Predictors of Health Deterioration Among Older Adults After 12 Months of Dialysis Therapy: A Longitudinal Cohort Study From New Zealand

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.

Valuing indigenous quality of life: A review of preference-based quality of life instruments and elicitation techniques with global older indigenous populations

Indigenous perspectives of quality of life (QoL) are different to that of non-Indigenous populations. Determining how to identify and value what is important to QoL for people from diverse cultural backgrounds is crucial for assessing effective outcomes for quality assessment and health economic evaluation to guide evidence-based decision making. This is particularly important for older Indigenous people who have complex care and support needs within health and aged-care systems. This scoping review aims to assess the existing literature in this field by firstly identifying preference based instruments that have been applied with older Indigenous peoples and secondly, exploring the extent to which existing preference based instruments applied with older Indigenous peoples encompass older Indigenous peoples QoL perspectives in their design and application. The inclusion criteria for the review were studies using preference based QoL instruments with an Indigenous population where the cohort was aged 50 years or over. This resulted in the critical analysis of 12 studies. The review identified that preference based QoL instruments have rarely been applied to date with older Indigenous populations with most instruments found to be designed for non-Indigenous adults. Typically, instruments have not incorporated Indigenous worldviews of QoL into either the content of the descriptive system or the elicitation techniques and corresponding value sets generated. To encapsulate Indigenous cultural perspectives accurately in economic evaluation, further research is required as to how QoL domains in preference based instruments for Indigenous peoples can be reflective of Indigenous perspectives. It is imperative that the QoL preferences of older Indigenous peoples are adequately captured within preference based QoL instruments applied with this population.

Health-Related Quality of Life and Disability Among Older New Zealanders With Kidney Failure: A Prospective Study

Background:

Disability is prevalent in individuals with kidney failure and can contribute to significantly reduced quality of life and survival. In older individuals with kidney failure, disability can be caused by a combination of factors, including issues directly related to their kidney disease and/or treatment, including weakness, low energy, and low activity. Few studies have investigated health-related quality of life (HRQoL) as a possible predictor of disability among older individuals experiencing kidney failure.

Objective:

This study aimed to determine if patient-reported HRQoL, and/or other factors at baseline, predicts disability in people with kidney failure, aged ≥65 years, after 12 months of follow-up.

Design:

The DOS65+ study was an accelerated longitudinal cohort design comprising of both cross-sectional and longitudinal components. Participants were eligible if they were aged ≥65 years, had chronic kidney disease stage 5G (CKD 5G) (estimated glomerular filtration rate (eGFR) <15 ml/min/1.73 m²), and had: commenced kidney replacement education, or were on an active conservative pathway, or were newly incident dialysis patients commencing dialysis therapy or prevalent on dialysis.

Setting:

Three New Zealand District Health Board (DHB) nephrology units (Counties Manukau, Hawke’s Bay, and Southern DHB) were involved in the study.

Participants:

Participants were eligible if they were aged ≥65 years, had CKD 5G (eGFR <15 ml/min/1.73 m²), and had: commenced kidney replacement education, or were on an active conservative pathway, or were newly incident dialysis patients commencing dialysis therapy or prevalent on dialysis.

Measurements:

Disability and HRQoL were measured by EQ-5D-3L, a WHO Disability Assessment Schedule (WHODAS) 2.0.

Methods:

Baseline and 12-month data from our longitudinal dialysis outcomes in older New Zealanders’ study were analyzed to determine if HRQoL at baseline predicted disability outcomes 12 months later.

Results:

Of the 223 participants at baseline, 157 participants completed a follow-up interview 12 months later. Individuals with “considerable disability” at baseline had a significantly (86%) higher risk of experiencing “considerable disability” at 12 months compared with those with “lesser/no disability” at baseline. Two thirds of those with  ≥3 comorbidities were experiencing “considerable disability.” In addition, those with problems with EQ-5D-3L self-care, EQ-5D-3L usual activities, and EQ-5D-3L anxiety/depression reported higher rates of disability.

