Cost analysis of ongoing care of patients with end-stage renal disease: the impact of dialysis modality and dialysis access

The impact of dialysate flow rate on haemodialysis adequacy: a systematic review and meta-analysis

Background

Patients with kidney failure treated with maintenance haemodialysis (HD) require appropriate small molecule clearance. Historically, a component of measuring 'dialysis adequacy' has been quantified using urea kinetic modelling that is dependent on the HD prescription. However, the impact of dialysate flow rate on urea clearance remains poorly described in vivo and its influence on other patient-important outcomes of adequacy is uncertain.

Methods

We searched Embase, MEDLINE and the Cochrane Library from inception until April 2022 for randomized controlled trials and observational trials comparing a higher dialysate flow rate (800 ml/min) and lower dialysate flow rate (300 ml/min) with a standard dialysis flow rate (500 ml/min) in adults (age ≥18 years) treated with maintenance HD (>90 consecutive days). We conducted a random effects meta-analysis to estimate the pooled mean difference in dialysis adequacy as measured by Kt/V or urea reduction ratio (URR).

Results

A total of 3118 studies were identified. Of those, nine met eligibility criteria and four were included in the meta-analysis. A higher dialysate flow rate (800 ml/min) increased single-pool Kt/V by 0.08 [95% confidence interval (CI) 0.05-0.10, P < .00001] and URR by 3.38 (95% CI 1.97-4.78, P < .00001) compared with a dialysate flow rate of 500 ml/min. Clinically relevant outcomes including symptoms, cognition, physical function and mortality were lacking and studies were generally at a moderate risk of bias due to issues with randomization sequence generation, allocation concealment and blinding.

Conclusion

A higher dialysate flow increased urea-based markers of dialysis adequacy. Additional high-quality research is needed to determine the clinical, economic and environmental impacts of higher dialysate flow rates.

Arteriovenous Fistula Maturation in Patients with Ipsilateral Versus Contralateral Tunneled Dialysis Catheter: A Systematic Review and Meta-analysis

BACKGROUND

Although it is evident that a prior history of tunneled dialysis catheter (TDC) affects arteriovenous fistula (AVF) function, it is unclear whether its location (contralateral versus ipsilateral to AVF) has any effect on AVF maturation and failure rates. We aimed to document this possible effect.

METHODS

This systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies comparing outcomes between patients with contralateral TDC (CONTRA group) and those with ipsilateral one (IPSI group) were examined for inclusion. A random effects model meta-analysis of the odds ratio (OR) was conducted. Primary outcomes were AVF functional maturation, assisted maturation, and failure rates.

RESULTS

Four eligible studies comprising 763 patients were included in the meta-analysis. There were no significant differences in terms of AVF functional maturation (OR: 1.49; 95% confidence interval [CI]: 0.64-3.47; I2 = 83.4%), assisted maturation (OR: 0.59; 95% CI: 0.29-1.19; I2 = 61.4%), and failure rates (OR: 0.67; 95% CI: 0.29-1.58; I2 = 83.3%) between the 2 study groups.

CONCLUSIONS

TDC laterality seems not to affect fistula maturation rate in patients requiring TDC placement and concurrent AVF creation, but rather, vein- and patient-related characteristics might play a more important role in choosing TDC access site. Further studies are needed to validate these results.

Integrated home dialysis model: facilitating home-to-home transition

Peritoneal dialysis (PD) and home hemodialysis (HHD) are the two home dialysis modalities offered to patients. They promote patient autonomy, enhance independence, and are generally associated with better quality of life compared to facility hemodialysis. PD offers some advantages (enhanced flexibility, ability to travel, preservation of residual kidney function, and vascular access sites) but few patients remain on PD indefinitely due to peritonitis and other complications. By contrast, HHD incurs longer and more intensive training combined with increased upfront health costs compared to PD, but is easier to sustain in the long term. As a result, the integrated home dialysis model was proposed to combine the advantages of both home-based dialysis modalities. In this paradigm, patients are encouraged to initiate dialysis on PD and transfer to HHD after PD termination. Available evidence demonstrates the feasibility and safety of this approach and some observational studies have shown that patients who undergo the PD-to-HHD transition have clinical outcomes comparable to patients who initiate dialysis directly on HHD. Nevertheless, the prevalence of PD-to-HHD transfers remains low, reflecting the multiple barriers that prevent the full uptake of home-to-home transitions, notably a lack of awareness about the model, home-care "burnout," clinical inertia after a transfer to facility HD, suboptimal integration of PD and HHD centers, and insufficient funding for home dialysis programs. In this review, we will examine the conceptual advantages and disadvantages of integrated home dialysis, present the evidence that underlies it, identify challenges that prevent its success and finally, propose solutions to increase its adoption.

Chronic kidney disease in America, Africa, and Asia: Overview of treatment cost and options

Chronic kidney disease (CKD) is one of the non-infectious diseases that threaten patients' lives on a daily basis. Its prevalence is high, but under-reported by patients and those living with the disease, as it is silent and asymptomatic in the early stages. Kidney disease increases the risk of heart and vascular disease. These problems can manifest themselves slowly, over a long period of time. Early detection and treatment can often prevent chronic kidney disease from worsening. As kidney disease progresses, it can lead to kidney failure, requiring dialysis or a kidney transplant to stay alive. In this narrative review, we will mainly discuss different treatment option costs in different countries and how much they cost healthcare systems in countries in three different continents.

Home versus in-centre haemodialysis for people with kidney failure

BACKGROUND

Home haemodialysis (HHD) may be associated with important clinical, social or economic benefits. However, few randomised controlled trials (RCTs) have evaluated HHD versus in-centre HD (ICHD). The relative benefits and harms of these two HD modalities are uncertain. This is an update of a review first published in 2014. This update includes non-randomised studies of interventions (NRSIs).

OBJECTIVES

To evaluate the benefits and harms of HHD versus ICHD in adults with kidney failure.

SEARCH METHODS

We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 9 October 2022 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. We searched MEDLINE (OVID) and EMBASE (OVID) for NRSIs.

SELECTION CRITERIA

RCTs and NRSIs evaluating HHD (including community houses and self-care) compared to ICHD in adults with kidney failure were eligible. The outcomes of interest were cardiovascular death, all-cause death, non-fatal myocardial infarction, non-fatal stroke, all-cause hospitalisation, vascular access interventions, central venous catheter insertion/exchange, vascular access infection, parathyroidectomy, wait-listing for a kidney transplant, receipt of a kidney transplant, quality of life (QoL), symptoms related to dialysis therapy, fatigue, recovery time, cost-effectiveness, blood pressure, and left ventricular mass.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed if the studies were eligible and then extracted data. The risk of bias was assessed, and relevant outcomes were extracted. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Meta-analysis was performed on outcomes where there was sufficient data.

MAIN RESULTS

From the 1305 records identified, a single cross-over RCT and 39 NRSIs proved eligible for inclusion. These studies were of varying design (prospective cohort, retrospective cohort, cross-sectional) and involved a widely variable number of participants (small single-centre studies to international registry analyses). Studies also varied in the treatment prescription and delivery (e.g. treatment duration, frequency, dialysis machine parameters) and participant characteristics (e.g. time on dialysis). Studies often did not describe these parameters in detail. Although the risk of bias, as assessed by the Newcastle-Ottawa Scale, was generally low for most studies, within the constraints of observational study design, studies were at risk of selection bias and residual confounding. Many study outcomes were reported in ways that did not allow direct comparison or meta-analysis. It is uncertain whether HHD, compared to ICHD, may be associated with a decrease in cardiovascular death (RR 0.92, 95% CI 0.80 to 1.07; 2 NRSIs, 30,900 participants; very low certainty evidence) or all-cause death (RR 0.80, 95% CI 0.67 to 0.95; 9 NRSIs, 58,984 patients; very low certainty evidence). It is also uncertain whether HHD may be associated with a decrease in hospitalisation rate (MD -0.50 admissions per patient-year, 95% CI -0.98 to -0.02; 2 NRSIs, 834 participants; very low certainty evidence), compared with ICHD. Compared with ICHD, it is uncertain whether HHD may be associated with receipt of kidney transplantation (RR 1.28, 95% CI 1.01 to 1.63; 6 NRSIs, 10,910 participants; very low certainty evidence) and a shorter recovery time post-dialysis (MD -2.0 hours, 95% CI -2.73 to -1.28; 2 NRSIs, 348 participants; very low certainty evidence). It remains uncertain if HHD may be associated with decreased systolic blood pressure (SBP) (MD -11.71 mm Hg, 95% CI -21.11 to -2.46; 4 NRSIs, 491 participants; very low certainty evidence) and decreased left ventricular mass index (LVMI) (MD -17.74 g/m2, 95% CI -29.60 to -5.89; 2 NRSIs, 130 participants; low certainty evidence). There was insufficient data to evaluate the relative association of HHD and ICHD with fatigue or vascular access outcomes. Patient-reported outcome measures were reported using 18 different measures across 11 studies (QoL: 6 measures; mental health: 3 measures; symptoms: 1 measure; impact and view of health: 6 measures; functional ability: 2 measures). Few studies reported the same measures, which limited the ability to perform meta-analysis or compare outcomes. It is uncertain whether HHD is more cost-effective than ICHD, both in the first (SMD -1.25, 95% CI -2.13 to -0.37; 4 NRSIs, 13,809 participants; very low certainty evidence) and second year of dialysis (SMD -1.47, 95% CI -2.72 to -0.21; 4 NRSIs, 13,809 participants; very low certainty evidence).

AUTHORS' CONCLUSIONS

Based on low to very low certainty evidence, HHD, compared with ICHD, has uncertain associations or may be associated with decreased cardiovascular and all-cause death, hospitalisation rate, slower post-dialysis recovery time, and decreased SBP and LVMI. HHD has uncertain cost-effectiveness compared with ICHD in the first and second years of treatment. The majority of studies included in this review were observational and subject to potential selection bias and confounding, especially as patients treated with HHD tended to be younger with fewer comorbidities. Variation from study to study in the choice of outcomes and the way in which they were reported limited the ability to perform meta-analyses. Future research should align outcome measures and metrics with other research in the field in order to allow comparison between studies, establish outcome effects with greater certainty, and avoid research waste.

