The early history of dialysis for chronic renal failure in the United States: a view from Seattle

Trends in Racial and Ethnic Disparities in the Receipt of Lifesaving Procedures for Hospitalized Patients With Decompensated Cirrhosis in the US, 2009-2018

Importance

Patients with decompensated cirrhosis are hospitalized for acute management with temporizing and lifesaving procedures. Published data to inform intervention development in this area are more than a decade old, and it is not clear whether there have been improvements in disparities in the receipt of these procedures over time.

Objective

To evaluate the associations of race and ethnicity with receipt of procedures to treat decompensated cirrhosis over time in the US.

Design, Setting, and Participants

This retrospective cross-sectional study analyzed National Inpatient Sample data on cirrhosis admissions among patients with portal hypertension-related complications from 2009 to 2018. All hospital discharges for individuals aged 18 years and older from 2009 to 2018 were assessed for inclusion. Admissions were included if they contained at least 1 cirrhosis-related International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code and at least 1 cirrhosis-related complication ICD-9-CM or ICD-10-CM code (ie, ascites, hepatic encephalopathy, variceal hemorrhage [VH], and hepatorenal syndrome [HRS]). Data were analyzed from January to June 2022.

Exposure

Hospitalization for decompensated cirrhosis.

Main Outcomes and Measures

The outcomes of interest were trends in the odds ratios (ORs) for receiving procedures (upper endoscopy, transjugular portosystemic shunt [TIPS], hemodialysis, and liver transplantation [LT]) for decompensated cirrhosis and mortality by race and ethnicity, modeled over time. Multivariable logistic regression was used to assess these outcomes.

Results

Among 717 580 admissions (median [IQR] age, 58 [52-67] years), 345 644 patients (9.8%) were Black, 623 991 patients (17.6%) were Hispanic, and 2 340 031 patients (47.4%) were White. Based on the modeled trends, by 2018, there were no significant differences by race or ethnicity in the odds of receiving upper endoscopy for VH. However, Black patients remained less likely than White patients to undergo TIPS for VH (OR, 0.54; 95% CI, 0.47-0.62) and ascites (OR, 0.34; 95% CI, 0.31-0.38). The disparity in receipt of LT improved for Black and Hispanic patients over the study period; however, by 2018, both groups remained less likely to undergo LT than their White counterparts (Black: OR, 0.66; 95% CI, 0.61-0.70; Hispanic: OR, 0.74; 95% CI, 0.70-0.78). The odds of death in Black and Hispanic patients declined over the study period but remained higher in Black patients than White patients in 2018 (OR, 1.08; 95% CI, 1.05-1.11).

Conclusions and Relevance

In this cross-sectional study of individuals hospitalized with decompensated cirrhosis, there were racial and ethnic disparities in receipt of complex lifesaving procedures and in mortality that persisted over time.

Homelessness, organ donation, transplantation, and a call for equity in the United States

While social justice is a pillar that society seeks to uphold, in the area of organ transplantation, social justice, equity, and inclusion fail in the unbefriended and undomiciled population. Due to lack of social support of the homeless population, such status often renders these individuals ineligible to be organ recipients. Though it can be argued that organ donation by an unbefriended, undomciled patient benefits the greater good, there is clear inequity in the fact that homeless individuals are denied transplants due to inadequate social support. To illustrate such social breakdown, we describe two unbefriended, undomiciled patients brought to our hospitals by emergency services with diagnoses of intracerebral haemorrhage that progressed to brain death. This proposal represents a call to action to remediate the broken system: how the inherent inequity in organ donation by unbefriended, undomiciled patients would be ethically optimized if social support systems were implemented to allow for their candidacy for organ transplantation.

Evaluation of outcomes with permanent vascular access in an elderly Korean population based on the National Health Insurance Service database

INTRODUCTION

As nearly half of patients with end-stage kidney disease (ESKD) who initiate hemodialysis (HD) are over 65 years old (commonly defined as elderly), the fistula first strategy is controversial even in HD patients ≥65 years.

METHODS

In Korea's National Health Insurance Service database from 2008 to 2019, 41,989 elderly (≥ 65 years) HD patients were retrospectively reviewed to identify their clinical characteristics and outcomes. Vascular access (VA) patencies, risk factors associated with patencies and patient survival between arteriovenous fistula (AVF) and arteriovenous graft (AVG) were compared.

RESULTS

Elderly AVF group (n = 28,467) had superior primary, primary assisted, and secondary patencies than elderly AVG group (n = 13,522) (all p values are <0.001). Patient survival was also better in the elderly AVF group than in the elderly AVG (p < 0.001). In multivariate Cox regression analyses for diverse outcomes, AVG (vs. AVF) was identified as a risk factor for all-cause mortality (adjusted hazard ratio [HR]: 1.307; 95% confidence interval [CI]: 1.272-1.343; p < 0.001), primary patency (adjusted HR: 1.745; 95% CI: 1.701-1.790; p < 0.001), primary-assisted patency (adjusted HR: 2.163; 95% CI: 2.095-2.233; p < 0.001), and secondary patency (adjusted HR: 3.718; 95% CI: 3.533-3.913; p < 0.001).

CONCLUSION

Our study demonstrated that as a permanent VA for HD, AVF should be strongly considered in elderly (≥ 65 years) ESKD Korean patients. The age limit for AVF creation in ESKD patients should be adjusted more upward.

How Do Kidney Disease Clinicians View Kidney Supportive Care and Palliative Care? A Qualitative Study

RATIONALE & OBJECTIVE

Kidney supportive care (KSC) is a developing area in medicine that integrates the expertise of kidney and palliative care practitioners to improve symptoms and quality of life for people with advanced kidney disease. The intersection of the practical aspects of KSC (including care activities and clinical referrals) with palliative and end-of-life care (EOLC) are largely unknown. The aim of this study was to explore kidney disease clinicians' experiences of KSC, palliative care, and EOLC.

STUDY DESIGN

An exploratory qualitative study using semistructured focus groups.

SETTING & PARTICIPANTS

Kidney disease clinicians (18 physicians, 3 trainees, and 33 kidney disease nurses) from 5 public hospitals were recruited across Victoria, Australia.

ANALYTICAL APPROACH

Thematic analysis of focus group transcripts.

