Education for patients with progressive CKD and acute-start dialysis

The integrated care model: facilitating initiation of or transition to home dialysis

A proportion of end-stage kidney disease (ESKD) patients require kidney replacement therapy to maintain clinical stability. Home dialysis therapies offer convenience, autonomy and potential quality of life improvements, all of which were heightened during the COVID-19 pandemic. While the superiority of specific modalities remains uncertain, patient choice and informed decision-making remain crucial. Missed opportunities for home therapies arise from systemic, programmatic and patient-level barriers. This paper introduces the integrated care model which prioritizes the safe and effective uptake of home therapies while also emphasizing patient-centered care, informed decision-making, and comprehensive support. The integrated care framework addresses challenges in patient identification, assessment, eligibility determination, education and modality transitions. Special considerations for urgent dialysis starts are discussed, acknowledging the unique barriers faced by this population. Continuous quality improvement is emphasized, with the understanding that local challenges may require tailored solutions. Overall, the integrated care model aims to create a seamless and beneficial transition to home dialysis therapies, promoting flexibility and improved quality of life for ESKD patients globally.

Preparing for kidney replacement therapy in pediatric advanced CKD: a review of literature and defining a multi-disciplinary clinical approach to patient-caregiver education

Pediatric patients with progressive chronic kidney disease (CKD) approaching kidney replacement therapy (KRT) make up a small population but carry significant morbidity and mortality. Patients and caregivers require comprehensive kidney failure education to ensure a smooth start to KRT. Choice of KRT modality can be influenced by medical comorbidities, patient/caregiver comprehension, and comfort with a particular modality, social and economic factors, and/or implicit bias of the health care team. As KRT modality can influence morbidity, mortality, and quality of life, we created a pediatric advanced CKD clinic to provide comprehensive KRT education and to promote informed decision-making for our advanced CKD patients and their caregivers.

Effectiveness of a brief hope intervention for chronic kidney disease patients on the decisional conflict and quality of life: a pilot randomized controlled trial

Background

Stage 5 chronic kidney disease (CKD) patients often experience decisional conflict when faced with the selection between the initiation of dialysis and conservative care. The study examined the effects of a brief hope intervention (BHI) on the levels of hope, decisional conflict and the quality of life for stage 5 CKD patients.

Methods

This is a single-blinded, randomized controlled trial (ClinicalTrials.gov identifier: NCT03378700). Eligible patients were recruited from the outpatient department renal clinic of a regional hospital. They were randomly assigned to either the intervention or the control group (intervention: n = 35; control: n = 37). All participants underwent a customized pre-dialysis education class, while the intervention group received also BHI. Data were collected prior to the intervention, immediately afterwards, and one month following the intervention. The Generalized Estimating Equation was used to measure the effects in the level of hope, decisional conflict scores (DCS) and Kidney Disease Quality of life (KDQOL-36) scores. Estimated marginal means and standard errors with 95% confidence intervals of these scores were also reported to examine the within group and between group changes.

Results

An increase of the hope score was found from time 1 (29.7, 1.64) to time 3 (34.4, 1.27) in the intervention group. The intervention had a significant effect on the KDQOL-36 sub-scores Mental Component Summary (MCS) (Wald χ² = 6.763, P = 0.009) and effects of kidney disease (Wald χ² = 3.617, P = 0.004). There was a reduction in decisional conflict in both arms on the DCS total score (Wald χ² = 7.885, P = 0.005), but the reduction was significantly greater in the control group (effect size 0.64).

Conclusions

The BHI appeared to increase the level of hope within the intervention arm. Nonetheless, differences across the intervention and control arms were not significant. The KDQOL-36 sub-scores on MCS and Effects of kidney disease were found to have increased and be higher in the intervention group. The DCS total score also showed that hope was associated with reducing decisional conflict.

Trial Registration

ClinicalTrials.gov Protocol Registration, NCT03378700. Registered July 12 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02830-7.

The effects of a brief hope intervention on decision-making in chronic kidney disease patients: A study protocol for a randomized controlled trial

AIMS

This study describes the study protocol of a manualized brief hope intervention that is based on the theoretical proposition - hope theory.