The Effects of Distance, Time, and Nonspatial Factors on Hemodialysis Access in Qatar

Background A long distance and time spent traveling to a hemodialysis (HD) center and other factors, such as comorbidities, can significantly impact HD patient compliance, satisfaction, and cost. Uncertainty about HD-dependent patients' geographical location may lead to inappropriate distribution of HD centers. The present study investigates travel time, distance, and nonspatial factors affecting HD center accessibility within a 30-km radius in the State of Qatar. Materials and methods The study included all HD-dependent patients residing in Qatar between March 1, 2020, and December 31, 2021. There were 921 patients dialyzed in six HD centers across Qatar. Our methodology incorporated descriptive and analytical cross-sectional designs to accurately identify the shortest routes and quickest travel times. We used two applications (Maptive {Vancouver, WA: BatchGeo LLC} and Google Maps {Mountain View, CA: Google LLC}) and marked a driving distance of 30 km as the main assessment scale and measurement standard, allowing optimum spatial accessibility determination. Results On average, patients traveled approximately 19±4.2 km, requiring almost 17.6±3.4 minutes to reach the assigned HD center three times per week. Based on geographic-spatial accessibility analysis, patients living in Umm Salal drove 31.4±3.5 km in 32.4±4.7 minutes, Al Daayen patients drove 30.2 km in 25.3 minutes, and others even drove more than 70 km to access HD sessions. Approximately 37.8% of Qatar's municipalities had no HD centers within their boundaries, but nearly 47% of HD-dependent patients lived in those municipalities. Additionally, some municipalities had HD centers; however, their general population density was less than 100 inhabitants/km2, and they had relatively few patients requiring regular HD. We noted a statistically significant correlation between the patients' residences and the locations of HD centers, whether they were located within or outside municipalities. Also, nonspatial factors may have affected the likelihood of reaching a hemodialysis center within a 30-km distance, including two or more comorbid conditions, having HD for at least five years, living in a municipality with more than 1,000 inhabitants/km2, being female, and attending dialysis centers that are more than 30 km away. Conclusion Although the available HD centers were sufficient for the present number of patients requiring HD, HD center locations did not match the patients' distribution, leading to difficulties for some patients. Understanding the impact of this geographic mismatch, population density, and other spatial factors helps significantly improve patient care and satisfaction at minimal cost. Furthermore, considering all these factors is crucial when planning new centers to achieve higher satisfaction and compliance as well as better health care.

Is the cost of the new home dialysis techniques still advantageous compared to in-center hemodialysis? An Italian single center analysis and comparison with experiences from western countries

Introduction

Potential advantages of home dialysis remained a questionable issue. Three main factors have to be considered: the progressive reduction in the cost of consumables for in-Center hemodialysis (IC-HD), the widespread use of incremental Peritoneal Dialysis (PD), and the renewed interest in home hemodialysis (H-HD) in the pandemic era. Registries data on prevalence of dialysis modalities generally report widespread underemployment of home dialysis despite PD and H-HD could potentially provide clinical benefits, improve quality of life, and contrast the diffusion of new infection among immunocompromised patients.

Methods

We examined the economic impact of home dialysis by comparing the direct and indirect costs of PD (53 patients), H-HD (21 patients) and IC-HD (180 patients) in a single hospital of North-west Italy. In order to achieve comparable weekly costs, the average weekly frequency of dialysis sessions based on the dialysis modality was calculated, the cost of individual sessions per patient per week normalized, and the monthly and yearly costs were derived.

Results

As expected, PD resulted the least expensive procedure (€ 23,314.79 per patient per year), but, notably, H-HD has a lower average cost than IC-HD (€ 35,535.00 vs. € 40,798.98). A cost analysis of the different dialysis procedures confirms the lower cost of PD, especially continuous ambulatory PD, compared to any extracorporeal technique.

Discussion

Among the hemodialysis techniques, home bicarbonate HD showed the lowest costs, while the weekly cost of Frequent Home Hemodialysis was found to be comparable to In-Center Bicarbonate Hemodialysis.

The impact of the Starting dialysis on Time, At home on the Right Therapy (START) project on the use of peritoneal dialysis

BACKGROUND

Peritoneal dialysis (PD) is actively promoted, but increasing PD utilisation is difficult. The objective of this study was to determine if the Starting dialysis on Time, At Home, on the Right Therapy (START) project was associated with an increase in the proportion of dialysis patients receiving PD within 6 months of starting therapy.

METHODS

Consecutive patients over age 18, with end-stage kidney failure, who started dialysis between 1 April 2015 and 31 March 2018 in the province of Alberta, Canada. Programmes were provided with high-quality data about the individual steps in the process of care that drive PD utilisation that were used to identify problem areas, design and implement interventions to address them, and then evaluate whether those interventions had impact. The primary outcome was the proportion of patients receiving PD within 6 months of starting dialysis. Secondary outcomes included hospitalisation, death or probability of transfer to haemodialysis (HD). Interrupted time series methodology was used to evaluate the impact of the quality improvement initiative on the primary and secondary outcomes.

RESULTS

A total of 1962 patients started dialysis during the study period. Twenty-seven per cent of incident patients received PD at baseline, and there was a 5.4% (95% confidence interval: 1.5-9.2) increase in the use of PD in the province immediately after implementation. There were no changes in the rates of hospitalisation, death or probability of transfer to HD after the introduction of START.

CONCLUSIONS

The approach used in the START project was associated with an increase in the use of PD in a setting with high baseline utilisation.

Early-Stage Chronic Kidney Disease and Related Health Care Spending

Importance

The global burden of chronic kidney disease (CKD) is substantial and potentially leads to higher health care resource use.

Objective

To examine the association between early-stage CKD and health care spending and its changes over time in the general population.

Design, Setting, and Participants

Cohort study using nationwide health checkup and medical claims data in Japan. Participants included individuals aged 30 to 70 years with estimated glomerular filtration rates (eGFR) of 30 mL/min/1.73 m2 or greater at the baseline screening in 2014. Data analyses were conducted from April 2021 to October 2023.

Exposure

The CKD stages at baseline, defined by the eGFR and proteinuria, were as follows: eGFR of 60 mL/min/1.73 m2 or greater without proteinuria, eGFR of 60 mL/min/1.73 m2 or greater with proteinuria, eGFR of 30 to 59 mL/min/1.73 m2 without proteinuria, and eGFR of 30 to 59 mL/min/1.73 m2 with proteinuria.

Main Outcome and Measures

The primary outcome was excess health care spending, defined as the absolute difference in health care spending according to the baseline CKD stages (reference group: eGFR ≥60 mL/min/1.73 m2 without proteinuria) in the baseline year (2014) and in the following 5 years (2015 to 2019).

Results

Of the 79 988 participants who underwent a health checkup (mean [SD] age, 47.0 [9.4] years; 22 027 [27.5%] female), 2899 (3.6%) had an eGFR of 60 mL/min/1.73 m2 or greater with proteinuria, 1116 (1.4%) had an eGFR of 30 to 59 mL/min/1.73 m2 without proteinuria, and 253 (0.3%) had an eGFR of 30 to 59 mL/min/1.73 m2 with proteinuria. At baseline, the presence of proteinuria and an eGFR less than 60 mL/min/1.73 m2 were associated with greater excess health care spending (adjusted difference, $178; 99% CI, $6-$350 for proteinuria; $608; 99% CI, $233-$983 for an eGFR of 30-59 mL/min/1.73 m2; and $1254; 99% CI, $134-$2373 for their combination). The study consistently found excess health care spending over the following 5 examined years.

Conclusions and Relevance

In this cohort study of nationwide health checkup and medical claims data in Japan, early-stage CKD was associated with excess health care spending over the 5 examined years, and the association was more pronounced with a more advanced disease stage.

Systems Innovations to Increase Home Dialysis Utilization

Globally, there is an interest to increase home dialysis utilization. The most recent United States Renal Data System (USRDS) data report that 13.3% of incident dialysis patients in the United States are started on home dialysis, while most patients continue to initiate KRT with in-center hemodialysis. To effect meaningful change, a multifaceted innovative approach will be needed to substantially increase the use of home dialysis. Patient and provider education is the first step to enhance home dialysis knowledge awareness. Ideally, one should maximize the number of patients with CKD stage 5 transitioning to home therapies. If this is not possible, infrastructures including transitional dialysis units and community dialysis houses may help patients increase self-care efficacy and eventually transition care to home. From a policy perspective, adopting a home dialysis preference mandate and providing financial support to recuperate increased costs for patients and providers have led to higher uptake in home dialysis. Finally, respite care and planned home-to-home transitions can reduce the incidence of transitioning to in-center hemodialysis. We speculate that an ecosystem of complementary system innovations is needed to cause a sufficient change in patient and provider behavior, which will ultimately modify overall home dialysis utilization.

Robotic tomographic ultrasound and artificial intelligence for management of haemodialysis arteriovenous fistulae

BACKGROUND

Arteriovenous fistulae (AVF) and Arteriovenous Grafts (AVG) may present a problematic vascular access for renal replacement therapy (RRT), reliant on recurrent specialist nurse and medical evaluation. Dysfunctional accesses are frequently referred 'out of the dialysis clinic' for specialist sonographic examination, with associated delays potentiating loss of vascular access viability and/or need for emergency intervention. Definitive anatomical and functional diagnostics based in the dialysis unit may help to solve these delays and associated complications.

OBJECTIVES

This publication reports a novel vascular access monitoring concept, Robotic Tomographic Ultrasound (RTU).

RESEARCH DESIGN

Robotic Tomographic Ultrasound incorporates a semi-autonomous, robotic vascular ultrasound system and purpose designed analysis software that can be deployed at the point of care. Three-dimensional scan data, as well as conventional B-Mode and Doppler data are obtained by the system and transferred to a cloud based reporting and analysis software. Scans are remotely annotated and interpreted by a sonographer, with diagnostic data presented securely to clinicians on their preferred web based application/web connected device.

RESULTS

Software developed specifically for pre AVF mapping, maturation and monitoring protocols, analyse the data and then present interpreted results to all caring clinicians to assist with decision making. Vascular access planning can be determined with high confidence with data from the Map module. Maturation data can be presented in line with institutional requirements to the dialysis nurse, facilitating precocious needle access.

CONCLUSION

Robotic Tomographic Ultrasound is a novel approach to vascular access management that may reduce the risk of loss of functional access by regular monitoring with the system; automated alerts guiding clinicians to the need for pre-emptive intervention, and the potential to increase longevity of the vascular access.

The FACT : Use of a novel intermittent pneumatic compression device to promote pre-surgery arm vein dilation in patients with chronic renal failure

BACKGROUND

Arteriovenous fistula (AVF) creation and maturation for hemodialysis is globally a topic of importance given the poor results and high costs associated with renal care. Successful AVF (surgical or endovascular) creation requires appropriate superficial veins and quality arteries. Many procedures fail due to initial small veins with limited blood flow capacity and distensibility. Intermittent pneumatic compression has previously shown success in trials to increase superficial veins in patients with end stage renal disease post AVF. The objective of this study is to investigate the role of an intermittent pneumatic device, the Fist Assist®, to dilate cephalic arm veins in patients with advanced chronic kidney disease (CKD) prior to AVF placement.

METHODS

Three centers enrolled subjects from June 2019 through July 2021. Baseline Doppler measurements of the cephalic vein in standard locations the forearm and upper arm with and without a blood pressure cuff were recorded. Patients were instructed and used Fist Assist® on their non-dominant arm for up to 4 h daily for 90 days. At approximately 3 months, Doppler measurements were repeated. The primary endpoint was cephalic vein enlargement with secondary endpoints based on percentage of veins approaching 2.5 mm in the forearm and 3.5 mm in the upper arm.

RESULTS

Thirty-seven subjects with CKD (mean eGFR 13.8 mL/min) were enrolled and completed the trial. Paired-difference t-tests (one tail) for aggregate data showed significant venous dilation of the cephalic vein in both the forearm and upper arm after use with the Fist Assist® (p < 0.05). Mean differences in the forearm veins were approximately 0.6 and 1.1 mm in the upper arm cephalic vein after Fist Assist® application. There were no major complications reported by any subject during the trial.