RESULTS

The 2 overarching themes highlighted by clinicians were their perception that their health care systems insufficiently addressed the needs of people with advanced kidney disease, as well as their aspirations to develop KSC services to improve health care experiences. Three subthemes were identified related to limitations in health care systems: (1) variation in the clinical scope of KSC, (2) limited integration of palliative care, and (3) experiences of challenging and compromised provision of EOLC. The second theme described aspirations for future KSC services to be more inclusive, seamless, and collaborative across health care providers with capacity to respond to meet changing palliative care needs.

LIMITATIONS

Findings may not be transferable to contexts outside of Victoria, Australia; data were collected in 2017-2018 and may not reflect current or future experiences.

CONCLUSIONS

Kidney clinicians described systemic challenges and compromises in care experiences and the need for development of KSC services. They expressed that this development would require a consistent and systematic approach that integrates palliative care and embeds KSC as part of kidney health service delivery.

Success rates and safety of a modified percutaneous PD catheter placement technique: Ultrasound-guided percutaneous placement of peritoneal dialysis catheters using a multifunctional bladder paracentesis trocar

BACKGROUND

We modified the blind Seldinger technique by incorporating ultrasound guidance and the use of a multifunctional bladder paracentesis trocar for PD catheter (PDC) placement, which can be easily performed by a nephrologist and is a feasible technique. To compare success rates and safety of our modified percutaneous PD catheter placement technique to open surgery.

METHODS

Two hundred and twelve stage-5 chronic kidney disease(CKD) patients receiving PD therapy from June 2016 to June 2019 were included, 105 patients treated by ultrasound-guided percutaneous placement of peritoneal dialysis catheters using a multifunctional bladder paracentesis trocar (Group A) and 107 patients receiving open surgical placement (Group B). Outcomes of patients via either catheter placement technique were retrospectively compared. The clinical success rate as defined by proper catheter drainage within 4 weeks after placement, complication rates (both technical complications and infections), and 1-year catheter survival were compared.

RESULTS

There was no significant difference in sex ratio, age, or previous abdominal surgery history between groups (P > .05). Both surgical time and incision length were significantly shorter in Group A than in Group B (P < .05). Clinical success rate was also higher inGroup A (P < .05). Moreover, Group A demonstrated lower overall complication rates (P < .05) and lower incidence rates of early peritonitis, initial drainage disorder, and peritubular leakage (all P < .05). One-year catheter survival was also higher in Group A (P < .05).

CONCLUSION

Percutaneous placement of PD catheters using our modified technique demonstrates superior success rates and safety compared to open surgery. In addition, our modified technique can be a better alternative to traditional Seldinger percutaneous catheterization for its higher success rate and safety, more accurate positioning.

Half a Century of Haemodialysis: Two Patient Journeys

The history of renal replacement therapy (RRT) for end-stage kidney disease (ESKD) started in 1960 and has reached, in these six decades, goals initially unforeseen. This report describes two patients who commenced dialysis at the age of 17 and 27, for 53 and 45 years, respectively, whereby the modality of RRT was mostly in the form of home haemodialysis. The history of these two patients, who started RRT in distant parts of the world, Australia and Croatia, highlights not only the advances made over time, to significantly delay the onset and reduce the morbidity and mortality associated with ESKD, but also underlines the importance of empowerment and commitment, added values in home haemodialysis.

Assessing the efficacy of coproduction to better understand the barriers to achieving sustainability in NHS chronic kidney services and create alternate pathways

CONTEXT

Too many people living with chronic kidney disease are opting for and starting on hospital-based dialysis compared to a home-based kidney replacement therapy. Dialysis services are becoming financially unsustainable.

OBJECTIVE

This study aimed to assess the efficacy of coproductive research in chronic kidney disease service improvement to achieve greater sustainability.

DESIGN

A 2-year coproductive service improvement study was conducted with multiple stakeholders with the specific intention of maximizing engagement with the national health kidney services, patients and public.

SETTING AND PARTICIPANTS

A national health kidney service (3 health boards, 18 dialysis units), patients and families (n = 50), multidisciplinary teams including doctors, nurses, psychologists, social workers, and so forth (n = 68), kidney charities, independent dialysis service providers and wider social services were part of this study.

FINDINGS

Coproductive research identified underutilized resources (e.g., patients on home dialysis and social services) and their potential, highlighted unmet social care needs for patients and families and informed service redesign. Education packages were reimagined to support the home dialysis agenda including opportunities for wider service input. The impacts of one size fits all approaches to dialysis on specialist workforce skills were made clearer and also professional, patient and public perceptions of key sustainability policies.

DISCUSSION AND CONCLUSIONS

Patient and key stakeholders mapped out new ways to link services to create more sustainable models of kidney health and social care. Maintaining principles of knowledge coproduction could help achieve financial sustainability and move towards more prudent adult chronic kidney disease services.

PATIENT OR PUBLIC CONTRIBUTION

Involved in developing research questions, study design, management and conduct, interpretation of evidence and dissemination.

Incremental Hemodialysis: What We Know so Far

Traditionally, patients that develop progressive chronic kidney disease in need of kidney replacement therapy are prescribed thrice weekly in-center hemodialysis sessions at the beginning of therapy. This empiric prescription is based on historic trials that were comprised of mostly prevalent patients. Incremental hemodialysis is the process of performing <3 sessions of dialysis per week or limiting dialysis dose by duration at the initial onset of treatment to provide a more gradual transition, mimicking the progressive nature of kidney disease. Adding clearance contributions from residual kidney function is the standard of care with peritoneal dialysis but has not routinely been employed with hemodialysis. Accounting for residual kidney function accompanied by improvement in adjuvant pharmacotherapy, such as newer potassium binding agents and dietary modification, can augment dialytic clearances and allow for an incremental approach. Utilizing incremental dialysis has been associated with both preserving residual kidney function as well as improving patient quality of life. Barriers to this approach include concerns regarding patient acceptance of dialysis prescription changes, adherence to therapy, and provider factors that would require a restructuring of the current thrice weekly hemodialysis rubric. Candidacy for incremental therapy has shown the best outcomes when urea clearances exceed 3 mL/min and urine volumes are >500 mL/day, although these measures have been deemed conservative. A significant amount of retrospective and registry data has been supportive of initiating incremental hemodialysis and several pilot studies have shown the feasibility of implementing such an approach. Larger, randomized control trials are needed to fully evaluate safety and efficacy to allow for more widespread acceptance of this patient-centered approach to chronic kidney disease.

