemodialysis or by renal transplantation at four facilities located within 2.5 km of each other. The objectives were to examine the distribution of patients among the three modes of treatment and to analyze patient transfers to alternate modes of ESRD therapy. While white patients at each facility were comparable (P greater than 0.05) on age, sex, travel time to treatment, marital status, work or employment status, and the presence of diabetes mellitus, the distribution of patients among the treatment modes differed significantly (P less than 0.001) across the facilities. Similarly, the sociodemographic and diagnostic characteristics of the nonwhite patients were comparable at each of the facilities (P greater than 0.05); however, despite observable variation among the facilities in the distribution of these patients, the differences did not achieve statistical significance (P greater than 0.05). Patient transfers to alternate modes of ESRD therapy were infrequent, and among center hemodialysis patients, the distribution of transfers differed significantly across the facilities (P less than 0.001). It is concluded that the distribution of patients was dependent on the patient's initial mode of therapy and the staff attitudes at the individual facilities.

Patients surviving 10 years of hemodialysis

Experience with 37 patients surviving 10 years of hemodialysis therapy was reviewed. These patients were compared with 103 patients who began hemodialysis between 1967 and 1971 and who subsequently died. Males had an excess risk of death. Patients with polycystic kidneys survived longer. There was more uncontrolled hypertension among a control group than in 10-year survivors. In survivors, the hematocrit level increased over time and averaged 30.4 percent at 10 years. Over 10 years, many complications arose including parathyroidectomy (24), pericarditis (13), gastrointestinal bleeding (11), myocardial infarction (10), septicemia (eight), and active tuberculosis (six). Despite complications, most patients are now stable. Between their eighth and 10th years they required an average of only one hospitalization with a mean stay of 9.7 days. Eighteen patients were not hospitalized. Excluding housewives, 67 percent of patients between ages 20 and 59 years are employed full-time and 10 percent part-time. Patients surviving 10 years are not progressively deteriorating and may look to the future with cautious optimism.

Comparison of home hemodialysis to continuous ambulatory peritoneal dialysis

We evaluated prospectively various outcome measurements of patients assigned initially to continuous ambulatory peritoneal dialysis (CAPD) and home hemodialysis (HHD) from February 1979 to August 1981 and the causes for failures of the techniques. Morbidity was assessed by time in hospital/time on dialysis. Fifty-six patients were trained for CAPD and 37 for HHD. Those assigned to CAPD experienced an increased frequency of hospitalization (7.5% CAPD, 2.8% HHD, respectively) primarily due to episodes of peritonitis. There was also a higher modality failure rate (43% vs. 16%). However, the groups were not comparable in all respects. For example, the CAPD population included 21 patients with major cardiovascular diseases versus only three in the HHD group. The demographic characteristics of both populations including race, sex, age, income, place of residence, marital status, and education were similar. At the time of this study there is no direct evidence showing that healthy patients otherwise able to perform HHD may be maintained with less morbidity for a prolonged period utilizing CAPD. Therefore, we suggest that HHD is the home method of choice for patients able to proceed with this technique. CAPD may be indicated for patients in whom the period of home dialysis is expected to be relatively short and who would be otherwise unable to carry out home dialysis, for example, patients awaiting transplantation and those unable to be maintained on hemodialysis because of impaired cardiac function. To fully evaluate CAPD as a long-term maintenance therapy, a prospective trial must be performed.

Management of end stage polycystic kidney disease with renal transplantation

Thirty renal transplants have been done in 25 patients with end stage polycystic kidney disease. All but 2 allografts were from a cadaver donor and the average followup was 5 plus or minus 0.9 years. THe 1 and 5-year patient survival rates after transplantation were 76 and 50 per cent, respectively, and allograft survival rates were 63.3 and 39.1 per cent at the same intervals. Of 14 patients at risk for more than 8 years 6 still have well functioning allografts. Nine patients underwent transplantation with both polycystic kidneys in situ and with no adverse sequelae resulting from the retained native kidneys. Despite the risk factors inherent in an older than normal population of cadaver allograft recipients, renal transplantation is an excellent method for treating end stage polycystic kidney disease and holds the prospect for long-term allograft and patient survival rates.