CONCLUSIONS

Fist Assist® use in patients with CKD is effective to enhance vein dilation. Forearm and upper arm cephalic veins increased on average 0.6 and 1.1 mm respectively after Fist Assist® application. This is the first trial to evaluate the effect of intermittent, focal pneumatic compression on pre-surgery vein diameter in patients with advanced CKD before AVF creation.

Antibiotic availability for outpatient treatment of acute peritonitis in chronic peritoneal dialysis patients: A case series

BACKGROUND

Peritoneal dialysis (PD) is a commonly used form of renal replacement therapy for patients that have reached end-stage renal disease. Acute bacterial peritonitis (ABP) in chronic PD patients results in pain, increased costs, injury to the peritoneal membrane, and PD modality failure. Optimal antibiotic treatment of acute bacterial peritonitis (ABP) in chronic PD patients should be intraperitoneal, outpatient-based, appropriate, prompt, and uninterrupted. We investigated the frequency of and predisposition to suboptimal antibiotic courses for ABP in our chronic PD patients.

METHODS

Twenty-four charts of patients with ABP were reviewed, to test the null hypothesis that all ABP patients received antibiotics optimally.

RESULTS

After 12 patient exclusions (hospitalization), 9 suboptimal antibiotic events were detected in 6 of the remaining 12 patients, disproving the null hypothesis (p < 0.02). Most suboptimal antibiotics courses (7 of 9) resulted from delays and/or gaps in therapy or antibiotics prescribed outside of community standard. Suboptimal antibiotic events occurred on nights and weekends rather than during the workweek (p < 0.02) and in the emergency room rather than the PD clinic (p < 0.02).

CONCLUSIONS

Suboptimal ABP antibiotic therapy occurs commonly and is influenced by time and location of presentation and lack of knowledge by patients and physicians. Prevention of suboptimal antibiotic courses in the treatment of ABP in chronic PD patients includes education of patients and providers and allowing emergency rooms and PD clinics to dispense antibiotics for home use.

The Influence of Peritoneal Dialysis Catheter Tip Design on Technique Survival: A Retrospective Observational Study

Introduction

The clinical practice guidelines for peritoneal access state that no particular peritoneal dialysis catheter (PDC) type has been proven superior to another. We present our experience with the use of different PDC tip designs.

Method

The study is a retrospective, real-world, observational, outcome analysis correlating the PDC tip design (straight vs. coiled-tip) and technique survival. The primary outcome was technique survival, and the secondary outcome included catheter migration and infectious complications.

Result

A total of 50 PDC (28 coiled-tip and 22 straight-tip) were implanted between March 2017 and April 2019 by using a guided percutaneous approach. The 1-month and 1-year technique survival in the coiled-tip PDC was 96.4% and 92.8%, respectively. Of the two coiled-tip catheters lost, one was a consequence of the patient having undergone live related kidney transplantation. The corresponding 1-month and 1-year technique survival with straight-tip PDC was 86.4% and 77.3%, respectively. When compared to straight-tip PDC, the use of coiled-tip PDC was associated with fewer early migration (3.6% vs. 31.8%; odds ratio (OR): 12.6; 95% confidence interval (CI): 1.41-112.39; P = 0.02) and a trend toward favorable 1-year technique survival (P = 0.07; numbers needed to treat = 11). Therapy-related complications noted in the study included peri-catheter leak and PD peritonitis. The PD peritonitis rate in the coiled-tip and straight-tip group was 0.14 and 0.11 events per patient year, respectively.

Conclusion

The use of coiled-tip PDC, when placed using a guided percutaneous approach, reduces early catheter migration and shows a trend toward favorable long-term technique survival.

Understanding the Current Landscape of Kidney Disease in Canada to Advance Precision Medicine Guided Personalized Care

Purpose of Review

To understand the impact of kidney disease in Canada and the priority areas of kidney research that can benefit from patient-oriented, precision medicine research using novel technologies.

Sources of Information

Information was collected through discussions between health care professionals, researchers, and patient partners. Literature was compiled using search engines (PubMed, PubMed central, Medline, and Google) and data from the Canadian Organ Replacement Register.

Methods

We reviewed the impact, prevalence, economic burden, causes of kidney disease, and priority research areas in Canada. After reviewing the priority areas for kidney research, potential avenues for future research that can integrate precision medicine initiatives for patient-oriented research were outlined.

Key Findings

Chronic kidney disease (CKD) remains among the top causes of morbidity and mortality in the world and exerts a large financial strain on the health care system. Despite the increasing number of people with CKD, funding for basic kidney research continues to trail behind other diseases. Current funding strategies favor existing clinical treatment and patient educational strategies. The identification of genetic factors for various forms of kidney disease in the adult and pediatric populations provides mechanistic insight into disease pathogenesis. Allocation of resources and funding toward existing high-yield personalized research initiatives have the potential to significantly affect patient-oriented research outcomes but will be difficult due to a constant decline of funding for kidney research.

Limitations

This is an overview primarily focused on Canadian-specific literature rather than a comprehensive systematic review of the literature. The scope of our findings and conclusions may not be applicable to health care systems in other countries.

Caregiver Burden of Autosomal Dominant Polycystic Kidney Disease: A Qualitative Study

Rationale & Objective

There is limited published research on how autosomal dominant polycystic kidney disease (ADPKD) impacts caregivers. This study explored how caregivers of individuals with ADPKD perceive the burdens placed on them by the disease.

Study Design

Qualitative study consisting of focus groups and interviews. Discussions were conducted by trained interviewers using semi-structured interview guides.

Setting & Participants

The research was conducted in 14 countries in North America, South America, Asia, Australia, and Europe. Eligible participants were greater than or equal to 18 years old and caring for a child or adult diagnosed with ADPKD.

Analytical Approach

The concepts reported were coded using qualitative research software. Data saturation was reached when subsequent discussions introduced no new key concepts.

Results

Focus groups and interviews were held with 139 participants (mean age, 44.9 years; 66.9% female), including 25 participants who had a diagnosis of ADPKD themselves. Caregivers reported significant impact on their emotional (74.1%) and social life (38.1%), lost work productivity (26.6%), and reduced sleep (25.2%). Caregivers also reported worry about their financial situation (23.7%). In general, similar frequencies of impact were reported among caregivers with ADPKD versus caregivers without ADPKD, with the exception of sleep (8.0% vs 28.9%, respectively), leisure activities (28.0% vs 40.4% respectively), and work/employment (12.0% vs 29.8%, respectively).

Limitations

The study was observational and designed to elicit concepts, and only descriptive analyses were conducted.

Conclusions

These findings highlight the unique burden on caregivers in ADPKD, which results in substantial emotional, social, and professional/financial impact.

Comparison of hospitalization cause and risk factors between patients undergoing hemodialysis and peritoneal dialysis

This retrospective study was designed to compare the cause of hospitalization and influencing factors between patients undergoing hemodialysis (HD) and peritoneal dialysis (PD). Baseline data and laboratory parameters of 192 dialysis patients (92 HD patients and 100 PD patients) were compared. Quantitative parameters with normal distribution were assessed using independent t-test or analysis of variance (ANOVA). Quantitative parameters with non-normal distribution were assessed by non-parametric test. Qualitative data were statistically compared using χ2 test. The number of patients with urban employee medical insurance (88 HD patients and 60 PD patients) and rural cooperative medical care (12 HD patients and 40 PD patients) significantly differed (P < .01). The hospitalization rate of PD patients was significantly higher than that of HD counterparts. The average length of hospital stay of PD patients was 10 days, remarkably longer than 8 days of HD patients (P < .01). The primary cause of hospitalization for HD patients was infection-related complications, followed by cardiovascular, cerebrovascular complications and dialysis access disorders. The primary cause of hospitalization for PD patients was infection-related complications, followed by dialysis access disorders, cardiovascular, and gastrointestinal complications. Compared with the HD group, the levels of hemoglobin, serum albumin, alkaline phosphatase, intact parathyroid hormone were significantly decreased, whereas serum urea nitrogen, serum creatinine, phosphorus levels and cardiothoracic ratio were remarkably increased in the PD group (all P < .01). The hospitalization rate of PD patients is relatively higher, and the length of hospital stay is longer. Extensive attention and efforts should be delivered to enhance the understanding of disease and lower the risk of complications for patients.

The cost of hospitalizations for treatment of hemodialysis catheter-associated blood stream infections in children: a retrospective cohort study

BACKGROUND

Hospitalization costs for treatment of hemodialysis (HD) catheter-associated blood stream infections (CA-BSI) in adults are high. No studies have evaluated hospitalization costs for HD CA-BSI in children or identified factors associated with high-cost hospitalizations.

METHODS

We analyzed 160 HD CA-BSIs from the Standardizing Care to Improve Outcomes in Pediatric End-stage Kidney Disease (SCOPE) collaborative database linked to hospitalization encounters in the Pediatric Health Information System (PHIS) database. Charge-to-cost ratios were used to convert hospitalization charges reported in PHIS database to estimated hospital costs. Generalized linear mixed modeling was used to assess the relationship between higher-cost hospitalization (cost above 50^th percentile) and patient and clinical characteristics. Generalized linear regression models were used to assess differences in mean service line costs between higher- and lower-cost hospitalizations.

RESULTS

The median (IQR) length of stay for HD CA-BSI hospitalization was 5 (3-10) days. The median (IQR) cost for HD CA-BSI hospitalization was $18,375 ($11,584-$36,266). ICU stay (aOR 5.44, 95% CI 1.62-18.26, p = 0.01) and need for a catheter procedure (aOR = 6.08, 95% CI 2.45-15.07, p < 0.001) were associated with higher-cost hospitalization.

CONCLUSIONS

Hospitalizations for HD CA-BSIs in children are often multiple days and are associated with substantial costs. Interventions to reduce CA-BSI may reduce hospitalization costs for children who receive chronic HD. A higher resolution version of the Graphical abstract is available as Supplementary information.

Nephrologists' Perspectives of the Potential Utilization of Home Hemodialysis in Saudi Arabia

Home hemodialysis (HD) is an attractive renal replacement modality that has been shown to provide several benefits to the patient and health-care system. However, home HD programs have not been well-established in Saudi Arabia. We aimed to explore the perspectives of adult nephrology consultants in Saudi Arabia about the potential utilization of home HD via a survey-based cross-sectional study. The survey was distributed via email to all adult nephrology consultants practicing in Saudi Arabia and registered in the Saudi Society of Nephrology and Transplantation. Out of 236 invited consultants, 151 (64%) participated in the study. Half of the participants defined home HD as a trained patient who can independently perform his/her HD sessions at home. Eighty-one (54%) consultants have never managed a patient on home HD during their nephrology training period. More than 70% of participants believed that home HD provides advantages over in-center HD, and that its utilization in Saudi Arabia would be feasible. Although 40% of participants worked in centers with no accredited nephrology training program, most of the remaining participants believed that the local training program did not provide enough teaching about home HD to trainees. Patients' refusal, the nephrologists' lack of motivation and experience, a lack of administrative support, and the lack of infrastructure and nursing support were identified by most participants as the major barriers to the utilization of home HD in Saudi Arabia. Addressing these barriers would be the first step to facilitate initiatives aiming to establish home HD programs in this country.