Comparison between the 'pull technique' and open surgery for peritoneal catheter removal in Chinese patients on peritoneal dialysis

BACKGROUND

The removal techniques for peritoneal dialysis (PD) catheters are open surgical dissection (OD) and the 'pull technique' (PT). The latter is limitedly used because of uncertainty about its feasibility and safety. This study aimed to compare the outcomes and complications between the two techniques.

METHODS

This retrospective study included patients who underwent PD catheter removal from January 2015 to January 2021 in four PD centres in China. The patients were grouped according to the different removal techniques and were followed up to observe the potential complications.

RESULTS

The demographic characteristics of patients in the PT (n = 68) and OD (n = 44) groups showed no significant difference. The indications for PD catheter removal were similar between the two groups, except for a higher frequency of peritonitis in the OD group (p = 0.010). In the PT group, the main complications were broken catheter (7.4%), superficial cuff infection (4.8%) and subcutaneous bleeding (4.8%). In the OD group, the main complications were death (9.1%) and subcutaneous bleeding (4.6%).

CONCLUSION

PT might be a safe and reliable technique for PD catheter removal compared to OD. Considering its simple and non-invasive nature, PT should be recommended as the alternative to OD in suitable PD patients.

Market Consolidation and Innovation in US Dialysis

While patients with end-stage kidney disease have benefited from innovations in clinical therapeutics and care delivery, these changes have been primarily incremental and have not fundamentally transformed care delivery. Dialysis markets are highly concentrated, which may impede innovation. Unique features of the dialysis industry that have contributed to consolidation can help to explain links between consolidation and innovation. We discuss these unique features and then provide a framework for considering the effects of consolidation on innovation in dialysis that focuses on the following economic considerations: (1) industry characteristics, composition, and stage of consolidation, (2) innovation characteristics and relative profitability, (3) the role of government regulation, and (4) innovation from smaller providers and new entrants. We present examples of how these considerations have influenced the adoption of alternative dialysis technologies such as peritoneal dialysis and erythropoietin-stimulating agents, and we discuss how consolidated markets can both help and hinder recent policy initiatives to transform dialysis care delivery. Only by considering these important drivers of consolidation, future efforts can be successful in transforming end-stage kidney disease care.

Pediatric hemodialysis access

Pediatric hemodialysis access is a demanding field. Procedures are infrequent, technically challenging, and associated with high complication and failure rates. Each procedure affects subsequent access and transplants sites. The choice is made easier and outcomes improved when access decisions are made by a multidisciplinary, pediatric, hemodialysis access team. This manuscript reviews the current literature and offers technical suggestions to improve outcomes.

Design and construction of three-dimensional physiologically-based vascular branching networks for respiratory assist devices

Microfluidic lab-on-a-chip devices are changing the way that in vitro diagnostics and drug development are conducted, based on the increased precision, miniaturization and efficiency of these systems relative to prior methods. However, the full potential of microfluidics as a platform for therapeutic medical devices such as extracorporeal organ support has not been realized, in part due to limitations in the ability to scale current designs and fabrication techniques toward clinically relevant rates of blood flow. Here we report on a method for designing and fabricating microfluidic devices supporting blood flow rates per layer greater than 10 mL min^-1 for respiratory support applications, leveraging advances in precision machining to generate fully three-dimensional physiologically-based branching microchannel networks. The ability of precision machining to create molds with rounded features and smoothly varying channel widths and depths distinguishes the geometry of the microchannel networks described here from all previous reports of microfluidic respiratory assist devices, regarding the ability to mimic vascular blood flow patterns. These devices have been assembled and tested in the laboratory using whole bovine or porcine blood, and in a porcine model to demonstrate efficient gas transfer, blood flow and pressure stability over periods of several hours. This new approach to fabricating and scaling microfluidic devices has the potential to address wide applications in critical care for end-stage organ failure and acute illnesses stemming from respiratory viral infections, traumatic injuries and sepsis.

The future of the artificial kidney

End-stage renal disease (ESRD) is increasing worldwide. In India, diabetes mellitus and hypertension are the leading causes of chronic kidney disease and ESRD. Hemodialysis is the most prevalent renal replacement therapy (RRT) in India. The ideal RRT must mimic the complex structure of the human kidney while maintaining the patient's quality of life. The quest for finding the ideal RRT, the “artificial kidney”– that can be replicated in the clinical setting and scaled-up across barriers– continues to this date. This review aims to outline the developments, the current status of the artificial kidney and explore its future potential.

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

In a groundbreaking meeting, leading global kidney disease organizations came together in the fall of 2020 as an International Home Dialysis Roundtable (IHDR) to address strategies to increase access to and uptake of home dialysis, both peritoneal dialysis and home hemodialysis. This challenge has become urgent in the wake of the coronavirus disease 2019 (COVID-19) pandemic, during which patients with advanced kidney disease, who are more susceptible to viral infections and severe complications, must be able to safely physically distance at home. To boost access to home dialysis on a global scale, IHDR members committed to collaborate, through the COVID-19 public health emergency and beyond, to promote uptake of home dialysis on a broad scale. Their commitments included increasing the reach and influence of key stakeholders with policy makers, building a cooperative of advocates and champions for home dialysis, working together to increase patient engagement and empowerment, and sharing intelligence about policy, education, and other programs so that such efforts can be operationalized globally. In the spirit of international cooperation, IHDR members agreed to document, amplify, and replicate established efforts shown to improve access to home dialysis and support new policies that facilitate access through procedures, innovation, and reimbursement.

Renal replacement treatment initiation with twice-weekly versus thrice-weekly haemodialysis in patients with incident dialysis-dependent kidney disease: rationale and design of the TWOPLUS pilot clinical trial

INTRODUCTION

The optimal haemodialysis (HD) prescription-frequency and dose-for patients with incident dialysis-dependent kidney disease (DDKD) and substantial residual kidney function (RKF)-that is, renal urea clearance ≥2 mL/min/1.73 m2 and urine volume ≥500 mL/day-is not known. The aim of the present study is to test the feasibility and safety of a simple, reliable prescription of incremental HD in patients with incident DDKD and RKF.