BACKGROUND

Patients with stage 5 chronic kidney disease often had decisional regret when facing the tension of treatment alternatives between dialysis initiation and palliative care. Hope has been found to account for therapeutic changes in clients with depressive symptoms, heightens positive expectations, and striving to accomplish chosen goals. Nevertheless, little is known about the effect of hope on decisional conflict and its influences to the quality of life in these chronic kidney disease patients.

DESIGN

This study is a single-blinded, randomized controlled trial.

METHODS

Participants will be recruited from a regional hospital (approved in April 2018). They will be randomly assigned in equal numbers to either the brief hope intervention or the control arm on completion of the baseline assessment on the possible need of dialysis initiation. Participants in the intervention group will receive the pre-dialysis education and a 4-week Brief Hope Intervention [consisting of four sessions at weekly intervals (two face-to-face sessions and two telephone follow-up sessions in between)], while those allocated to the control arm will receive the renal education and social chats. Outcome measures will be carried out prior to the intervention (baseline), immediately, and 1 month after the intervention. These consist of the hope level, decisional conflict, and quality of life. Healthcare resources use data will be reported.

IMPACT

The study results have the potential to add scientific evidence to the research-tested programme when developing renal services integral to multimodal care management to optimize decision-making and attain better health outcomes.

Evaluating Factors Contributing to Dropout in a Large Peritoneal Dialysis Program

BACKGROUND

The low prevalence of peritoneal dialysis (PD) (9%) vs. hemodialysis (HD) (88.2%) is partly due to patient dropout from therapy.

METHODS

This retrospective study identified patients who withdrew from PD between 2016 and 2018 in our program. We evaluated all other factors as controllable losses. Analysis included time on therapy at dropout (very early, early or late) and method of initiation (HD to PD conversion, unplanned PD, or planned start).

RESULTS

Eighty-three patients enrolled into our PD program. 27 dropped out; 24 were due to controllable factors, 3 due to death, with a median age at dropout of 52 years old. We determined psychosocial factors (PF) to be the largest controllable factor influencing dropout; contributing a 63% rate among all controllable factors. When considering time until dropout, 100% of very early dropout patients and 50% of late dropout patients did so due to PF. Among early dropout patients 67% dropped out due to other medical reasons. The mean time to dropout for PF, other, and infection (INF) were 13, 26, and 33 months, respectively. When considering type of initiation, we found PF to be the largest attributable factor with 50% of unplanned, 100% of planned, and 50% of conversions stopping therapy.

CONCLUSIONS

Our study indicates that the primary reason for controllable loss from therapy was secondary to PF regardless of the time on therapy or the method of initiation to therapy.

Patient Education and Support During CKD Transitions: When the Possible Becomes Probable

Patients transitioning from kidney disease to kidney failure require comprehensive patient-centered education and support. Efforts to prepare patients for this transition often fail to meet patients' needs due to uncertainty about which patients will progress to kidney failure, nonindividualized patient education programs, inadequate psychosocial support, or lack of assistance to guide patients through complex treatment plans. Resources are available to help overcome barriers to providing optimal care during this time, including prognostic tools, educational lesson plans, decision aids, communication skills training, peer support, and patient navigation programs. New models are being studied to comprehensively address patients' needs and improve the lives of kidney patients during this high-risk time.

Educating Patients about CKD: The Path to Self-Management and Patient-Centered Care

Patient education is associated with better patient outcomes and supported by international guidelines and organizations, but a range of barriers prevent widespread implementation of comprehensive education for people with progressive kidney disease, especially in the United States. Among United States patients, obstacles to education include the complex nature of kidney disease information, low baseline awareness, limited health literacy and numeracy, limited availability of CKD information, and lack of readiness to learn. For providers, lack of time and clinical confidence combine with competing education priorities and confusion about diagnosing CKD to limit educational efforts. At the system level, lack of provider incentives, limited availability of practical decision support tools, and lack of established interdisciplinary care models inhibit patient education. Despite these barriers, innovative education approaches for people with CKD exist, including self-management support, shared decision making, use of digital media, and engaging families and communities. Education efficiency may be increased by focusing on people with progressive disease, establishing interdisciplinary care management including community health workers, and providing education in group settings. New educational approaches are being developed through research and quality improvement efforts, but challenges to evaluating public awareness and patient education programs inhibit identification of successful strategies for broader implementation. However, growing interest in improving patient-centered outcomes may provide new approaches to effective education of people with CKD.