Patients’ perspectives of home and self-assist haemodialysis and factors influencing dialysis choices in Singapore

Background

The rise in end stage kidney disease (ESKD) prevalence globally calls for a need to deliver quality and cost-effective dialysis. While most are familiar with centre-based haemodialysis (HD), there is a move to increase uptake of home-based modalities (peritoneal dialysis (PD) or home haemodialysis (HHD)) and self-assist haemodialysis (SAHD) due to the economic, clinical and lifestyle advantages they confer. However, HHD and SAHD are not yet widely adopted in Singapore with majority of patients receiving in-centre HD. Although much research has examined patient decision-making around dialysis modality selection, there is limited literature evaluating patient’s perspectives of HHD and SAHD in Asia where the prevalence of these alternative modalities remained low. With this background, we aimed to evaluate patient’s perspectives of HHD and SAHD and the factors influencing their choice of dialysis modality in Singapore to determine the challenges and facilitators to establishing these modalities locally.

Methods

Semi-structured interviews were conducted with 17 patients on dialysis from a tertiary hospital in Singapore in this exploratory qualitative study. Data collected from one-to-one interviews were analysed via thematic content analysis and reported via an interpretative approach.

Results

The findings were segregated into: (1) factors influencing choices of dialysis modality; (2) perspectives of HHD; and (3) perspectives of SAHD. Modality choices were affected by environmental, personal, social, financial, information and family-related factors. Most perceived HHD as providing greater autonomy, convenience and flexibility while SAHD was perceived as a safer option than HHD. For both modalities, patients were concerned about self-care and burdening their family.

Conclusions

The findings provided a framework for healthcare providers to understand the determinants affecting patients’ dialysis modality decisions and uncovered the facilitators and challenges to be addressed to establish HHD and SAHD modalities in Singapore.

Differences in hospitalisation between peritoneal dialysis and haemodialysis patients

BACKGROUND

Dialysis is associated with frequent hospitalisations. Studies comparing hospitalisations between peritoneal dialysis (PD) and haemodialysis (HD) report conflicting results and mostly analyse data of patients that remain on their initial dialysis modality. This cohort study compares hospitalisations between PD and HD patients taking into account transitions between modalities.

METHODS

The Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes collected hospitalisation data of patients who started dialysis between 2012 and 2017. Primary outcome was hospitalisation rate, analysed with a multi-state model that attributed each hospitalisation to the current dialysis modality.

RESULTS

In total, 695 patients (252 PD, 443 HD) treated in 31 Dutch hospitals were included. The crude hospitalisation rate for PD was 2.3 ( ± 5.0) and for HD 1.4 ( ± 3.2) hospitalisations per patient-year. The adjusted hazard ratio for hospitalisation rate was 1.1 (95%CI 1.02-1.3) for PD compared with HD. The risk for first hospitalisation was 1.3 times (95%CI 1.1-1.6) higher for PD compared with HD during the first year after dialysis initiation. The number of hospitalisations and number of hospital days per patient-year were significantly higher for PD. The most common causes of PD and HD hospitalisations were peritonitis (23%) and vascular access-related problems (33%).

CONCLUSION

PD was associated with higher hospitalisation rate, higher risk for first hospitalisation and higher number of hospitalisations compared with HD. Since the PD hospitalisations were mainly caused by peritonitis, more attention to infection prevention is necessary for reducing the number of hospitalisations in the future.

Impact of quality improvement initiatives to improve CKD referral patterns: a systematic review protocol

INTRODUCTION

Chronic kidney disease (CKD) is a global-health problem. A significant proportion of referrals to nephrologists for CKD management are early and guideline-discordant, which may lead to an excess number of referrals and increased wait-times. Various initiatives have been tested to increase the proportion of guideline-concordant referrals and decrease wait times. This paper describes the protocol for a systematic review to study the impacts of quality improvement initiatives aimed at decreasing the number of non-guideline concordant referrals, increasing the number of guideline-concordant referrals and decreasing wait times for patients to access a nephrologist.

METHODS AND ANALYSIS

We developed this protocol by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols (2015). We will search the following empirical electronic databases: MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, PsycINFO and grey literature for studies designed to improve guideline-concordant referrals or to reduce unnecessary referrals of patients with CKD from primary care to nephrology. Our search will include all studies published from database inception to April 2021 with no language restrictions. The studies will be limited to referrals for adult patients to nephrologists. Referrals of patients with CKD from non-nephrology specialists (eg, general internal medicine) will be excluded.

ETHICS AND DISSEMINATION

Ethics approval will not be required, as we will analyse data from studies that have already been published and are publicly accessible. We will share our findings using traditional approaches, including scientific presentations, open access peer-reviewed platforms, and appropriate government and public health agencies.

PROSPERO REGISTRATION NUMBER

CRD42021247756.

Pretransplant Dialysis and Preemptive Transplant in Living Donor Kidney Recipients

Background

The optimal timing of dialysis access placement in individuals with stage 5 CKD is challenging to estimate. Preemptive living donor kidney transplant (LDKT) is the gold-standard treatment for ESKD due to superior graft survival and mortality, but dialysis initiation is often required. Among LDKT recipients, we sought to determine which clinical characteristics were associated with preemptive transplant. Among non-preemptive LDKT recipients, we sought to determine what dialysis access was used, and their duration of use before receipt of living donor transplant.

Methods

We retrospectively extracted data on 569 LDKT recipients, >18 years old, who were transplanted between January 2014 and July 2019 at UCSF, including dialysis access type (arteriovenous fistula [AVF], arteriovenous graft [AVG], peritoneal dialysis catheter [PD], and venous catheter), duration of dialysis, and clinical characteristics.

Results

Preemptive LDKT recipients constituted 30% of our cohort and were older, more likely to be White, more likely to have ESKD from polycystic kidney disease, and less likely to have ESKD from type 2 diabetes. Of the non-preemptive patients, 26% used AVF, 0.5% used AVG, 32% used peritoneal catheter, 11% used venous catheter, and 31% used more than one access type. Median (IQR) time on dialysis for AVF/AVG use was 1.86 (0.85-3.32) years; for PD catheters, 1.12 (0.55-1.92) years; for venous catheters, 0.66 (0.23-1.69) years; and for multimodal access, 2.15 (1.37-3.72) years.

Conclusions

We characterized the dialysis access landscape in LDKT recipients. Venous catheter and PD were the most popular modality in the first quartile of dialysis, and patients using these modalities had shorter times on dialysis compared with those with an AVF. Venous catheter or PD can be considered a viable bridge therapy in patients with living donor availability given their shorter waitlist times. Earlier referral of patients with living donor prospects might further minimize dialysis need.

Identifying subgroups of adult high-cost health care users: a retrospective analysis

BACKGROUND

Few studies have categorized high-cost patients (defined by accumulated health care spending above a predetermined percentile) into distinctive groups for which potentially actionable interventions may improve outcomes and reduce costs. We sought to identify homogeneous groups within the persistently high-cost population to develop a taxonomy of subgroups that may be targetable with specific interventions.

METHODS

We conducted a retrospective analysis in which we identified adults (≥ 18 yr) who lived in Alberta between April 2014 and March 2019. We defined "persistently high-cost users" as those in the top 1% of health care spending across 4 data sources (the Discharge Abstract Database for inpatient encounters; Practitioner Claims for outpatient primary care and specialist encounters; the Ambulatory Care Classification System for emergency department encounters; and the Pharmaceutical Information Network for medication use) in at least 2 consecutive fiscal years. We used latent class analysis and expert clinical opinion in tandem to separate the persistently high-cost population into subgroups that may be targeted by specific interventions based on their distinctive clinical profiles and the drivers of their health system use and costs.

RESULTS

Of the 3 919 388 adults who lived in Alberta for at least 2 consecutive fiscal years during the study period, 21 115 (0.5%) were persistently high-cost users. We identified 9 subgroups in this population: people with cardiovascular disease (n = 4537; 21.5%); people receiving rehabilitation after surgery or recovering from complications of surgery (n = 3380; 16.0%); people with severe mental health conditions (n = 3060; 14.5%); people with advanced chronic kidney disease (n = 2689; 12.7%); people receiving biologic therapies for autoimmune conditions (n = 2538; 12.0%); people with dementia and awaiting community placement (n = 2520; 11.9%); people with chronic obstructive pulmonary disease or other respiratory conditions (n = 984; 4.7%); people receiving treatment for cancer (n = 832; 3.9%); and people with unstable housing situations or substance use disorders (n = 575; 2.7%).

INTERPRETATION

Using latent class analysis supplemented with expert clinical review, we identified 9 policy-relevant subgroups among persistently high-cost health care users. This taxonomy may be used to inform policy, including identifying interventions that are most likely to improve care and reduce cost for each subgroup.

Long-term Results of Interwoven Nitinol Stents to Treat the Radiocephalic Anastomotic Arteriovenous Fistula Stenosis

Introduction:

Juxta-anastomotic stenosis (JXAS) is a common problem afflicting the arteriovenous fistula (AVF). This study aimed to evaluate the safety and long-term efficacy of an interwoven nitinol stent (Supera, Abbott Vascular, Santa Clara, CA, USA) in the treatment of radiocephalic AVF JXAS.

Methods:

A single-center, retrospective, observational study was conducted of patients with failing AVF due to JXAS treated with an interwoven nitinol stent. End points included JXAS target lesion primary patency, access circuit primary patency, assisted access circuit primary patency, and endovascular intervention rate (EIR).

Results:

Sixty patients were treated with a Supera stent in the JXAS between February 2014 and March 2020. One patient was excluded (AVF used for illicit drug use), leaving 59 patients (67.8% male, mean age 66.9 ± 11.4 years [range: 40–84]) with typical medical comorbidities. Overall, 45.8% of patients had previous AVF intervention. The stent was inserted with a 100% technical success rate with a mean follow-up of 729.6 ± 456.0 days (range: 5–2182 days). Juxta-anastomotic stenosis target lesion primary patency was 68.2 ± 6.6%, 53.3 ± 7.5%, and 46.2 ± 8.1% at 12, 24, and 36 months, respectively. The EIR was .64 (0–3.29) procedures/patient/year, after which the assisted access circuit primary patency rate was 94.3 ± 3.2% at 12, 24, and 36 month time points. Three thrombosed circuits occurred which were all successfully salvaged with no difference in patency by indication for procedure and no AVFs lost/abandoned out to 3 years. Avoidance of stent post-dilatation and the presence of stent mal-apposition were associated with improved primary patency, and reduced EIR, which may suggest an importance in vessel preparation prior to stent implantation.

Conclusion:

Interwoven nitinol stent treatment of the failing AVF with JXAS results in promising 3 year JXAS patency, with a low rate of endovascular re-intervention for those circuits developing restenosis. All AVFs were maintained over 3 years, demonstrating this treatment allows for long-term radiocephalic AVF vascular access.