METHODS AND ANALYSIS

This parallel-group, open-label randomised pilot trial will enrol 50 patients from 14 outpatient dialysis units. Participants will be randomised (1:1) to receive twice-weekly HD with adjuvant pharmacological therapy for 6 weeks followed by thrice-weekly HD (incremental HD group) or outright thrice-weekly HD (standard HD group). Age ≥18 years, chronic kidney disease progressing to DDKD and urine output ≥500 mL/day are key inclusion criteria; patients with left ventricular ejection fraction <30% and acute kidney injury requiring dialysis will be excluded. Adjuvant pharmacological therapy (ie, effective diuretic regimen, patiromer and sodium bicarbonate) will complement twice-weekly HD. The primary feasibility end points are recruitment rate, adherence to the assigned HD regimen, adherence to serial timed urine collections and treatment contamination. Incidence rate of clinically significant volume overload and metabolic imbalances in the first 3 months after randomisation will be used to assess intervention safety.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Institutional Review Board of Wake Forest School of Medicine in North Carolina, USA. Patient recruitment began on 14 June 2019, was paused between 13 March 2020 and 31 May 2020 due to COVID-19 pandemic, resumed on 01 June 2020 and will last until the required sample size has been attained. Participants will be followed in usual care fashion for a minimum of 6 months from last individual enrolled. All regulations and measures of ethics and confidentiality are handled in accordance with the Declaration of Helsinki.

TRIAL REGISTRATION NUMBER

NCT03740048; Pre-results.

Sterile inflammation in the pathogenesis of maturation failure of arteriovenous fistula

Chronic kidney disease is a widespread terminal illness that afflicts millions of people across the world. Hemodialysis is the predominant therapeutic management strategy for kidney failure and involves the external filtration of metabolic waste within the circulation. This process requires an arteriovenous fistula (AVF) for vascular access. However, AVF maturation failures are significant obstacles in establishing long-term vascular access for hemodialysis. Appropriate stimulation, activation, and proliferation of smooth muscle cells, proper endothelial cell orientation, adequate structural changes in the ECM, and the release of anti-inflammatory markers are associated with maturation. AVFs often fail to mature due to inadequate tissue repair and remodeling, leading to neointimal hyperplasia lesions. The transdifferentiation of myofibroblasts and sterile inflammation are possibly involved in AVF maturation failures; however, limited data is available in this regard. The present article critically reviews the interplay of various damage-associated molecular patterns (DAMPs) and the downstream sterile inflammatory signaling with a focus on the NLRP3 inflammasome. Improved knowledge concerning AVF maturation pathways can be unveiled by investigating the novel DAMPs and the mediators of sterile inflammation in vascular remodeling that would open improved therapeutic opportunities in the management of AVF maturation failures and its associated complications.

Arteriovenous Fistula Versus Graft Access Strategy in Older Adults Receiving Hemodialysis: A Pilot Randomized Trial

Background

It is unclear whether surgical placement of an arteriovenous (AV) fistula (AVF) confers substantial clinical benefits over an AV graft (AVG) in older adults with end-stage kidney disease (ESKD). We report vascular access outcomes of a pilot clinical trial.

Study Design

Pilot randomized parallel-group open-label trial.

Setting & Participants

Patients 65 years and older with ESKD and no prior AV access receiving maintenance hemodialysis through a tunneled central venous catheter referred for AV access placement by their treating nephrologist.

Intervention

Participants were randomly assigned in a 1:1 ratio to surgical placement of an AVG or AVF.

Outcomes

Index AV access primary failure, successful cannulation, adjuvant interventions and infections.

Results

Of 122 older adults receiving hemodialysis and no prior AV access surgery, 24% died before (n = 18) or were too sick for (n = 11) referral for a permanent AV access. Of 46 eligible patients, 36 (78%) consented and were randomly assigned to AVG (n = 18) and AVF (n = 18) placement, of whom 13 (72%) and 16 (89%) underwent index AV access surgical placement, respectively. At a median follow-up of 321.0 days, primary AV access failure was noted in 31% in each group. The proportion of patients with successful cannulation was 62% (8 of 13) in the AVG and 50% (8 of 16) in the AVF group; median times to successful cannulation were 75.0 and 113.5 days, respectively. Endovascular procedures were recorded in 38% and 44%, and surgical reinterventions, in 23% and 25%, respectively. AV access infection was seen in 3 (23%) and 2 (13%) patients, respectively.

Limitations

Small sample size precludes statistical inference.

Conclusions

Almost one-quarter of older adults with incident ESKD and a central venous catheter as primary access were not referred for AV access placement due to medical reasons. Based on these limited results, there is little reason to favor either an AVF or AVG in this population until results from a larger randomized clinical trial become available.

Funding

Government funding to an author (Dr Murea is supported by National Institutes of Health∖National Institute on Aging grant 1R03 AG060178-01).

Trial Registration

NCT03545113.

The current and future landscape of dialysis

The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis — particularly haemodialysis and most notably in high-income countries (HICs) — the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization.

Dialysis is a life-saving therapy; however, costs of dialysis are high, access is inequitable and outcomes are inadequate. This Review describes the current landscape of dialysis therapy from an epidemiological, economic, ethical and patient-centred framework, and describes initiatives that are aimed at stimulating innovations in the field to one that supports high-quality, high-value care.

The global dialysis population is growing rapidly, especially in low-income and middle-income countries; however, worldwide, a substantial number of people lack access to kidney replacement therapy, and millions of people die of kidney failure each year, often without supportive care.

The costs of dialysis care are high and will likely continue to rise as a result of increased life expectancy and improved therapies for causes of kidney failure such as diabetes mellitus and cardiovascular disease.

Patients on dialysis continue to bear a high burden of disease, shortened life expectancy and report a high symptom burden and a low health-related quality of life.

Patient-focused research has identified fatigue, insomnia, cramps, depression, anxiety and frustration as key symptoms contributing to unsatisfactory outcomes for patients on dialysis.

Initiatives to transform dialysis outcomes for patients require both top-down efforts (that is, efforts that promote incentives based on systems level policy, regulations, macroeconomic and organizational changes) and bottom-up efforts (that is, patient-led and patient-centred advocacy efforts as well as efforts led by individual teams of innovators).

Patients, payors, regulators and health-care systems increasingly demand improved value in dialysis care, which can only come about through true patient-centred innovation that supports high-quality, high-value care.