CARE OF A PATIENT'S VASCULAR ACCESS FOR HAEMODIALYSIS: A NARRATIVE LITERATURE REVIEW

BACKGROUND

Patients requiring haemodialysis have diverse clinical needs impacting on the longevity of their vascular access and their quality of life. A clinical practice scenario is presented that raises the potential of unsafe cannulation of a patient's vascular access as a result of minimal patient empowerment. Vascular access care is the responsibility of everyone, including the patient and carer.

AIM

The aim of this narrative literature review (1997-2014) is to explore the current understanding of what factors influence the care of vascular access for haemodialysis.

METHOD

A narrative literature review allows the synthesis of the known literature pertinent to the research question into a succinct model or unique order to enable new understandings to emerge. The bio-ecological model was used to guide the thematic analysis of the literature.

RESULTS

The narrative literature review revealed five themes related to care of vascular access: patient experience; relationships-empowerment and shared decision making; environment of healthcare; time; and quality of life as the outcome of care.

CONCLUSION

The management of vascular access is complicated. Current available literature predominantly concentrates on bio-medical aspects of vascular access care. Contextualised vascular access care in the complex ecology of the patient and carer's lives has the potential to enhance nursing practice and patient outcomes.

Systems to cultivate suitable patients for home dialysis

The key to developing, initiating, and maintaining a strong home dialysis program is a fundamental commitment by the entire team to identify and cultivate patients who are suitable candidates to perform home dialysis. This process must start as early as possible in the disease trajectory, and must include a passionate and daily focus by physicians, nurses, social workers, and other members of the multidisciplinary team. This effort must be constant and sustained over months, with active promotion of home dialysis for suitable patients at every opportunity. Cultivation of suitable patients must become a defining and overarching mission for the entire program. This article reviews some of the components involved in this worthwhile effort and provides practical tips and links to resources.

Timing of Initiation of RRT and Modality Selection

There is no shortage of studies and registry data examining outcomes of patients on dialysis and those with a renal transplant. However, recently, there has been a greater focus on the events leading up to the institution of kidney replacement therapy. Associative data suggest that early and consistent predialysis care leads to better outcomes, including greater take-on to home-based therapy, diminished use of tunneled venous hemodialysis catheters, and improved early and even late survival. What transpires during predialysis visits is also important. Simple dissemination of facts to the unprepared patient is unlikely to be effective in moving the patient and family along in the process of the series of choices that have to be made around therapy. A more flexible and circumspect approach is needed, including recognizing when the patient is or is not ready for change. There seems to be no optimal timing of dialysis start that can be applied to the ESRD population as a whole, although the pendulum seems to be swinging back toward symptom-based rather than eGFR-based starts.

Can peritoneal dialysis be applied for unplanned initiation of chronic dialysis?

Late referral of patients with chronic kidney disease (CKD) and unforeseeable deterioration of residual renal function in known CKD patients remain a major problem leading to the need of unplanned start on chronic dialysis without a mature access for dialysis. In most centres worldwide, these patients are started on haemodialysis (HD) using a temporary tunnelled central venous catheter (CVC) for access. However, during the last decade, increasing clinical experience with unplanned start on peritoneal dialysis (PD) right after PD catheter implantation has been published. Key studies are reviewed in the present paper, and the results seem to indicate that compared with patients starting PD in a planned setting with peritoneal resting after PD catheter implantation, patients starting unplanned PD have an increased risk of mechanical complications but apparently no increased risk of infectious complications. In contrast, patients starting unplanned HD using a temporary CVC have an increased risk of both mechanical and infectious complications when compared with patients starting planned HD using an arterio-venous fistula or a permanent CVC. Regarding clinical outcome in terms of survival, unplanned PD seems to be at least as safe as unplanned HD. Combining the unplanned PD programme with a nurse-assisted PD programme is crucial in order to offer the patient a real opportunity to choose a home-based dialysis option. In conclusion, unplanned start on PD seems to be a feasible, safe and efficient alternative to unplanned start on HD for the late referred patient with end-stage renal disease and urgent need for dialysis.