Factors affecting arteriovenous access patency after percutaneous transluminal angioplasty in chronic haemodialysis patients under vascular access monitoring and surveillance: a single-centre observational study

OBJECTIVES

Maintenance of vascular access (VA) patency after percutaneous transluminal angioplasty (PTA) is important and remains a challenge despite VA monitoring and surveillance. The aim of this study was to examine factors affecting the post-PTA arteriovenous access (AVA) patency in patients who have been on close VA monitoring and surveillance for access flow.

DESIGN

Retrospective cohort study.

SETTING

A single medical centre in Taiwan.

PARTICIPANTS

Records of patients who received chronic haemodialysis between 1 January 2017 and 31 December 2018 were retrospectively reviewed. Patients were divided into two groups (without or with PTA intervention on AVA).

PRIMARY AND SECONDARY OUTCOME

Patients were followed until reintervention PTA, termination or abandoned VA or end of study. In addition to routine monitoring, VA flow surveillance was performed every 3 months for detection of VA dysfunction adhering to Kidney Disease Outcomes Quality Initiative guidelines.

RESULTS

A total of 508 patients were selected for study inclusion (with PTA, n=231; without PTA, n=277). At baseline, variables that differed between groups included malignancy and levels of albumin, uric acid, potassium, phosphorous, high-density lipoprotein, total bilirubin and ferritin (all p<0.05). Significant between-group differences were observed for β-adrenergic blocking agents (with PTA, 49.8%; without PTA, 37.5%; p, 0.007) and ADP inhibitors (with PTA, 23.8%; without PTA, 11.2%; p<0.001). Among patients with PTA, those with acute myocardial infarction, high ferritin level or arteriovenous graft (AVG) had a significantly higher risk of reintervention post-PTA (p<0.05). Dipeptidyl peptidase-4 inhibitors, thiazolidinediones, ADP inhibitors, and warfarin use were predictors of post-PTA patency (p<0.05).

CONCLUSIONS

AVG access type, acute myocardial infarction, and high ferritin levels are risk factors for re-intervention post-PTA. These findings may be useful in the development of prophylactic strategies for monitoring VA function and tailoring surveillance programs for these dialysis patients.

OUP accepted manuscript

Patients on chronic hemodialysis are counseled to reduce dietary sodium intake to limit their thirst and consequent interdialytic weight gain (IDWG), chronic volume overload and hypertension. Low-sodium dietary trials in hemodialysis are sparse and mostly indicate that dietary education and behavioral counseling are ineffective in reducing sodium intake and IDWG. Additional nutritional restrictions and numerous barriers further complicate dietary adherence. A low-sodium diet may also reduce tissue sodium, which is positively associated with hypertension and left ventricular hypertrophy. A potential alternative or complementary approach to dietary counseling is home delivery of low-sodium meals. Low-sodium meal delivery has demonstrated benefits in patients with hypertension and congestive heart failure but has not been explored or implemented in patients undergoing hemodialysis. The objective of this review is to summarize current strategies to improve volume overload and provide a rationale for low-sodium meal delivery as a novel method to reduce volume-dependent hypertension and tissue sodium accumulation while improving quality of life and other clinical outcomes in patients undergoing hemodialysis.

Costs of Assisted Home Dialysis: A Single-Payer Canadian Model From Manitoba

Rationale & Objective

The prevalence of kidney failure is increasing globally. Most of these patients will require life-sustaining dialysis at a substantial cost to the health care system. Assisted peritoneal dialysis (PD) and assisted home hemodialysis (HD) are potential alternatives to in-center HD and have demonstrated equivalent outcomes with respect to mortality and morbidity. We aim to describe the costs associated with assisted continuous cycling PD (CCPD) and assisted home HD.

Study Design

Cost minimization model.

Setting & Population

Adult incident maintenance dialysis patients in Manitoba, Canada.

Intervention

Full- and partial-assist home HD and CCPD. Full-assist modalities were defined as nurse-assisted dialysis setup and takedown performed by a health care aide, whereas partial-assist modalities only included nurse-assisted setup. Additionally, full-assist home HD was evaluated under a complete care scenario with the inclusion of a health care aide remaining with the patient throughout the duration of treatment.

Outcomes

Annual per-patient maintenance and training costs related to assisted and self-care home HD and CCPD, presented in 2019 Canadian dollars.

Model, Perspective, & Time Frame

This model took the perspective of the Canadian public health payer using a 1-year time frame.

Results

Annual total per-patient maintenance (and training) costs by modality were the following: full-assist CCPD, $75.717 (initial training costs, $301); partial-assist CCPD, $67,765 ($4,385); full-assist home HD, $47,862 ($301); partial-assist home HD, $44,650 ($14,813); and full-assist home HD (complete care), $64,659 ($301).

Limitations

This model did not account for costs taken from the societal perspective or costs related to PD failure and modality switching. Additionally, this analysis reflects only costs experienced by a single center.

Conclusions

Assisted home-based dialysis modalities are viable treatment options for patients from a cost perspective. Future studies to consider graduation rates to full self-care from assisted dialysis and the cost implications of respite care are needed.

Treatment Patterns, Outcomes, and Costs Associated With Localized Upper Tract Urothelial Carcinoma

Background

Upper tract urothelial carcinoma (UTUC) is a heterogeneous disease that presents a clinical management challenge for the urologic surgeon. We assessed treatment patterns, costs, and survival outcomes among patients with nonmetastatic UTUC.

Methods

We identified 4114 patients diagnosed with nonmetastatic UTUC from 2004 to 2013 in the Survival Epidemiology, and End Results-Medicare population-based database. Patients were stratified into low- or high-risk disease groups. Median total costs from 30 days prior to diagnosis through 365 days after diagnosis were compared between groups. Overall and cancer-specific survival were evaluated using Cox proportional hazards regression. All statistical tests were 2-sided.

Results

After risk stratification, 1027 (24.9%) and 3087 (75.0%) patients were classified into low- vs high-risk UTUC groups. Most patients underwent at least 1 surgical intervention (95.1%); 68.4% underwent at least 1 endoscopic intervention. Patients diagnosed with high- vs low-risk UTUC were more likely to undergo nephroureterectomy (83.6% vs 72.0%; P < .001); few patients with low-risk disease were exclusively managed endoscopically (16.9%). At 365 days after diagnosis, costs of care for high- vs low-risk UTUC were statistically significantly higher ($108 520 vs $91 233; median difference $16 704, 95% confidence interval [CI] = $11 619 to $21 778; P < .001). Those with high-risk UTUC had worse cancer-specific and overall survival compared with patients with low-risk UTUC (cancer-specific survival hazard ratio [HR] = 4.14, 95% CI = 3.19 to 5.37; overall survival HR = 1.78, 95% CI = 1.62 to 1.96).

Conclusions

UTUC continues to be managed primarily with nephroureterectomy, regardless of risk stratification, and patients with high-risk UTUC have worse overall and cancer-specific survival. Substantial costs are associated with management of low- and high-risk UTUC, with the latter being more costly up to 1 year from diagnosis.

Cost-Effectiveness of Home Hemodialysis With Bedside Portable Dialysis Machine "DIMI" in the United Arab Emirates

Background and objective

The incidence and prevalence of patients requiring renal replacement therapies (RRTs) are increasing worldwide and a large number of these patients die prematurely due to the unavailability of treatment. While in-center hemodialysis remains the most commonly practiced modality globally, more and more patients find it unsuitable due to their frail condition, difficulty in ambulation, and time lost in traveling, etc. Such patients find the self-administered or nurse-assisted home hemodialysis (NAHHD) more suitable. The costly and recurring nature of these therapies prompted us to evaluate and compare the cost-effectiveness aspect of these two treatment modalities. Thus, the aim of the study was to investigate if home hemodialysis (HHD) with a portable hemodialysis machine was cost-effective in comparison to in-center hemodialysis for patients of end-stage renal failure (ESRF) in the United Arab Emirates (UAE). This is the first study of its kind to be conducted in the UAE.

Methodology

The study topic was developed based on an informal inquiry from the health regulator of Abu Dhabi if HHD was cost-effective compared to in-center hemodialysis with an emphasis on a portable dialysis machine. No such head-to-head study performed in the UAE was available. Hence, a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) design was chosen as the investigative method. An outline of the study was drafted, and a literature search of Science of Web, PubMed, and Cochrane Evidence was performed using the keywords "Home Hemodialysis", "home-based Dialysis", "Cost-effectiveness of Dialysis", "Cost-effectiveness of renal replacement therapy", etc. A review of the article titles was performed to include the articles relevant to the cost of RRTs and the economic burden of ESRF. Full text and abstracts of those articles were retrieved, studied, and, the articles that were found not relevant were excluded. The remaining articles were studied and used in the evidence synthesis. DIMI was chosen to represent a standard type of recently developed portable dialysis machines.

Results

It was interesting to find out during the review that HHD and in-center hemodialysis had been developed simultaneously but the former had eventually fallen out of favor. The review revealed that HHD is not only as effective as in-center hemodialysis but is also associated with better survival benefits over the latter. Several studies have found it to be significantly cost-effective compared to in-center hemodialysis. Newer types of HHD machines make it easier for the patients or their family/caregivers to administer it safely and effectively at home and while traveling. They have regenerated interest in HHD and the Medicare administration in the USA has already decided to make use of it at a more frequent rate.

Conclusion

Based on the evidence in the available literature, HHD is cost-effective when compared to in-center hemodialysis in terms of survival benefits, quality of life (QoL) of patients, and monetary savings. Newer portable bedside dialysis machines provide better safety and have simplified the procedure of hemodialysis, making HHD more acceptable to patients and caregivers. We believe HHD should be the preferred modality of treatment instead of in-center hemodialysis, and that applies to UAE too.

Impact of assistance on peritonitis due to breach in aseptic procedure in diabetic patients: A cohort study with the RDPLF data

BACKGROUND

Diabetic patients often have physical impairment that could lead to manipulation errors in peritoneal dialysis (PD) and touch contamination. Nurse assistance in diabetic PD patients is known to help prevent peritonitis. We made the hypothesis that this lower risk of peritonitis was observed thanks to prevention of breach in aseptic procedure. We evaluated the impact of nurse-assisted PD on specific causes of peritonitis, especially on peritonitis due to a breach in aseptic procedure.

METHODS

This was a retrospective observational study of the data from the French Language Peritoneal Dialysis Registry. All diabetic patients older than age 18 years starting PD in France between 1 January 2012 and 31 December 2015 were included in the study. The event of interest was the first peritonitis event due to a breach in aseptic procedure. Death, kidney transplantation and peritonitis due to another mechanism were considered as competing events. We examined the association of the covariates with all the possible outcomes using a subdistribution hazard model developed for survival analysis in the presence of competing risks.

RESULTS

Four thousand one hundred one diabetic patients incident in PD were included in the study. At least one peritonitis event occurred in 1611 patients over the study period. A breach in aseptic procedure was reported in 441/1611 cases (27.3%): 209/575 (36.3%) in the self-care PD group, 56/217 (25.8%) in the family-assisted PD group and 176/819 (21.5%) in the nurse-assisted PD group. Both nurse and family assistance were associated with a lower risk of peritonitis due to breach in aseptic procedure in bivariate analysis. After adjustment on age, modified Charlson index, sex and diabetic nephropathy, patients treated by nurse-assisted PD (subdistribution hazard ratio (sd-HR) 0.52, 95% confidence interval (CI) 0.40-0.67) and those treated by family-assisted PD (sd-HR 0.70, 95% CI 0.51-0.95) had a lower likelihood of peritonitis due to a connection error compared to self-care PD in multivariate analysis. The modality of assistance was not associated with other causes of peritonitis in the multivariate analysis.