Medium cut-off dialyzers in a large population of hemodialysis patients in Colombia: COREXH registry

Expanded hemodialysis (HDx) provides increased clearance of conventional and large middle molecules through innovative medium cutoff (MCO) membranes. However, there is a paucity of real-world data regarding the benefits and safety of HDx. This large observational study evaluated outcomes among patients in Colombia undergoing HDx at a extended dialysis clinical services provider. This was a prospective single cohort study of prevalent patients who were treated with HDx; baseline information was collected from the most recent data before patients were started on HDx. Patients were followed prospectively for 1 year for changes in serum albumin and other laboratory parameters compared with the baseline. Survival, hospitalization and safety were assessed from the start of HDx. A total of 1000 patients were invited to enroll; 992 patients met the inclusion criteria for data analysis and 638 patients completed the year of follow-up. Seventy-four (8%) patients died during 866 patient-years (PY) of follow-up; the mortality rate was 8.54 deaths/100 PY (95% confidence interval [CI], 6.8-10.7). There were 673 hospitalization events with a rate of 0.79 events/PY (95% CI, 0.73-0.85) with 6.91 hospital days/PY (95% CI, 6.74-7.09). The observed variability from baseline and maximum average change in mean serum albumin levels were -1.8% and -3.5%, respectively. No adverse events were related to the MCO membrane. HDx using an MCO membrane maintains stable serum albumin levels and is safe in terms of nonoccurrence of dialyzer related adverse events.

Randomized controlled trials for comparison of laparoscopic versus conventional open catheter placement in peritoneal dialysis patients: a meta-analysis

Background

The application of laparoscopic catheterization technology in peritoneal dialysis (PD) patients has recently increased. However, the advantages and disadvantages of laparoscopic versus conventional open PD catheter placement are still controversial. The aim of this meta-analysis is to assess the complications of catheterization in PD patients and to provide a reference for choosing a PD-catheter placement technique in the clinic.

Methods

We searched numerous databases, including Embase, PubMed, CNKI and the Cochrane Library, for published randomized controlled trials (RCTs).

Results

Eight relevant studies (n = 646) were included in the meta-analysis. The pooled results showed a lower incidence of catheter migration (OR: 0.42, 95% CI: 0.19 to 0.90, P: 0.03) and catheter removal (OR: 0.41, 95% CI: 0.21 to 0.79, P: 0.008) but a higher incidence of bleeding (OR: 3.25, 95% CI: 1.18 to 8.97, P: 0.02) with a laparoscopic approach than with a conventional approach. There was no significant difference in the incidence of omentum adhesion (OR: 0.32, 95% CI: 0.05 to 2.10, P: 0.24), hernia (OR: 0.38, 95% CI: 0.09 to 1.68, P: 0.20), leakage (OR: 0.69, 95% CI: 0.38 to 1.26, P: 0.23), intestinal obstruction (OR: 0.96, 95% CI: 0.48 to 1.91, P: 0.90) or perforation (OR: 0.95, 95% CI: 0.06 to 15.42, P: 0.97). The statistical analysis showed no significant difference in early (OR: 0.44, 95% CI: 0.15 to 1.33, P: 0.15), late (OR: 0.89, 95% CI: 0.41 to 1.90, P: 0.76) or total (OR: 0.68, 95% CI: 0.42 to 1.12, P: 0.13) peritonitis infections between the 2 groups, and there are no no significant difference in early (OR: 0.39, 95% CI: 0.06 to 2.36, P: 0.30), late (OR: 1.35, 95% CI: 0.78 to 2.33, P: 0.16) or total (OR: 1.20, 95% CI: 0.71 to 2.02, P: 0.17) tunnel or exit-site infections between the 2 groups.

Conclusion

Laparoscopic catheterization and conventional open catheter placement in PD patients have unique advantages, but laparoscopic PD catheterization may be superior to conventional open catheter placement. However, this conclusion needs to be confirmed with further large-sample-size, multi-centre, high-quality RCTs.

Comparison of the complications of open surgery versus laparoscopic technique in insertion of peritoneal dialysis catheter

Background:

Invention of peritoneal dialysis (PD) has opened new windows for patients under dialysis due to its fewer time requirement and being ambulatory in comparison to hemodialysis. Open surgery and laparoscopic technique have been utilized for peritoneal catheter embedding; however, data about the superior technique are controversial. This study aimed to assess the outcomes of open surgery versus laparoscopic technique and compare their complications in those with survival of over and less than a year in patients who need PD for the first time.

Materials and Methods:

This randomized clinical trial study was conducted on 121 cases admitted for PD. Patients were randomly divided into two groups undergoing either open or laparoscopic surgery for embedding PD catheter. Patients’ demographics, as well as PD function and complications, were followed for a 12-month duration and compared between the two groups.

Results:

Catheter survival for over 12 months occurred in 39 patients (65%) underwent laparoscopic surgery, and 45 (73.8%) patients underwent open surgery (P = 0.09). Complications, including catheter obstruction, leak, abdominal hernia, and peritonitis, were not statistically different between the two techniques over 12 months of survival (P > 0.05). Complications among the catheters with less than a year survival, including obstruction, leak, catheter displacement, hernia, and peritonitis, were not significantly different comparing open surgery with laparoscopic technique (P > 0.05).

Conclusion:

Considering complications, PD catheter implantation through laparoscopic surgery was not statistically different from open surgery, neither for those with less than 12 months of survival nor for those with over a year.

Think before you leap: cutaneous hypersensitivity to polytetrafluoroethylene arteriovenous graft masquerading as infection

Polytetrafluoroethylene (PTFE) graft is a synthetic graft commonly used in chronic haemodialysis patients. Expected complications of synthetic grafts include infection, thrombosis, oedema and pain. PTFE is a non-textile graft that is chemically inert, electronegative and hydrophobic. Due to their chemical properties, PTFE grafts have lower risks of these adversities. We present a patient with a rare case of cutaneous hypersensitivity to a PTFE graft.

Blood-borne viral infections in pediatric hemodialysis

Hemodialysis patients are at increased risk for development of blood-borne viral infections. Human immunodeficiency virus (HIV), a once fatal infection, has become treatable, but continues to be associated with increased mortality. Hepatitis B and C viral infections can lead to acute and chronic hepatitis, cirrhosis, or hepatocellular carcinoma. Young children and immunocompromised patients are more likely to develop chronic disease leading to increased morbidity and mortality, as compared to the healthy population. The hemodialysis population is at increased risk of blood-borne viral infections as compared to the general population due to multiple factors. Here we review risk factors of blood-borne viral infections, strategies for prevention, and approach to therapy in the pediatric hemodialysis population.