Psychosocial disability during maintenance hemodialysis

Overall psychosocial functioning was assessed in 21 maintenance hemodialysis patients. The Ruesch Social Disability Scale, which provides an overall Social Disability (DS) score as well as subscores for Physical Impairment (PI), Behavioral Impairment (BI), and Social Modifiers (MS), was utilized. A majority of the patients (13) experienced Major Social Disability and the mean DS score of this sample was in the Major Social Disability range (mean = 52.1 +/- 10.9). There were no differences between the mean DS score of men and women. Married patients had DS scores significantly lower than those who were divorced or never married (P less than .05). Patients with more than five years of maintenance hemodialysis had a mean DS score significantly higher than those with less then five years of maintenance hemodialysis (P less than .03). In those patients with more than five years of hemodialysis, the MS scale was significantly elevated (P less than .01) in comparison with their counterparts, whereas the BI and PI scores were not different. The data suggest that serious psychosocial impairment is a common sequela of maintenance hemodialysis, especially for long-term patients and those who are not married. Therapeutic approaches directed toward improved social functioning are indicated.

Physical activity and employment status of patients on maintenance dialysis

Existing data on the clinical outcome of maintenance dialysis for end-stage kidney disease focus mainly on the duration of life. We surveyed 18 dialysis centers to gain a broader overview of the current status of 2481 patients on dialysis, irrespective of the type or location of dialysis. The results suggest that 12 per cent of dialysis patients are diabetics and that 53 per cent are 50 years of age or older. There was considerable variation among centers in the degree of rehabilitation; nevertheless, only 60 per cent of the nondiabetic patients and 23 per cent of the diabetic patients were capable of a level of physical activity beyond that of caring for themselves. Only one quarter of the patients worked outside the home, whereas one third worked at home. These results suggest that a larger proportion of dialysis patients than previously suspected are severely debilitated. There is a need for improved data on the quality and length of life of patients on maintenance dialysis.

Physical, emotional and social adjustments to home dialysis

Forty home dialysis patients and their families were interviewed by means of a standard questionnaire to determine their physical, emotional, and social adjustment to treatment. The results indicated a reasonable level of health, particularly in patients under the age of 50 years. However, home dialysis produced considerable strain in the family, particularly in the dialysis partners. Home training programmes should provide appropriate learning and technical experience for the dialysis partners and continued support, including integrated medical and paramedical services, domiciliary visiting, and regular holidays. Limited-care dialysis facilities should be provided where home dialysis is impractical or becomes intolerable.

Incidence and prevalence of home dialysis

The proportion of patients on home hemodialysis in the United States has declined continuously since 1972 despite an increasing total number of patients treated by dialysis. Regional variations and the experience in Europe are described. The reasons for the changing pattern of dialysis in the United States are discussed, together with possible measures which could help to reverse the present trend of increasing use of more expensive center dialysis which has features making rehabilitation more difficult for many patients.

Whatever happened to home hemodialysis?

Advantages of home hemodialysis over center include better patient survival and rehabilitation, more patient convenience, decreased risk of hepatitis, and cheaper costs. Home dialysis places stress on the family and requires a great time commitment of the helper. Ninety-three patients began home dialysis training at our institution. Seventy-eight successfully completed training and five patients are still in training. Of the seventy-eight who completed training, fifty (64%) are still performing home dialysis for periods of from one month to 6 1/2 years. 10% received a kidney transplant, 13% died, and 13% have returned to a center for dialysis. Family stress was the major reason for return to a center in the ten patients who chose to do so. Even though home dialysis is superior to center dialysis, the percentage of patients being treated in the home in this country is diminishing. Possible reasons for this decline are discussed.