CONCLUSION

While both nurse-assisted PD and family-assisted PD were associated with lower risk of peritonitis due to a breach in aseptic procedure compared to self-care PD in our study, the protective effect was greater with nurse assistance.

Arteriovenous Fistula Formation with Adjuvant Endovascular Maturation

INTRODUCTION

The clinical utility of the native arteriovenous fistula (AVF) is limited by a prolonged time to maturation, low overall maturation rate, and subsequent abandonment. Endovascular intervention is increasingly accepted as first line therapy to treat AVF stenosis. The objective of this study was to evaluate AVF formation outcomes when early endovascular intervention was selectively performed to bring about timely AVF maturation.

METHODS

A retrospective study (February 2014- February 2020) was performed on 82 AVF consecutive patients (mean age 62.5±13.5 (17-83); 58 male (70.7%)) with end-stage renal failure who had Vascular Access (VA) construction at a single institution. Four year AVF patency, vascular diameters, haemodialysis parameters, re-intervention rate, and mortality were analysed.

RESULTS

Radiocephalic AVF was the most common fistula constructed (71 patients; 88.6%). Post formation evaluation (46.2+/-56.0 days (5-343)) revealed 33 (40.2%) immature AVFs. Subsequently, 19 patients underwent endovascular procedures consisting of angioplasty/stenting of the juxta-anastomosis, cannulation and/or outflow segments to bring about timely maturation of the AVF. Hence 93.9% of AVFs had reached functional patency (maturation) by 6 months post formation, with a mean time to maturation of 67.8 +/- 65.9 (5-320) days. After reaching maturation, Primary Access Functional Patency was 82 +/- 4.3 % at 6 months, 58+/- 5.5% at 12 months and 34 +/- 6.8% at 48 months. Primary Assisted Access Functional Patency was 95 +/- 2.4% at 6 months, 90 +/-3.3 % at 12 months and 83 % +/- 4.7 % at 48 months. 121 endovascular interventions were performed to maintain patency, equating to an endovascular reintervention rate of .37 procedures/patient year. Mean arterial, venous and brachial flow rates did not change significantly after maturation with a mean fistula (primary assisted functional patency) survival time of 5.9 +/- 0.26 (5.33- 6.36) years from maturation. Only 12 thromboses occurred after the first post formation follow up review, which were all salvaged using endovascular techniques leading to 100% Total secondary functional patency at 4 years. 5 year estimated all-cause mortality was 45.6 +/-12.7%.

CONCLUSION

Arteriovenous fistula maturation rate and time to maturation can be improved when early endovascular intervention is selectively performed post formation. This allows for near universal maturation where, once matured, the use of ongoing endovascular re-intervention allows for a low re-intervention rate and long term patency providing for reliable long term renal vascular access.

Evidence-Based Decision Making 7: Health Economics in Clinical Research

The pressure for health-care systems to provide more resource-intensive health care and newer more costly therapies is significant, despite limited health-care budgets. As such, demonstration that a new therapy is effective is no longer sufficient to ensure that it is funded within publicly funded health-care systems. The impact of a therapy on health-care costs is also an important consideration for decision makers who must allocate scarce resources. The clinical benefits and costs of a new therapy can be estimated simultaneously using economic evaluation; the strengths and limitations of which are discussed herein. In addition, within this chapter, we discuss the important economic outcomes that can be collected within a clinical trial (alongside the clinical outcome data) enabling consideration of the impact of the therapy on overall resource use, thus enabling performance of an economic evaluation, if the therapy is shown to be effective.

Do remote dialysis services really cost more? An economic analysis of hospital and dialysis modality costs associated with dialysis services in urban, rural and remote settings

Background

Rates of end-stage kidney disease in Australia are highest in the Northern Territory (NT), with the burden of disease heaviest in remote areas. However, the high cost of delivering dialysis services in remote areas has resulted in centralisation, requiring many people to relocate for treatment. Patients argue that treatment closer to home improves health outcomes and reduces downstream healthcare use. Existing dialysis cost studies have not compared total health care costs associated with treatment in different locations.

Objective

To estimate and compare, from a payer perspective, the observed health service costs (all cause hospital admissions, emergency department presentations and maintenance dialysis) associated with different dialysis models in urban, rural and remote locations.

Methods

Using cost weights attributed to diagnostic codes in the NT Department of Health’s hospital admission data set (2008–2014), we calculated the mean (SD) total annual health service costs by dialysis model for 995 dialysis patients. Generalized linear modeling with bootstrapping tested the marginal cost differences between different explanatory variables to estimate ‘best casemix’/‘worst casemix’ cost scenarios.

Results

The mean annual patient hospital expenditure was highest for urban models at $97 928 (SD $21 261) and $43 440 (SD $5 048) and lowest for remote at $19 584 (SD $4 394). When combined with the observed maintenance dialysis costs, expenditure was the highest for urban models at $148 510 (SD $19 774). The incremental cost increase of dialysing in an urban area, compared with a rural area, for a relocated person from a remote area, was $5 648 more and increased further for those from remote and very remote areas to $10 785 and $15 118 respectively.

Conclusions

This study demonstrates that dialysis treatment in urban areas for relocated people has health and cost implications that maybe greater than the cost of remote service delivery. The study emphasises the importance of considering all health service costs and cost consequences of service delivery models.

Key points for decision makers

Relocation for dialysis treatment has serious health and economic consequences. Relocated people have low dialysis attendance and high hospital costs in urban areas. While remote dialysis service models are more expensive than urban models, the comparative cost differences are significantly reduced when all health service costs are included. The delivery of equitable and accessible dialysis service models requires a holistic approach that incorporates the needs of the patient; hence dialysis cost studies must consider the full range of cost impacts beyond the dialysis treatments alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06612-z.

Most people requiring ongoing treatment for end-stage kidney disease in the Northern Territory (NT) identify as Aboriginal with the majority residing in areas classified as remote or very remote. Unlike other jurisdictions in Australia, haemodialysis in a satellite unit is the most common form of treatment. However, there is a geographic mismatch between demand and service provision, with services centralised in urban areas. Patients and communities have long advocated for services at or closer to home, maintaining that the consequences of relocation and dislocation have far reaching health, psychosocial and economic ramifications. We analysed retrospective hospital data for 995 maintenance dialysis patients, stratified by the model of care they received in urban, rural and remote locations. Using cost weights attributed to diagnosis codes, we costed hospital admissions, emergency department presentations and maintenance dialysis attendances, to provide a mean total health service cost/patient/year for each model of care. We found that urban services were associated with low observed maintenance dialysis and high hospital costs, but the inverse was true for remote and very remote models. Remote models had high maintenance dialysis costs (due to expense of remote service delivery and good dialysis attendance) but low hospital usage and costs. When adjusted for other variables such as age, dialysis vintage and comorbidities, lower total hospital costs were associated with rural and remote service provision. In an environment of escalating demand and constrained budgets, this study underlines the need for policy decisions to consider the full cost consequences of different dialysis service models.

Cost of Potentially Preventable Hospitalizations Among Adults With Chronic Kidney Disease: A Population-Based Cohort Study

BACKGROUND

Prior studies report high hospitalization rates among patients with chronic kidney disease (CKD) and approximately 10% to 20.9% of hospitalizations are potentially preventable.

OBJECTIVE

To determine the rate, proportion, and cost of potentially preventable hospitalizations and whether this varied by CKD category.

DESIGN

Retrospective cohort study using population-based data.

SETTING

Alberta, Canada.

PATIENTS

All adults with an outpatient serum creatinine measurement between January 1 and December 31, 2017 in the Alberta Kidney Disease Network data repository.

MEASUREMENTS

CKD risk categories were based on measures of proteinuria (where available), eGFR, and use of dialysis. Patients were linked to administrative data to capture frequency and cost of hospital encounters and followed until death or end of study (December 31, 2018). The outcomes of interest were the rate and cost of potentially preventable hospitalizations, as identified using the Canadian Institute for Health Information (CIHI)-defined ambulatory care sensitive condition (ACSC) algorithm and a CKD-related ACSC algorithm.

METHODS

Unadjusted and adjusted rates per 1000-patient years, proportions, and cost attributable to preventable hospitalizations were identified for the cohort as a whole and for patients within each CKD risk category.

RESULTS

Of the 1,110,895 adults with eGFR and proteinuria measurements, 181,422 had CKD. During a median follow-up of 1 year, there were 62,023 hospitalizations among patients with CKD resulting in a total cost of $946 million CAD; 6907 (11.1%) of these hospitalizations were for CIHI-defined ACSCs while 4323 (7.0%) were for CKD-related ACSCs. Adjusted rates of hospitalization for ACSCs increased with CKD risk category and were highest among patients treated with dialysis. Among CKD patients, the total cost of potentially preventable hospitalizations was $79 million and $58 million CAD for CIHI-defined and CKD-related ACSCs (8.4% and 6.2% of total hospitalization cost, respectively).

LIMITATIONS

Based on the ACSC construct, we were unable to determine if these hospitalizations were truly preventable.

CONCLUSIONS

Potentially preventable hospitalizations have a substantial cost and burden on the health care system among people with CKD. Effective strategies that reduce preventable admissions among CKD patients may lead to significant cost savings.

TRIAL REGISTRATION

Not applicable-observational study design.

A retrospective observational population-based study to assess the prevalence and burden of illness of type 2 diabetes with an estimated glomerular filtration rate < 90 mL/min/1.73 m2 in Ontario, Canada

AIM

To better understand the healthcare burden of people with type 2 diabetes (T2D) and estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73 m² in Ontario, Canada.

MATERIALS AND METHODS

We used administrative data to evaluate the prevalence of T2D, eGFR < 90 mL/min/1.73 m² and adverse cardiovascular co-morbidities in individuals aged ≥ 30 years living in Ontario, Canada. We also examined incremental healthcare costs and healthcare resource utilization (HCRU) for these patients with specific incident cardiovascular and renal outcomes, in comparison with controls without these outcomes.

RESULTS

While the prevalence of T2D in the general population aged ≥ 30 years in Ontario increased by 1.8% over a 5-year period (2011-2012 to 2015-2016), the prevalence of eGFR < 90 mL/min/1.73 m² among people with T2D increased by 35%. In comparison with corresponding controls without these outcomes, the per patient average total costs (Canadian dollars) over a 2-year analysis period were higher for patients with cardiovascular disease/chronic kidney disease related death ($69 827; n = 32 407), doubling of serum creatinine ($52 260; n = 22 825), those who started dialysis ($150 627; n = 3499) or received a kidney transplant ($50 664; n = 651). Similarly, HCRU was significantly greater for patients with these incident outcomes.

CONCLUSIONS

This real-world retrospective study highlights an increasing prevalence of T2D, eGFR < 90 mL/min/1.73 m² , and the substantially higher healthcare costs and HCRU when these patients have adverse cardiovascular and renal outcomes. The existence of such a large economic burden underpins the importance of preventing these diabetes-related complications.