Limitations:

Selection bias is likely to have been an issue in this study as participants were excluded from the follow-up interview if they had an intercurrent illness requiring hospitalization within 2 weeks of the survey interview or if the treating nephrologist judged that the individual’s ability to take part was significantly impaired. Sample size meant there were a limited number of explanatory/confounding variables that could be investigated in the multivariable model.

Conclusions:

EQ-5D-3L mobility and self-care may be useful in predicting subsequent disability for individuals with CKD 5G. Although individuals with kidney failure often experience disability, previous studies have not clearly identified HRQoL or disability as predictors of later disability for individuals with kidney failure. Therefore, we would recommend the assessment of mobility and self-care, in conjunction with existing disabilities in the clinical review and pre-dialysis education of individuals with kidney failure as they approach the need for kidney replacement therapy.

Trial registration: the Australian and New Zealand clinical trials registry: ACTRN12611000024943.

Interventions to improve the well-being of family caregivers of patients on hemodialysis and peritoneal dialysis: a systematic review

Background

The family caregivers of patients on hemodialysis (HD) and peritoneal dialysis (PD) typically experience higher burden than the general population because of the nature of tasks these caregivers need to carry out as a part of homecare. This fact influences both the caregivers’ quality of life and the quality of their care toward the patient. Thus, this study aimed to review the effectiveness and limitations of interventions in improving the well-being of family caregivers of patients on HD and PD.

Methodology

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Cochrane Handbook for Systematic Reviews of Interventions (version 5.1.0). The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Embase, MEDLINE, VHL Regional Portal, Scopus, and Web of Science databases were searched queried for randomized controlled trials that developed interventions aimed at improving the well-being of family caregivers of patients undergoing HD and/or PD from 2009 to 2020. The study protocol was registered at the International Prospective Register of Systematic Reviews (registration no. CRD42020151161).

Results

Six studies met the inclusion criteria, all of which addressed caregivers of patients undergoing HD. All interventions reported in the included studies were carried out in group sessions, which addressed topics such as patient assistance and care, treatment complications, coping strategies, caregiver self-care practices, problem solving, and self-efficacy. The studies found significant improvement in the caregiver’s well-being.

Conclusions

Group session interventions are effective in improving the well-being of family caregivers of patients undergoing HD. In regard to PD, there is insufficient evidence to make recommendations for caregivers of patients with this treatment.

Predictors of Health Deterioration Among Older New Zealanders Undergoing Dialysis: A Three-Year Accelerated Longitudinal Cohort Study

Background:

Patient involvement in dialysis decision-making is crucial, yet little is known about patient-reported outcomes over time on dialysis.

Objective:

To examine health-related outcomes over 24 and 36 months in an older cohort of dialysis patients.

Design:

The “Dialysis outcomes in those aged ≥65 years study” is a prospective longitudinal cohort study of New Zealanders with kidney failure.

Setting:

Three New Zealand nephrology units.

Patients:

Kidney failure (dialysis and predialysis) patients aged 65 or above. We have previously described outcomes after 12 months of dialysis therapy relative to baseline.

Measurements:

Patient-reported social and health factors using the SF-36, EQ-5D, and Kidney Symptom Score questionnaires.

Methods:

This article describes and compares characteristics of 120 older kidney failure patients according to whether they report “Same/better” or “Worse” health 24 and 36 months later, and identifies predictors of “worse health.” Modified Poisson regression modeling estimated relative risks (RR) of worse health.

