Central venous catheter outcomes in nocturnal hemodialysis

Vascular Access for Home Hemodialysis: A Perspective on Tunneled Central Venous Catheters at Home

Expansion of home hemodialysis (HHD) provides an opportunity to improve clinical outcomes, reduce cost of care, and address the staffing challenges currently faced in caring for patients with kidney failure on replacement therapy. To increase HHD expansion, current practices and barriers to home dialysis must be examined and addressed. One such barrier is vascular access for HHD; although tunneled hemodialysis central venous catheters (CVCs) have been used for decades, physicians still hesitate to send patients home without a mature, functional arteriovenous access. An expert panel of clinicians was convened by Outset Medical, a manufacturer of hemodialysis systems, to review the literature and generate consensus recommendations regarding the use of CVCs for HHD. Consistent with the most recent Kidney Disease Outcomes vascular access guidelines, the end-stage kidney disease life plan should be created via shared decision making for modality choices, with the corresponding dialysis access individualized for the patient, and for whom a CVC may represent the most appropriate vascular access to provide HHD.

Going Home: Access for Home Modalities

The cost and health burden of ESRD continues to increase globally. Total Medicare expenditure on dialysis has increased from 229 million USD in 1973 to 35.4 billion USD in 2016. Dialysis access can represent almost a tenth of these costs. Central venous catheters have been recognized as a significant factor driving costs and mortality in this population. Home dialysis, which includes peritoneal dialysis and home hemodialysis, is an effective way of reducing costs related to renal replacement therapy, reducing central venous catheter usage and in many cases improving the clinical and psychosocial aspects of patients' health. Addressing access-related issues for peritoneal dialysis, urgent-start peritoneal dialysis and home hemodialysis can have impact on the success of home dialysis. This article reviews issues related to dialysis access for home therapies.

[Low flux dialysate daily home hemodialysis: A result for the 62 first French and Belgian patients]

Since 2011, a new device is available for low flux dialysate quotidian home hemodialysis in France and Belgium. This study aims to evaluate the characteristics and dialysis prescriptions for Nx Stage System One™ users. We retrospectively included patients trained between 2011 and 2013 in France and Belgium. We collected data concerning their clinical features, their dialysis prescriptions, their laboratory parameters until 6 months of dialysis and, reason for dropping in case of cessation. Sixty-two patients from 31 centers, aged 48±18 years old, with a sex ratio 46/16 (M/F) are included with a median Charlson comorbidity index of 1 [0-3]. Of these patients, 71% are anuric and have been on dialysis for a mean time of 136.6±125 months. Previously, most of them had been taken care of in satellite units of dialysis (45%) and 14% are incident patients. In total, A total of 60% have an arterio-veinous fistula (AVF), with 18 patients using the Buttonhole system and 2 patients have a tunneled catheter. Median time for training was 26.5 days (17-45). Among the patients, 69% are dialyzed 6 days a week, during a mean time of 142.5±20 minutes with a volume of 20.9±3 liters of dialysate and without anticoagulant (63%). Predialytic levels of hemoglobin, creatinin, urea, phosphorus and β2microglobulin remain stable. On the contrary, there is a significant improvement of albumin and bicarbonate levels. Technique survival was 75% at 1 year, and major reason for cessation was kidney transplant. It seems that this device fits for young patients, with few comorbidities and a long past in renal chronic failure. These results suggest that dialysis adequacy is acceptable despite low dialysate volumes but need confirmation with a longer follow up and a larger cohort.

Patient selection and training for home hemodialysis

Patient selection and training is arguably the most important step toward building a successful home hemodialysis (HD) program. We present a step-by-step account of home HD training to guide providers who are developing home HD programs. Although home HD training is an important step in allowing patients to undergo dialysis in the home, there is a surprising lack of systematic research in this field. Innovations and research in this area will be pivotal in further promoting a higher acceptance rate of home HD as the renal replacement therapy of choice.

Association of Vascular Access Type with Mortality, Hospitalization, and Transfer to In-Center Hemodialysis in Patients Undergoing Home Hemodialysis

BACKGROUND AND OBJECTIVES

In individuals undergoing in-center hemodialysis (HD), use of central venous catheters (CVCs) is associated with worse clinical outcomes compared with use of arteriovenous access. However, it is unclear whether a similar difference in risk by vascular access type is present in patients undergoing home HD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Our study examined the associations of vascular access type with all-cause mortality, hospitalization, and transfer to in-center HD in patients who initiated home HD from 2007 to 2011 in 464 facilities in 43 states in the United States. Patients were followed through December 31, 2011. Data were analyzed using competing risks hazards regression, with vascular access type at the start of home HD as the primary exposure in a propensity score-matched cohort (1052 patients; 526 with CVC and 526 with arteriovenous access).