Starting Dialysis on Time, At Home on the Right Therapy (START): Description of an Intervention to Increase the Safe and Effective Use of Peritoneal Dialysis

Background:

Most of the patients with end-stage kidney failure are treated with dialysis. Jurisdictions around the world are actively promoting peritoneal dialysis (PD) because it is equivalent to hemodialysis in terms of clinical outcomes, but is less costly. Unfortunately, PD penetration remains low.

Objectives:

The Starting dialysis on Time, At Home, on the Right Therapy (START) Project had 2 overarching goals: (1) to provide information that would help programs increase the safe and effective use of PD, and (2) to reduce inappropriate, early initiation of dialysis in patients with kidney failure. In this article, we focus on the first objective and describe the rationale for START and the methods employed.

Design:

The START Project was a comprehensive, province-wide quality improvement intervention.

Setting:

The START project was implemented in both Alberta Kidney Care (AKC)-South and AKC-North, including all 7 renal programs in the province.

Patients:

The project included all patients who commenced maintenance dialysis between October 1, 2015, and March 31, 2018, in Alberta, Canada who met our inclusion criteria.

Measurements:

We reported baseline characteristics of incident dialysis patients overall, and by site. Our key performance indicator was the proportion of patients who received PD for any period of time within 180 days of the first dialysis treatment. Reports also included detailed metrics pertaining to the 6 steps in the process of modality selection and we had the capacity to provide more granular data on an as-needed basis. To understand loss of PD patients, we reported the numbers of incident patients who recovered kidney function, experienced technique failure, received a transplant, were lost to follow-up, transferred to another program, or died.

Methods:

START provided dialysis programs with a conceptual framework for understanding the drivers of PD utilization. High-quality, detailed data were collected using a tool that was custom-built for this purpose, and were mapped to steps in the process of care that drove the outcomes of interest. This allowed sites to identify gaps in care, develop action plans, and implement local interventions to address them. The process was supported by an Innovation Learning Collaborative consisting of 3 learning sessions that brought frontline staff together from across the province to share strategies and learnings. Ongoing data collection allowed teams to determine whether their interventions were effective at each subsequent learning session, and to revisit their interventions if required (the “Plan-Do-Study-Act Cycle”).

Results:

Future work will report on the impact of the START project on incident PD utilization at a provincial and regional level.

Limitations:

The time required to design and implement interventions in practice, as well as the need for multiple PDSA (Plan-Do-Study-Act) cycles to see results, meant that the true potential may not be realized during a relatively short intervention period. Change required buy-in and support from local and provincial leadership and frontline staff. In the absence of accountability for local performance, we relied on the goodwill of participating programs to use the information and resources provided to effect change. Finally, the burden of documentation and data collection for frontline staff was high at baseline. We anticipated that adding supplemental data collection would be difficult.

Conclusions:

The START project was a comprehensive, province-wide initiative to maximize the safe and effective use of PD in Alberta, Canada. It standardized the management of incident dialysis patients, leveraged high-quality data to facilitate the reporting of metrics mapped to steps in the process of care that drove incident PD utilization, and helped programs to identify gaps in care and target them for improvement. Future work will report on the impact of the program on incident utilization at the provincial and regional level.

Nocturnal Hemodialysis: Why Aren't More People Doing It?

Nocturnal hemodialysis is a form of intensive hemodialysis, which may be done in center or at home. Despite the documented clinical and economic benefits of ncturnal hemodialysis, uptake of this modality has been relatively low. In this review, we aim to address the potential barriers and possible mitigation strategies. Among the patient-related barriers, lack of knowledge and awareness remains the most common barrier, while administrative inertia to change from conventional in-center hemodialysis continues to be a challenge. Current global effort to grow home dialysis will re-focus the need for better patient education, innovate home dialysis technology, and evolve new models of care. New patient-focused policy will allow changes in reimbursement and develop appropriate momentum toward an integrated "home first model" to kidney replacement therapy.

Evidence-Based Decision Making 5: Knowledge Translation and the Knowledge to Action Cycle

There is a significant gap between what is known and what is implemented by key stakeholders in practice (the evidence to practice gap). The primary purpose of knowledge translation is to address this gap, bridging evidence to clinical practice. The knowledge to action cycle is one framework for knowledge translation that integrates policy makers throughout the research cycle. The knowledge to action cycle begins with the identification of a problem (usually a gap in care provision). After identification of the problem, knowledge creation is undertaken, depicted at the center of the cycle as a funnel. Knowledge inquiry is at the wide end of the funnel, and moving down the funnel, the primary data is synthesized into knowledge products in the form of educational materials, guidelines, decision aids, or clinical pathways. The remaining components of the knowledge to action cycle refer to the action of applying the knowledge that has been created. This includes adapting knowledge to local context, assessing barriers to knowledge use, selecting, tailoring implementing interventions, monitoring knowledge use, evaluating outcomes, and sustaining knowledge use. Each of these steps is connected by bidirectional arrows and ideally involves health-care decision makers and key stakeholders at each transition.

Assisted peritoneal dialysis and transfer to haemodialysis: a cause-specific analysis with data from the RDPLF

Background

Technique failure, defined as death or transfer to haemodialysis (HD), is a major concern in peritoneal dialysis (PD). Nurse-assisted PD is globally associated with a lower risk of transfer to HD. We aimed to evaluate the association between assisted PD and the risk of the different causes of transfer to HD.

Methods

This was a retrospective study using data from the French Language PD Registry of patients on incident PD from 2006 to 2015. The association between the use of assisted PD and the causes of transfer to HD was evaluated using survival analysis with competing events in unmatched and propensity score-matched cohorts.

Results

The study included 11 093 incident PD patients treated in 123 French PD units. There were 4273 deaths, 3330 transfers to HD and 2210 renal transplantations. The causes of transfer to HD were inadequate dialysis (1283), infection (524), catheter-related problems (334), social issues (250), other causes linked to PD (422), other causes not linked to PD (481) and encapsulating peritoneal sclerosis (6). Nurse-assisted PD patients were older and more comorbid. Assistance by nurse was associated with a higher risk of death [cause-specific hazard ratio (cs-HR) 2.49, 95% confidence interval (CI) 2.26–2.74], but with a lower risk of transfer to HD [subdistributionHR (sd-HR) 0.68, 95% CI 0.62–0.76], especially due to inadequate dialysis (cs-HR 0.83, 95% CI 0.75–0).

Conclusions

The lower risk of transfer to HD associated with nurse assistance should encourage decision makers to launch reimbursement programmes in countries where it is not available.

The Impact of a Pre-Dialysis Educational Program on the Mode of Renal Replacement Therapy in a Saudi Hospital: A Retrospective Cohort Study

Background

Self-care and peritoneal dialysis (PD) benefits have been underutilized in patients with end-stage renal disease (ESRD). The pre-dialysis education program (PDEP) has been generally introduced as an acceptable tool in increasing the rates of PD and has been reportedly recommended for ESRD patients as part of the introduced care. We aim to study the effect of PDEP on ESRD and whether they would prefer PD of center-based hemodialysis (HD).

Methods

This is a retrospective cohort study that was done at King Fahad Armed Forces Hospital in Jeddah, Saudi Arabia, in the dialysis center. Data were collected on patients and included demographics, preference of renal replacement therapy modality, and other possible factors that may affect patient choices such as educational level, economic status, and age.

Results

A total of 213 ESRD patients that met our criteria were included, with a total of 75 patients receiving PDEP. Out of those who received the PDEP, 57.3% and 42.7% of patients decided to perform HD and PD, respectively. There was a significant impact of PDEP on reducing HD choice [OR (95% CI) = 0.11 (0.05-0.24); P-value < 0.001]. Infections did not occur in 50.5% of the included patients while 45.8%, 3.3%, and 0.5% had central line-associated bloodstream infection (CLABSI), other infections, and peritonitis, respectively. Most of the PD patients (81.8%) did not have an infection as compared to 42.3% of the HD patients. HD was also associated with increased admission days [OR (95% CI) = 1.27 (1.07-1.51); P-value = 0.007].

Conclusion

We found that PDEP positively impacted the rate of PD while PD was associated with favorable outcomes and lower infection rates, emphasizing the importance of an educational program.

Peritoneal Dialysis Utilization and Outcome: What are we Facing?

Penetration of peritoneal dialysis (PD) varies tremendously across the world. It ranges from about 80% in Hong Kong and Mexico to just a few percentage points in the United States, Japan, and Germany. While PD is growing in China, India, and some Eastern European and South American countries, it is declining in many European and North American countries. In terms of outcomes, the survival of PD patients is generally comparable to that of hemodialysis (HD) patients and better than that of HD patients during the first few years on dialysis. According to the U.S. Renal Data System, survival of patients on PD has been improving faster than that of patients on HD. In terms of cost, PD is usually cheaper than HD. Hence, declining PD utilization is unjustified. Work is required to identify and overcome negative factors such as physician bias, unfair medical reimbursement systems, and poor patient education.

Self-care training using the Tablo hemodialysis system

INTRODUCTION

Recently published results of the investigational device exemption (IDE) trial using the Tablo hemodialysis system confirmed its safety and efficacy for home dialysis. This manuscript reports additional data from the Tablo IDE study on the training time required to be competent in self-care, the degree of dependence on health care workers and caregivers after training was complete, and participants' assessment of the ease-of-use of Tablo.

METHODS

We collected data on the time required to set up concentrates and the Tablo cartridge prior to treatment initiation. We asked participants to rate system setup, treatment, and takedown on a Likert scale from 1 (very difficult) to 5 (very simple) and if they had required any assistance with any aspect of treatment over the prior 7 days. In a subgroup of 15 participants, we recorded the number of training sessions required to be deemed competent to do self-care dialysis.

FINDINGS

Eighteen men and 10 women with a mean age of 52.6 years completed the study. Thirteen had previous self-care experience using a different dialysis system. Mean set up times for the concentrates and cartridge were 1.1 and 10.0 minutes, respectively. Participants with or without previous self-care experience had similar set-up times. The mean ease-of-use score was 4.5 or higher on a scale from 1 to 5 during the in-home phase. Sixty-five percent required no assistance at home and on average required fewer than four training sessions to be competent in managing their treatments. Results were similar for participants with or without previous self-care experience.

CONCLUSIONS

Participants in the Tablo IDE trial were able to quickly learn and manage hemodialysis treatments in the home, found Tablo easy to use, and were generally independent in performing hemodialysis.

Spontaneous Dislodgement of Tunneled Dialysis Catheters after De Novo versus Over-The-Wire-Exchange Placement

PURPOSE

To evaluate dislodgement of tunneled dialysis catheters (TDCs) in de novo (DN) placement with ultrasound versus over-the-wire exchange (OTWE).

MATERIALS AND METHODS

Data were collected retrospectively on all TDC placements at this institution from 2001 to 2019 and were excluded if no removal date was recorded or if dwell time was more than 365 days. Information on TDC brand, placement, insertion/removal, and removal reason were collected. Multiple logistic regression evaluated factors associated with TDC dislodgement. DN placement and OTWE were compared for rate of dislodgement (generalized estimating equations method) and TDC dwell time (survival analysis).