Achieving a person-centered approach to dialysis discontinuation: An historical perspective

In this essay, we describe the evolution of attitudes toward dialysis discontinuation in historical context, beginning with the birth of outpatient dialysis in the 1960s and continuing through the present. From the start, attitudes toward dialysis discontinuation have reflected the clinical context in which dialysis is initiated. In the 1960s and 1970s, dialysis was only available to select patients and concerns about distributive justice weighed heavily. Because there was strong enthusiasm for new technology and dialysis was regarded as a precious resource not to be wasted, stopping treatment had negative moral connotations and was generally viewed as something to be discouraged. More recently, dialysis has become the default treatment for advanced kidney disease in the United States, leading to concerns about overtreatment and whether patients' values, goals, and preferences are sufficiently integrated into treatment decisions. Despite the developments in palliative nephrology over the past 20 years, dialysis discontinuation remains a conundrum for patients, families, and professionals. While contemporary clinical practice guidelines support a person-centered approach toward stopping dialysis treatments, this often occurs in a crisis when all treatment options have been exhausted. Relatively little is known about the impact of dialysis discontinuation on the experiences of patients and families and there is a paucity of high-quality person-centered evidence to guide practice in this area. Clinicians need better insights into decision-making, symptom burden, and other palliative outcomes that patients might expect when they discontinue dialysis treatments to better support decision-making in this area.

Precision Medicine in the Transition to Dialysis and Personalized Renal Replacement Therapy

Launched in 2016, the overarching goal of the Precision Medicine Initiative is to promote a personalized approach to disease management that takes into account an individual's unique underlying biology and genetics, lifestyle, and environment, in lieu of a one-size-fits-all model. The concept of precision medicine is pervasive across many areas of nephrology and has been particularly relevant to the care of advanced chronic kidney disease patients transitioning to end-stage kidney disease (ESKD). Given many uncertainties surrounding the optimal transition of incident ESKD patients to dialysis and transplantation, as well as the high mortality rates observed during this delicate transition period, there is a pressing urgency for implementing precision medicine in the management of this population. Although the traditional paradigm has been to commence incident hemodialysis patients on a 3 times/week treatment regimen, largely driven by adequacy targets, there has been growing recognition that alternative treatment regimens (ie, incremental hemodialysis) may be preferred among certain subpopulations when taking into consideration factors such as patients' residual kidney function, volume status fluctuations, symptoms, and preferences. In this review, we examine the origins of current practices in how dialysis is initiated among incident ESKD patients; incremental dialysis therapy as a dynamic and patient-centric approach that is tailored to patients' unique characteristics; recent data on the incremental hemodialysis regimen and outcomes; and future research directions using a precision nephrology approach to ESKD management with the potential to develop novel approaches, tools, and collaborative efforts to improve the health, well-being, and survival of this population.

Decision-making experiences of patients with end-stage kidney disease (ESKD) regarding treatment in Ghana: a qualitative study

BACKGROUND

This is the first qualitative study to explore patient decision-making regarding end-stage kidney disease (ESKD) treatment in sub-Saharan Africa. The study addresses an important gap in the literature concerning choice and decision-making in an international context.

METHODS

The study employed a qualitative research design, using grounded theory methodology. In-depth interviews were conducted with twenty-two adult patients with ESKD in 3 clinical settings in Ghana. Data analysis involved coding and a constant comparative approach to generate key themes. Ethical approval was gained from relevant ethics committees both in Ghana and the United Kingdom.

RESULTS

Four main factors (personal, financial, healthcare system, and support network) were identified to influence patient decision-making regarding ESKD treatment in Ghana. Treatment was initiated for various reasons, including, initially, the urgent need to avoid premature death. Many approached their condition hoping for a cure and did not always understand the chronic nature of their condition. Financial and geographical inaccessibility of renal replacement therapy (RRT), as well as a relative lack of biomedical treatment choices, made decision making daunting for the individual with ESKD in Ghana. The subject of death or conservative management was not openly discussed. Rather patients did everything possible to seek alternative forms of treatment, including the simultaneous use of other non-RRT and traditional or faith-based healing approaches.

CONCLUSIONS

Whilst similarities exist, this study illuminates stark cultural and contextual differences which make decision-making on ESKD treatment a daunting experience for the individual with ESKD in Ghana - as compared to those in high-income countries. The challenges associated with ESKD management in Ghana calls for meticulous efforts at primary prevention of the disease, including interventions directed at effective management of diabetes mellitus, hypertension and other chronic kidney disease (CKD) precursor conditions. Enhancing information provision would promote informed decision making, particularly within the initial stages of patient decision-making.

Non-medical facilitators and barriers towards accessing haemodialysis services: an exploration of ethical challenges

BACKGROUND

Like most of the sub-Saharan countries, Tanzania faces significant increase in the number of patients diagnosed with an end-stage renal disease (ESRD) among which only a few manage to receive chronic haemodialysis services (CHD). Yet little is known about the non-medical facilitators and barriers towards accessing these services and the associated ethical challenges.

METHODS

A phenomenological study design which employed a qualitative approach was used. The study was conducted at the dialysis unit harboured within Muhimbili National Hospital. Data were collected from purposively sampled health care providers and ESRD patients by using in-depth interviews. Text data obtained were analysed based on inductive and deductive content analysis methods to formulate major themes.

RESULTS

Fourteen key informants were interviewed including nephrologists, renal nurses, social workers, nutritionists and ESRD patients. Three major themes were formulated: a) non-medical facilitators towards accessing CHD services which enshrines two sub-themes (membership to health insurance scheme and family support), (b) non-medical barriers towards accessing CHD services which enshrines four sub-themes (affordability of treatment costs, geographical accessibility, availability of CHD resources and acceptability of treatment procedures) and lastly (c) ethical challenges associated with accessing CHD services which also enshrines three sub-themes (dual role of health care providers, patients autonomy in decision making, and treatment disparity).

CONCLUSION

Non-medical facilitators to access CHD benefits few patients whereas non-medical barriers leave many ESRD patients untreated or partially treated. On the other hand, ethical challenges like treatment inequality are quickly gaining momentum. There is a need for guideline highlighting importance, position, and limitation of non-medical factors in the delivery of CHD services in Tanzania and other developing countries.

A History of Leadership in Dialysis: Perspectives From Seasoned Leaders

The history of chronic dialysis in the United States highlights the impact nephrology leaders have on improving kidney disease care. Belding Scribner and his Seattle team transformed end-stage renal disease from a fatal illness to a treatable condition with use of the first successful Scribner shunt in 1960. Advances in dialysis machines emerged from Les Babb and Richard Drake finding ways to treat more patients. Innovative nephrology leaders foster incremental change leading to the technically complex, life-sustaining treatments that are widely available to end-stage renal disease patients today. The Nephrology Oral History Project consists of interviews with patient, nurse, and nephrologist pioneers who have witnessed and contributed to these advancements in kidney disease care. This article includes Nephrology Oral History Project excerpts illustrating leadership contributions to dialysis machines, peritoneal dialysis catheters, and treatment best practices. In addition to individual contributions, improvements in treatment also come from patient and provider organizations leading the way and collectively advocating for change. Nephrology leaders continue to play a crucial role in improving dialysis outcomes and quality of life.