RESULTS

Over a median follow-up of 312 days, 110 patients died, 604 had at least one hospitalization, and 202 transferred to in-center hemodialysis. Compared with arteriovenous access use, CVC use was associated with higher risk for mortality (hazard ratio, 1.73; 95% confidence interval, 1.18 to 2.54) and hospitalization (hazard ratio, 1.19; 95% confidence interval, 1.02 to 1.39). CVC use was not associated with increased risk for transfer to in-center HD. The results of analyses in the entire unmatched cohort (2481 patients), with vascular access type modeled as a baseline exposure at start of home HD or a time-varying exposure, were similar. Analyses among a propensity score-matched cohort of patients undergoing in-center HD also showed similar risks for death and hospitalization with use of CVCs.

CONCLUSIONS

In a large cohort of patients on home HD, CVC use was associated with higher risk for mortality and hospitalization. Additional studies are needed to identify interventions which may reduce risk associated with use of CVCs among patients undergoing home HD.

Financial implications to Medicare from changing the dialysis modality mix under the bundled prospective payment system

BACKGROUND

The economic burden of treating end-stage renal disease (ESRD) continues to grow. As one response, effective January 1, 2011, Medicare implemented a bundled prospective payment system (PPS, including injectable drugs) for dialysis patients. This study investigated the 5-year budget impact on Medicare under the new PPS of changes in the distribution of patients undergoing peritoneal dialysis (PD), in-center hemodialysis (ICHD), and home hemodialysis (HHD).

METHODS

An Excel-based budget impact model was created to assess dialysis-associated Medicare costs. The model accounted for dialysis access establishment, the current monthly capitation physician payment for ESRD, Medicare dialysis payments (including start-up costs), training, oral drug costs, and the costs and probabilities of adverse events including access failure, hospitalization for access infection, pneumonia, septicemia, and cardiovascular events. United States Renal Data System (USRDS) data were used to project the US Medicare dialysis patient population across time. The baseline scenario assumed a stable distribution of PD (7.7%), HHD (1.3%) and ICHD (91.0%) over 5 years. Three comparison scenarios raised the proportions of PD and HHD by (1) 1% and 0.5%, (2) 2% and 0.75%, and (3) 3% and 1% each year; a fourth scenario held HHD constant and lowered PD by 1% per year.

RESULTS

Under the bundled PPS, scenarios that increased PD and HHD from 7.7% and 1.3% over 5 years resulted in cumulative savings to Medicare of $114.8M (Scenario 1, 11.7% PD and 3.3% HHD at year 5), $232.9M (Scenario 2, 15.7% PD and 4.3% HHD at year 5), and $350.9M (Scenario 3, 19.7% PD and 5.3% HHD at year 5). When the PD population was decreased from 7.7% in 2013 to 3.7% by 2017 with a constant HHD population, the total Medicare payment for dialysis patients increased by over $121.2M.

CONCLUSIONS

Under Medicare bundled PPS, increasing the proportion of patients on PD and HHD vs ICHD could generate substantial savings in dialysis-associated costs to Medicare.

Vascular access-related infection in nocturnal home hemodialysis

Frequent hemodialysis is associated with increased vascular access adverse events. We hypothesized that bacteremia would be more frequent in patients with central venous catheter (CVC) than arteriovenous fistula or arteriovenous graft (AVF/AVG) in nocturnal home hemodialysis (NHHD). We reviewed blood culture reports and concurrent clinical data for a cohort of one hundred eighty-seven NHHD patients between January 1, 2006 and June 30, 2012. The primary outcome was time to first bacteremia, technique failure, or death after commencing NHHD. Types of bacteremia and clinical consequences were analyzed. Analyses were adjusted for a priori defined confounders. One hundred eighty-seven patients were included with a total follow up of six hundred five patient years. Initial vascular access was AVF in seventy-eight (42%) patients, AVG in eleven (6%) patients, and CVC in ninety-eight (52%) patients. A total of 79.3% of patients with a CVC reached the composite endpoint of bacteremia, technique failure, or death in the study period; 44.5% of patients with an AVF or AVG reached this composite endpoint. Adjusted time to first bacteremia, technique failure, or death was significantly shorter in patients with initial CVC access (hazard ratio 2.42, 95% confidence interval 1.50-3.90, p < 0.001). Risk factors for bacteremia were comorbid status quantified by the Charlson Comorbidity Index (p < 0.001) and diabetes (p < 0.001). Coagulase negative staphylococcus was the commonest organism cultured accounting for 51.4% bacteremias. The second commonest organism was staphylococcus aureus (20.3% bacteremias). Patients undergoing NHHD with a CVC have a shorter duration to first infection, technique failure, or death than those with permanent vascular access.

Is Dorothy correct? The role of patient education in promoting home dialysis

The major payer of dialysis services in the United States, Medicare, has established incentives to encourage the use of home dialysis. However, this modality remains underutilized. We think that a major cause of this situation is ineffective education of the prospective dialysis population regarding the choices of kidney replacement modalities. We discuss the value of patient education and the consequences of failing to educate prospective dialysis patients. We then explore approaches to achieve patient education goals and the physician's and education team's roles in the development of an individual patient's life plan.