RESULTS

In total, 5328 TDCs were included with 66% (3522) placed DN and 32% (1727) via OTWE. Mean dwell time was 65 ± 72 days, and dislodgement occurred in 4% (224). TDC dislodgement rates in the DN and OTWE groups were 0.48 and 0.93 per 1000 catheter days, respectively. Brand (Ash Split vs. VectorFlow), placement technique (OTWE vs. DN), laterality (left vs. right), and site (left vs. right internal jugular vein) were significant predictors of dislodgement. OTWE placement exhibited 1.7 times the odds of dislodgement (95% confidence interval, 1.2-2.6; P = .004) compared to DN and had significantly higher probability of dislodgement across time (hazard ratio = 2.0; P < .001) compared to DN. Dislodgement rates for OTWE vs. DN were 8% vs. 3% (3 months), 13% vs. 6% (6 months), and 38% vs. 17% (1 year).

CONCLUSIONS

TDC spontaneous dislodgement rates were significantly and consistently higher after OTWE compared to DN placement. These data support more careful attention to catheter fixation after OTWE placement.

Laparoscopic-Assisted Peritoneal Dialysis Catheter Placement, an Improvement on the Single Trocar Technique

In 2002, Ochsner laparoscopic surgeons and nephrologists began placing peritoneal dialysis (PD) catheters via a laparoscopic-assisted method. We compared laparoscopically placed PD catheters (LAPD) with catheters most recently placed without laparoscopic aid (STPD). The method for this study is a retrospective chart review. Demographics of both groups were similar. Nine of 20 (45%) in the STPD group and 16 of 23 (70%) in the LAPD group had had previous abdominal surgery. Three of 20 (15%) of STPD had complications, including one small bowel injury. Four of 23 (17.4%) of the LAPD had complications. One of 20 (5%) in the STPD group and 3 of 23 (13%) in the LAPD group had dialysate leaks. In the STPD group, 8 of 20 (40%) had catheter problems that led to removal in 7 (35%). In the LAPD group, 6 of 23 (26%) had catheter malfunction: 3 were salvaged with a laparoscopic procedure; 3 (13%) were removed for malfunction. 1) LAPD allows proper PD placement after complex abdominal surgery; 2) Although dialysate leak complications are increased, bowel perforation risk is less; 3) Because of proper placement, PD catheter malfunction rate is less with LAPD; 4) Although no results obtained statistical significance, we found LAPD superior to STPD and have converted to this technique.

Economic Benefits of Switching From Intravenous to Subcutaneous Epoetin Alfa for the Management of Anemia in Hemodialysis Patients

Background:

Erythropoiesis-stimulating agents including epoetin alfa have been a mainstay of anemia management in patients with chronic kidney disease. Although the standard practice has been to administer epoetin alfa to patients on hemodialysis (HD) intravenously (IV), subcutaneous (SQ) epoetin alfa is longer acting and achieve the same target hemoglobin level to be maintained at a reduced dose and cost.

Objective:

The primary objective of this study was to determine the economic benefits of change in route of epoetin alfa administration from IV to SQ in HD patients. The secondary objectives were (1) to determine the differences in epoetin alfa doses at the pre-switch (IV) and post-switch period (SQ) and (2) to determine serum hemoglobin concentration, transferrin saturation, ferritin level, IV iron dose and cost in relationship to route of epoetin alfa administration.

Design:

This retrospective observational study included patients who transitioned from IV to SQ epoetin alfa.

Setting:

Two HD sites in southern Saskatchewan (Regina General Hospital, and Wascana Dialysis Unit, Regina) and 2 sites in northern Saskatchewan (St. Paul’s [SPH] Hospital, and SPH Community Renal Health Center, Saskatoon).

Patients:

The study includes 215 patients who transitioned from IV to SQ and were alive at the end of 12-month follow-up period.

Measurements:

We calculated the dose and cost of different routes of epoetin alfa administration/patient month. Also, serum hemoglobin, markers of iron stores (transferrin saturation and ferritin), IV iron dose, and cost were determined in relation to route of epoetin alfa administration.

Methods:

Data were gathered from 6 months prior (IV) to 12 months after switching treatment to SQ. The paired t-test and Wilcoxon signed-rank test were used to compare variables between pre-switch (IV) and post-switch (SQ) period.

Results:

The median cost (interquartile range) of epoetin alfa/patient-month decreased from (CAD508.3 [CAD349-CAD900.8]) pre-switch (IV) to (CAD381.2 [CAD247-CAD681]) post-switch (SQ) (P < .001), a decrease of 25%. The median epoetin alfa dose/patient-month reduced from (38 500 [25 714.3-64 166.5] international unit) pre-switch to (26 750.3 [17 362.6-48 066] IU) post-switch (P < .001), a decrease of 30.51%. The mean hemoglobin concentration (± standard deviation) for patients in both periods remained stable (103.3 ± 9.2 vs 104.3 ± 13.3 g/L, P = .34) and within the target range. There were no significant differences in transferrin saturation, ferritin, and IV iron dose and cost between the 2 study periods.

Limitations:

We were unable to consistently obtain information across all the sites on hospitalizations, inflammatory markers, nutritional status, and gastrointestinal bleeding. In addition, as our study sample was subject to survival bias, we cannot generalize our study results to other populations.

Conclusions:

We have shown that administering epoetin alfa SQ in HD patients led to a 30.51% reduction in dose and 25% reduction in cost while achieving equivalent hemoglobin levels. Given the cost sparing advantages without compromising care while achieving comparable hemoglobin levels, HD units should consider converting to SQ mode of administration.

Trial registration:

The study was not registered on a publicly accessible registry as it was a retrospective chart review and exempted from review by the Research Ethics Board of the former Regina Qu’Appelle Health Region.

Single-stage basilic vein transposition-An effective and viable autogenous access for dialysis

INTRODUCTION

The National Kidney Foundation's/Kidney Disease Outcomes Quality Initiative recommends autogenous arteriovenous fistulas as the preferred method for long-term hemodialysis access. Basilic vein transposition is not only an alternative in patients with failed arteriovenous access but also can be the first option for arteriovenous access in patients with inadequate cephalic vein. Several studies have shown better patency rates, cost-effectiveness, and fewer complications of autogenous access over prosthetic arteriovenous grafts.

AIMS AND OBJECTIVES

To analyze patency, complication rates, and outcomes of single-stage basilic vein transposition.

MATERIALS AND METHODS

A single-center retrospective non-randomized study conducted at Ramaiah Medical College and Hospitals, Bangalore from July 2015 to June 2018. A total of 94 consented patients who underwent single-stage basilic vein transposition were included in the study. All the surgeries were done in a single stage under regional anesthesia. All the complications and patency rates were calculated at the end of one year. Statistical analysis was performed using the Chi-square test, and patency rates were assessed using the Kaplan-Meir survival curve.

RESULTS

A total of 94 single-stage basilic vein transposition was performed. Fifty-four patients had a previous failed autogenous access and 40 had either absent or thrombosed cephalic vein. The mean age was 56.6 years with 59.57% males. The mean basilic vein and brachial artery diameter was 3.6 and 3.8 mm, respectively. The primary patency rate at one year was 84%. Edema and thrombosis were the most common complication in our study.

CONCLUSION

Single-stage basilic vein transposition is a feasible surgical option in end-stage renal disease patients and provides durable autogenous access with very reasonable outcomes in terms of complication rates and patency rates.

The Effect of Risk of Maturation Failure and Access Type on Arteriovenous Access-Related Costs among Hemodialysis Patients

BACKGROUND

Several studies report lower costs associated with attaining and maintaining patency for arteriovenous (AV) fistulas as compared to AV grafts among patients receiving hemodialysis. However, these costs may vary according to the AV access's risk of failure to mature (FTM). The aim of this study was to examine the effect of AV access type and risk of FTM on the total costs of attaining and maintaining AV access patency over 1, 3, and 5 years postcreation, among incident accesses.

METHODS

All first AV access creations (January 1, 2002-January 1, 2018), revisions/resections, and interventions from a single academic institution were prospectively captured. The units costs (from 2011 in CA$) were estimated primarily through the provincial patient Ontario Case Costing Initiative database. The present value of total vascular access-related costs from a third-party payer perspective was calculated by multiplying specific unit costs by the number of AV access creations, revisions/resections, and interventions from the date of creation to 1, 3, and 5 years post creation. The potential associations of AV access type and FTM risk stratum with AV access cost were examined using log-linear models and generalized estimating equations.

RESULTS

A total of 906 patients were included in the study, of which 696 had fistulas and 210 had grafts. The median present value of total costs to attain and maintain AV access over 1, 3, and 5 years was positively associated with the highest FTM risk stratum in all models. It was not associated with AV access type when the interaction between AV access type and FTM risk stratum was considered.

CONCLUSIONS

The costs of attaining and maintaining AV access were increased among patients with high/very high FTM risk. Risk of FTM, related interventions, and costs should be considered when choosing vascular access type for an individual patient.

Barriers to Utilization of Chronic Peritoneal Dialysis in Network #1, New England

Objective

The percentage of prevalent end-stage renal disease (ESRD) patients maintained on chronic peritoneal dialysis (CPD) therapy in the United States declined from 15% in 1991 to 8.1% in 2002. Previous studies indicate that nephrologists in the United States feel 32.6% of prevalent ESRD patients should be on CPD therapy. The present study was designed to better understand the reasons for the discrepancy in actual versus desired prevalence of CPD utilization.

Methods

The medical directors of all dialysis centers in New England were mailed a questionnaire about the nephrologists’ opinions concerning the percentage of patients that should be maintained on CPD therapy, reasons that limited patients’ selection of CPD as initial therapy, and concerns about the current status of CPD therapy. The nephrologists were also invited to free text any other comments or concerns.

Results

A total of 117 questionnaires were sent; 59 (50.4%) were returned. These medical directors cared for a median of 10 (range 1 – 100) patients on CPD therapy, meaning 15% of dialysis patients in New England are maintained on CPD therapy. The medical directors felt that 29% (range 10% – 50%) of prevalent ESRD patients should be maintained on CPD therapy. The most common reasons cited by the nephrologists as barriers to CPD therapy included patient preference (54%), contraindications to performing CPD therapy (32%), poor social support (31%), significant comorbid disease (20%), late referrals and acute hospital starts (19%), problems with education re chronic kidney disease (12%), and problems with the structure and organization of CPD facilities (12%). These same medical directors stated that concerns about technique failure (25%), long-term viability of CPD therapy (25%), and mortality rates of CPD patients (17%) impacted on their use of CPD therapy as renal replacement therapy for patients with ESRD.

Conclusion

Nephrologists in New England felt that 29% of prevalent ESRD patients should be maintained on CPD therapy, yet the actual incidence of CPD utilization in New England is 15%. A variety of factors were cited by the nephrologists as important reasons limiting CPD utilization. These nephrologists were also concerned about technique failure and long-term viability of CPD therapy. It is necessary that we look closely at each domain cited by the nephrologists if CPD therapy is to remain a viable option for patients with ESRD in the United States.