Results:

Of 120 patients at 12 months, 47.5% had worse health or had died by 24 months. Of those surviving at 24 months (n = 80), 40% had “Worse health” or had died at 36 months. Variables independently associated with reduced risk of “Worse health” (24 months) were as follows: Māori ethnicity (RR = 0.44; 95% CI = 0.26-0.75), Pacific ethnicity (RR = 0.39; 95% CI = 0.33-0.46); greater social satisfaction (RR = 0.57; 95% CI = 0.46-0.7). Variables associated with an increased risk of “Worse health” were as follows: problems with usual activities (RR = 1.32; 95% CI = 1.04-1.37); pain or discomfort (RR = 1.48; 95% CI = 1.34, 1.63). At 36 months, lack of sense of community (RR = 1.41; 95% CI = 1.18-1.69), 2 or more comorbidities (RR = 1.21; 95% CI = 1.13-1.29), and problems with poor health (RR = 1.47; 95% CI = 1.41-1.54) were associated with “Worse health.”

Limitations:

Participant numbers restricted the number of variables able to be included in the multivariable model, and hence there may have been insufficient power to detect certain associations.

Conclusions:

In this study, the majority of older dialyzing patients report “Same/better health” at 24 and 36 months. Māori and Pacific people report better outcomes on dialysis. Social and/or clinical interventions aimed at improving social satisfaction, sense of community, and help with usual activities may impact favorably on the experiences for older dialysis patients.

Trial registration:

Australian and New Zealand clinical trials registry: ACTRN12611000024943.

Comparison of physical activity and quality of life in home haemodialysis (HHD) patients versus conventional in-centre haemodialysis (ICHD) patients: the observational, longitudinal, prospective, international, multicentric SeCoIA study protocol

BACKGROUND

Home haemodialysis (HHD), has shown improved clinical outcomes, as well as a better quality of life, compared to conventional in-centre haemodialysis (ICHD) but still has a global low prevalence among end-stage renal disease patients. Haemodialysis (HD) patients tend to be sedentary but only few studies, mainly in North American ICHD patients, have evaluated the level of activity in HD patients.

METHODS

SeCoIA is an observational, longitudinal, prospective, international, multicentric, study, conducted in metropolitan France and Belgium. The main objective of the study is to quantify the physical activity measured by the total daily number of steps, in HHD patients compared to ICHD patients. The SeCoIA study will include 80 HHD patients and 80 ICHD patients,. Secondary objectives will be to characterize the HHD population and to confirm HHD efficiency on clinical parameters, as well as quality of life (QoL), in current practice. Physical activity will be measured by a 3-axis accelerometer. Accelerometers have been shown to provide accurate information, on both physical activity and sedentary behaviour. Patients will be instructed to wear the device and complete a patient diary 7 consecutive days after inclusion and the first week of each month for 12 months. Decision to undergo HDD or ICHD is independent of the study and follow-up frequency remains at the discretion of the physician/centre. QoL and quality of sleep will be respectively assessed by the Kidney Disease Quality of Life 1.2 (KDQOL™) and the Pittsburg Sleep Quality index (PSQI) questionnaires at inclusion, 6- and 12-month visits. Patients presenting a restless leg syndrome (RLS) will also complete the International Restless Legs Syndrome rating scale (IRLS) questionnaire.

DISCUSSION

The SeCoIA study will be the first large cohort study (160 patients) evaluating physical activity, objectively measured with a 3-axis accelerometer, in HHD versus ICHD patients. The present study will also include a comparison of QoL with a focus on RLS between HHD and ICHD. It is anticipated that HHD patients will have an improved physical activity and QoL which should encourage physicians to further promote HHD.

TRIAL REGISTRATION

Clinical trial NCT03737578 study registered on November 9, 2018 (Retrospectively registered).

Quality of life in older adults receiving hemodialysis: a qualitative study

PURPOSE

Patient priorities for quality of life change with age. We conducted a qualitative study to identify quality of life themes of importance to older adults receiving dialysis and the extent to which these are represented in existing quality of life instruments.