Intensive hemodialysis-keeping the faith

In this issue of Kidney International, Tennankore et al. present a robust observational study that evaluates different submodalities of intensive hemodialysis. Their paper addresses a critical question, but more importantly illustrates the limits of statistical adjustment when there is major crossover between groups and important center effect. Intensive hemodialysis remains a strong contender to meet the needs of modern patients, and-no matter how challenging-well-deserving of further definitive study in clinical trials.

Randomized Controlled Trial Comparing Open Versus Laparoscopic Placement of a Peritoneal Dialysis Catheter and Outcomes: The CAPD I Trial

OBJECTIVE

To determine the best operation technique, open versus laparoscopic, for insertion of a peritoneal dialysis (PD) catheter with regard to clinical success. Clinical success was defined as an adequate function of the catheter 2 - 4 weeks after insertion.

METHODS

All patients with end-stage renal disease who were suitable for PD and gave informed consent were randomized for either open surgery or laparoscopic surgery. A previous laparotomy was not considered an exclusion criterion. Laparoscopic placement had the advantage of pre-peritoneal tunneling, the possibility for adhesiolysis, and placement of the catheter under direct vision. Catheter fixation techniques, omentopexy, or other adjunct procedures were not performed. Other measured parameters were in-hospital morbidity and mortality and post-operative infections.

RESULTS

Between 2010 and 2016, 95 patients were randomized to this study protocol. After exclusion of 5 patients for various reasons, 44 patients received an open procedure and 46 patients a laparoscopic procedure. Gender, age, body mass index (BMI), hypertension, current hemodialysis, severe heart failure, and previous an abdominal operation were not significantly different between the groups. However, in the open surgery group, fewer patients had a previous median laparotomy compared with the laparoscopic group (6 vs 16 patients; p = 0.027). There was no statistically significant difference in mean operation time (36 ± 24 vs 38 ± 15 minutes) and hospital stay (2.1 ± 2.7 vs 3.1 ± 7.3 days) between the groups. In the open surgery group 77% of the patients had an adequate functioning catheter 2 - 4 weeks after insertion compared with 70% of patients in the laparoscopic group (p = not significant [NS]). In the open surgery group there was 1 post-operative death (2%) compared with none in the laparoscopic group (p = NS). The morbidity in both groups was low and not significantly different. In the open surgery group, 2 patients had an exit-site infection and 1 patient had a paramedian wound infection. In the laparoscopic group, 1 patient had a transient cardiac event, 1 patient had intraabdominal bleeding requiring reoperation, and 1 patient had fluid leakage that could be managed conservatively. The survival curve demonstrated a good long-term function of PD.

CONCLUSION

This randomized controlled trial (RCT) comparing open vs laparoscopic placement of PD catheters demonstrates equal clinical success rates between the 2 techniques. Advanced laparoscopic techniques such as catheter fixation techniques and omentopexy might further improve clinical outcome.

What the non-nephrologist needs to know about dialysis

The End-Stage Renal Disease (ESRD) program now serves approximately 675,000 individuals in the United States at a cost of $26.1 billion to the Medicare system. Given the size of this population, healthcare providers from all disciplines will deliver care to patients on dialysis. Mortality remains high among patients on chronic dialysis, with 42.3% surviving 5 years. As this is a vulnerable population, it is important in the care of ESRD patients that non-nephrologists have a working knowledge of issues germane to dialysis. This review examines the physiology, mechanics, complications, and care delivery concerns of kidney dialysis modalities relevant to the non-nephrologist. The majority of patients receive in-center hemodialysis thrice weekly, with a small proportion on home-based therapies such as peritoneal dialysis or home hemodialysis. Inpatients may undergo hemodialysis or peritoneal dialysis, and in critically ill patients, continuous renal replacement therapies are utilized. Practical aspects of each of these modalities are discussed.

Dialysis in the 1960s and the First Hollow Fiber Dialyzer

The history of the development of the first hollow fiber dialyzer as part of a federally funded project at Dow Chemical in Walnut Creek, California is interesting, as this project represented an initial step in the technical advances that dialysis has experienced over the last 40 years. The project, important in its own right, was revolutionary; the predominant design of dialyzers in use at the time employed either flat membranes or collapsed large cellulose tubing. The hollow fiber dialyzer project, in addition to being technologically important, brought together several individuals who over the intervening four decades have launched careers and collaborations that have had a profound impact, as well as resulting in major advances and contributions to a greater understanding of the dialysis process and adequate delivery of care.

Children tolerate intradialytic oral nutrition

BACKGROUND

People undergoing haemodialysis (HD) often have poor nutrition, which in turn can contribute to worse outcomes. Inadequate nutrition has a particularly deleterious effect on growth and neurocognitive development, as well as mortality, in children and adolescents. Nutritional supplementation can improve outcomes but can be difficult to administer.

OBJECTIVE

Determine the tolerability of intradialytic oral nutrition in children and adolescents.

DESIGN

A cross-sectional quality improvement study in an outpatient paediatric HD unit. Intervention was intradialytic oral nutritional supplementation provided as protein bars and/or meals.

SUBJECTS

Children and adolescents undergoing outpatient HD who were able to participate in surveys and eat by mouth.

MEASUREMENTS

Adverse effects and symptoms on nurse- and patient-reported surveys, respectively. Relationships between the predictor variables and the outcomes were assessed using generalised estimating equations.

RESULTS

The majority of children felt better after eating on dialysis (72%) with no adverse effects (80%). On unadjusted analyses and confirmed with generalised estimating equation modelling, children who reported being hungry felt better after eating on dialysis, despite being more likely to have adverse effects.

CONCLUSION

The study demonstrates that our children and adolescents feel better after eating on HD with minimal adverse effects. The finding that hungry patients are more likely to feel better despite having a higher likelihood of an adverse effect demonstrates the tolerability of eating on HD. Intradialytic oral nutrition could be a safe and well-tolerated opportunity to provide supplemental nutrition to paediatric HD patients and improve outcomes.