Home haemodialysis

Haemodialysis (HD) began as an intensive care treatment offered to a very select number of patients in an attempt to keep them alive. Outcomes were extremely poor, and the procedure was cumbersome and labor intensive. With increasing expertise and advances in dialysis equipment, HD is now recognised as a life-sustaining treatment that is considered a standard of care for children with end stage renal disease (ESRD). Assessment of efficacy has evolved from mere survival, through achieving minimal standards of "adequate" dialysis with reduced morbidity, towards the provision of "optimal dialysis", which includes attempts to more closely mimic normal renal function, and of individualised care that maximizes the patient's health, psychosocial well-being and life potential. There is a renewed interest in dialysis, and the research profile has extended, exploring themes around convective versus diffusive treatments, HD time versus frequency and home versus in-centre dialysis. The results thus far have led dialysis care full circle from prolonged, home-based therapies to shorter, intense in-centre dialysis back to the belief that long or frequent HD at home achieves the best outcomes.

The impact of extended-hours home hemodialysis and buttonhole cannulation technique on hospitalization rates for septic events related to dialysis access

Few studies adequately document adverse events in patients receiving long, slow, and overnight hemodialysis (NHD). Concerns about high rates of dialysis access complications have been raised. This is an observational cohort study comparing hospital admission rates for vascular access complications between alternate nightly NHD (n=63) and conventional hemodialysis (n=172) patients established on chronic hemodialysis for at least 3 months. Overall, hospital admission rates and hospital admission rates for cardiac and all infective events are also reported. The NHD cohort was younger and less likely to be female, diabetic, or have ischemic heart disease than the conventional hemodialysis cohort. When NHD and buttonhole cannulation technique were used simultaneously, there was a demonstrated increased risk of septic dialysis access events: incidence rate ratio 3.0 (95% confidence interval 1.04-8.66) (P=0.04). The majority of blood culture isolates in NHD patients were gram-positive organisms, particularly Staphylococcus aureus. Alternate nightly NHD did not significantly change total hospital admissions or hospital admissions for indications other than dialysis access complications, compared with conventional hemodialysis. Our data suggest that buttonhole cannulation technique should be used with caution in patients performing extended-hours hemodialysis as this combination appears to increase the risk of septic access complications. Randomized-controlled trials are needed to confirm these findings.

Novel Trends in Haemodialysis: Where Are We Heading?

The mortality and morbidity of end-stage renal failure patients undergoing conventional thrice weekly in-centre haemodialysis remain alarmingly high despite continuing advances in haemodialysis technologies and improvements in clinical care. Home haemodialysis continues to be under-utilised in many parts of the world despite the reported benefits. Alternative haemodialysis regimens including longer and/or more frequent dialysis (e.g. nocturnal haemodialysis and short daily haemodialysis), haemodiafiltration and the use of high flux dialysers have become more widespread in recent years as nephrologists struggle to improve the dismal survival figures. Whilst most of the encouraging data have come from observational studies, many randomised controlled trials which will provide more robust data are already underway. This review aims to provide a concise update of the recent and novel trends in haemodialysis. Key words: Haemodiafiltration, High flux dialysis, Home haemodialysis, Nocturnal haemodialysis, Short daily haemodialysis

Intensified hemodialysis regimens: neglected treatment options for children and adolescents

During recent years, the importance of intensified dialysis regimens has gathered increasing interest, especially after the Hemodialysis (HEMO) Study Group reported that a higher dose of thrice-weekly hemodialysis failed to improve clinical outcomes. Long nocturnal hemodialysis (three to six times per week) or short daily hemodialysis are the currently used forms of intensified dialysis. There is substantial evidence for cardiovascular and quality-of-life improvements as well as financial benefits with intensified hemodialysis. Preliminary experience with daily hemodialysis and hemodiafiltration in children has been reported. Given the continuing shortage of donor organs for kidney transplantation, the increasing incidence of end-stage renal disease (ESRD) and recognition of the deleterious effects of long-lasting ESRD, growth retardation, and poor social rehabilitation, more intensified dialysis regimens are a much-needed therapeutical option in both adults and children.

More frequent hemodialysis: back to the future?

An increase in the length of the standard in-center hemodialysis treatment by 30 to 45 minutes per session was not associated with an improvement in mortality in long-term hemodialysis patients enrolled in the HEMO study. Testing the possibility that delivering still higher doses of hemodialysis may have a beneficial effect on patient outcomes will require the use of more frequent hemodialysis or a much longer duration for each dialysis session. "Short-daily hemodialysis," actually 6 times per week hemodialysis for 1.5 to 3 hours per session, can provide some increase in small molecule clearance as measured by urea kinetics. "Long nocturnal daily hemodialysis," actually 6 times per week hemodialysis for 6 to 8 hours per session, provides a significant increase in both small-molecular-weight and large-molecular-weight clearance and often alleviates the need to take phosphate binders. The National Institutes of Health is sponsoring 2 clinical trials via the Frequent Hemodialysis Network to determine the impact of these 2 modalities on intermediate outcomes, compared with standard 3-times-per-week hemodialysis.