METHODS

We conducted semi-structured interviews with 12 adults aged ≥ 75 years receiving hemodialysis to elicit participant perspectives on what matters most to them in life. We used framework analysis methodology to process interview transcripts (coding, charting, and mapping), identify major themes, and compare these themes by participant frailty status. We examined for representation of our study's subthemes in the Kidney Disease Quality of Life (KDQOL-36) and the World Health Organization Quality of Life for Older Adults (WHOQOL-OLD) instruments.

RESULTS

Among the 12 participants, average age was 81 (4.2) years, 7 African-American, 6 women, and 6 met frailty criteria. We identified two major quality of life themes: (1) having physical well-being (subthemes: being able to do things independently, having symptom control, maintaining physical health, and being alive) and (2) having social support (subthemes: having practical social support, emotional social support, and socialization). Perspectives on the subthemes often varied by frailty status. For example, being alive meant surviving from day-to-day for frail participants, but included a desire for new life experiences for non-frail participants. The majority of the subthemes did not correspond with domains in the KDQOL-36 and WHOQOL-OLD instruments.

CONCLUSION

Novel instruments are likely needed to elicit the dominant themes of having physical well-being and having social support identified by older adults receiving dialysis.

A Review of the Development and Application of Generic Preference-Based Instruments with the Older Population

Older people (aged 65 years and over) are the fastest growing age cohort in the majority of developed countries, and the proportion of individuals defined as the oldest old (aged 80 years and over) living with physical frailty and cognitive impairment is rising. These population changes put increasing pressure on health and aged care services, thus it is important to assess the cost effectiveness of interventions targeted for older people across health and aged care sectors to identify interventions with the strongest capacity to enhance older peoples' quality of life and provide value for money. Cost-utility analysis (CUA) is a form of economic evaluation that typically uses preference-based instruments to measure and value health-related quality of life for the calculation of quality-adjusted life-years (QALYS) to enable comparisons of the cost effectiveness of different interventions. A variety of generic preference-based instruments have been used to measure older people's quality of life, including the Adult Social Care Outcomes Toolkit (ASCOT); Health Utility Index Mark 2 (HUI2); Health Utility Index Mark 3 (HUI3); Short-Form-6 Dimensions (SF-6D); Assessment of Quality of Life-6 dimensions (AQoL-6D); Assessment of Quality of Life-8 dimensions (AQoL-8D); Quality of Wellbeing Scale-Self-Administered (QWB-SA); 15 Dimensions (15D); EuroQol-5 dimensions (EQ-5D); and an older person specific preference-based instrument-the Investigating Choice Experiments Capability Measure for older people (ICECAP-O). This article reviews the development and application of these instruments within the older population and discusses the issues surrounding their use with this population. Areas for further research relating to the development and application of generic preference-based instruments with populations of older people are also highlighted.

Artificial Intelligence Prediction Model for the Cost and Mortality of Renal Replacement Therapy in Aged and Super-Aged Populations in Taiwan

BACKGROUND

Prognosis of the aged population requiring maintenance dialysis has been reportedly poor. We aimed to develop prediction models for one-year cost and one-year mortality in aged individuals requiring dialysis to assist decision-making for deciding whether aged people should receive dialysis or not.

METHODS

We used data from the National Health Insurance Research Database (NHIRD). We identified patients first enrolled in the NHIRD from 2000-2011 for end-stage renal disease (ESRD) who underwent regular dialysis. A total of 48,153 Patients with ESRD aged ≥65 years with complete age and sex information were included in the ESRD cohort. The total medical cost per patient (measured in US dollars) within one year after ESRD diagnosis was our study's main outcome variable. We were also concerned with mortality as another outcome. In this study, we compared the performance of the random forest prediction model and of the artificial neural network prediction model for predicting patient cost and mortality.

RESULTS

In the cost regression model, the random forest model outperforms the artificial neural network according to the mean squared error and mean absolute error. In the mortality classification model, the receiver operating characteristic (ROC) curves of both models were significantly better than the null hypothesis area of 0.5, and random forest model outperformed the artificial neural network. Random forest model outperforms the artificial neural network models achieved similar performance in the test set across all data.