Effectiveness of pay-for-performance for chronic kidney disease patients on hemodialysis: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to assess the evidence on the effectiveness of implementation of a pay-for-performance program on clinical outcomes in the adult chronic kidney disease (CKD) patient receiving hemodialysis.The review question is: What is the effectiveness of implementation of a pay-for-performance program on clinical outcomes in the adult CKD patient receiving hemodialysis, as compared to the period immediately before implementation of the program?More specifically, the objectives are to identify.

Incremental and infrequent hemodialysis: a new paradigm for both dialysis initiation and conservative management

Registry or national dialysis data show that a sizeable proportion of contemporary dialysis patients have substantial levels of residual kidney function especially upon transitioning to dialysis therapy. However, among incident hemodialysis patients, the prevailing paradigm has been to initiate "full-dose" triweekly treatment schedules irrespective of native kidney function in most developed countries. Recognizing the benefits of residual kidney function upon the health and survival of dialysis patients, there has been growing interest in incremental hemodialysis, in which dialysis frequency and dose are tailored according to the degree of patients' residual kidney function. Infrequent hemodialysis can also be used for those who prefer a more conservative approach in managing uremia. Clinical practice guidelines support the use of twice-weekly hemodialysis among patients with adequate residual kidney function (renal urea clearance >3 mL/min/1.73 m2), and a growing body of evidence indicates that incremental hemodialysis is associated with better preservation of residual kidney function without adversely impacting survival. Nonetheless, incremental hemodialysis remains an underutilized approach in this population. In this review, we will discuss the history of the twice- versus triweekly hemodialysis schedules; current clinical practice guidelines regarding infrequent hemodialysis; emerging data on incremental treatment regimens and outcomes; and guidelines for the practical implementation of incremental and infrequent hemodialysis in the clinical setting.

Treatment of End-stage Kidney Failure without Renal Replacement Therapy

For the majority of patients with end-stage kidney failure (ESKF) replacement of excretory renal function by dialysis or transplantation (RRT) can extend life and alleviate symptoms. Historically, the availability of RRT has been insufficient and this remains the case for much of the world. However, RRT is now widely available in healthcare systems of higher income countries. Increasing numbers of elderly patients are developing ESKF. RRT in this population is largely by dialysis, comorbidity is high and life expectancy short. Evidence of effectiveness coupled with the burden of treatment among these individuals has raised concerns that health services in high-income countries may have moved from an era of unmet need into one of potential over-treatment. Alongside the requirement to make treatment more patient-centered, this has driven the development of comprehensive conservative care as an alternative approach for older comorbid individuals with ESKF, with the potential for acceptable symptom control and reduced treatment burden. This paper provides a largely UK-perspective on treating ESKF without RRT. Emphasis is on the need for high-quality evidence to inform treatment decisions. Complexities of defining, delivering and improving treatment of ESKF without dialysis care are explored. Quantitative and qualitative evidence are summarized and the relationship with palliative and terminal care examined. A framework is suggested for classifying management of ESKF and recommendations made to improve delivery of nondialysis care in the future. For patients with a poor prognosis, such treatment may not result in significantly different survival or quality of life when compared with dialysis. There is a key need to generate the best possible evidence of person-centered health outcomes associated with the various treatment options for ESKF and to present this to patients in a balanced, personalized way that allows them to make the treatment decision most appropriate for them.

Personal Support Worker (PSW)-supported home hemodialysis: A paradigm shift

INTRODUCTION

Despite improving clinical outcomes associated with the use of home hemodialysis (HD), its utilization is low in most countries. The inability or unwillingness of patients and their families to participate in their own treatment is one of the most important barriers to the adoption of home HD.

METHODS

We hypothesized that paid helper-delivered home HD supported by public funds would be successful and welcomed by patients and be delivered at an affordable cost. We conducted a pilot project to dialyze six patients at home using Personal Support Workers (PSW) and resolve regulatory, organizational and financial constraints.

FINDINGS

cWe provided publically-funded PSW-supported home HD to six patients. We describe the administrative structure of the pilot project allowing scalability and turnkey operation in the province of Ontario. Regulatory and insurance concerns were resolved and patients and staff were enthusiastic. The projected total dialysis cost, when economies of scale are met, are expected to be lower than the cost of in-center HD.

DISCUSSION

A second phase of the project is currently under way including 8 hospitals and 67 patients. If equally successful, it may have significant implications for the delivery of care for End Stage Renal Disease in Ontario and similar jurisdictions. It promises to increase the utilization of home dialysis possibly at a lower cost than in-center HD. This would be particularly important in providing dialysis in underserviced and geographically hard to access areas.

Ultrafiltration Rate Thresholds in Maintenance Hemodialysis: An NKF-KDOQI Controversies Report

High hemodialysis ultrafiltration rate (UFR) is increasingly recognized as an important and modifiable risk factor for mortality among patients receiving maintenance hemodialysis. Recently, the Kidney Care Quality Alliance (KCQA) developed a UFR measure to assess dialysis unit care quality. The UFR measure was defined as UFR≥13mL/kg/h for patients with dialysis session length less than 240 minutes and was endorsed by the National Quality Forum as a quality measure in December 2015. Despite this, implementation of a UFR threshold remains controversial. In this NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) Controversies Report, we discuss the concept of the UFR, which is governed by patients' interdialytic weight gain, body weight, and dialysis treatment time. We also examine the potential benefits and pitfalls of adopting a UFR threshold as a clinical performance measure and outline several aspects of UFR thresholds that require further research.

Survival by Dialysis Modality-Who Cares?

In light of the recent emphasis on patient-centered outcomes and quality of life for patients with kidney disease, we contend that the nephrology community should no longer fund, perform, or publish studies that compare survival by dialysis modality. These studies have become redundant; they are methodologically limited, unhelpful in practice, and therefore a waste of resources. More than two decades of these publications show similar survival between patients undergoing peritoneal dialysis and those receiving thrice-weekly conventional hemodialysis, with differences only for specific subgroups. In clinical practice, modality choice should be individualized with the aim of maximizing quality of life, patient-reported outcomes, and achieving patient-centered goals. Expected survival is often irrelevant to modality choice. Even for the younger and fitter home hemodialysis population, quality of life, not just duration of survival, is a major priority. On the other hand, increasing evidence suggests that patients with ESRD continue to experience poor quality of life because of high symptom burden, unsolved clinical problems, and unmet needs. Patients care more about how they will live instead of how long. It is our responsibility to align our research with their needs. Only by doing so can we meet the challenges of ESRD patient care in the coming decades.