CONCLUSIONS

Applying artificial intelligence modeling could help to provide reliable information about one-year outcomes following dialysis in the aged and super-aged populations; those with cancer, alcohol-related disease, stroke, chronic obstructive pulmonary disease (COPD), previous hip fracture, osteoporosis, dementia, and previous respiratory failure had higher medical costs and a high mortality rate.

Modality transition on renal replacement therapy and quality of life of patients: a 10-year follow-up cohort study

PURPOSE

Despite advance in renal replacement therapy (RRT), patients with chronic end-stage renal disease (ESRD) face various limitations, and renal transplantation (Tx) is the treatment that impacts most on quality of life (QoL). This study aimed to assess changes in QoL in a cohort of ESRD dialysis patients.

METHODS

Sociodemographic, clinical, nutritional, lifestyle, and QoL data were collected from 712 patients at baseline (time 1) and after 10 years of follow-up (time 2) for patients surviving. The QoL was assessed through the 36-Item Short Form Health Survey (SF-36) and the multiple linear regression model was used to analyze the factors associated with change in QoL.

RESULTS

A total of 205 survivors were assessed and distributed into three groups according to current RRT (Dialysis-Dialysis, Dialysis-Tx, and Dialysis-Tx-Dialysis). At time 1, only age was significantly different among groups; at time 2, transplant patients sustained greater social participation, job retention, and improvement in SF-36 scores. The factors associated with change in QoL were more time on dialysis interfering negatively on physical functioning (p = 0.002), role-physical limitations (p  = 0.002), general health (p  = 0.007), social functioning (p = 0.02), role-emotional (p = 0.003), and physical components ( p = 0.002); non-participation in social groups at times 1 and 2 reducing vitality (p = 0.02) scores; and having work at time 2, increasing vitality (p = 0.02) and mental health (p  = 0.02) scores.

CONCLUSIONS

QoL was shown to be dynamic throughout the years of RRT, transplantation being the treatment with more benefits to the ESRD. More time on dialysis and limited social and occupational routine were associated with a reduction in QoL.

Longitudinal patterns of health-related quality of life and dialysis modality: a national cohort study

Background

Health-related quality of life (HrQoL) varies among dialysis patients. However, little is known about the association of dialysis modality with HrQoL over time. We describe longitudinal patterns of HrQoL among chronic dialysis patients by treatment modality.

Methods

National retrospective cohort study of adult patients who initiated in-center dialysis or a home modality (peritoneal or home hemodialysis) between 1/2013 and 6/2015. Patients remained on the same modality for the first 120 days of the first two years. HrQoL was assessed by the Kidney Disease and Quality of Life-36 (KDQOL) survey in the first 120 days of the first two years after dialysis initiation. Home modality patients were matched to in-center patients in a 1:5 fashion.

Results

In-center (n=4234) and home modality (n=880) patients had similar demographic and clinical characteristics. In-center dialysis patients had lower mean KDQOL scores across several domains compared to home modality patients. For patients who remained on the same modality, there was no change in HrQoL. However, there were trends towards clinically meaningful changes in several aspects of HrQoL for patients who switched modalities. Specifically, physical functioning decreased for patients who switched from home to in-center dialysis (p< 0.05).

Conclusions

Among a national cohort of chronic dialysis patients, there was a trend towards different patterns of HrQoL life that were only observed among patients who changed modality. Patients who switched from home to in-center modalities had significant lower physical functioning over time. Providers and patients should be mindful of HrQoL changes that may occur with dialysis modality change.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1198-5) contains supplementary material, which is available to authorized users.

Burden of Care and Quality of Life Among Caregivers for Adults Receiving Maintenance Dialysis: A Systematic Review

RATIONALE & OBJECTIVE

Dialysis is a burdensome and complex treatment for which many recipients require support from caregivers. The impact of caring for people dependent on dialysis on the quality of life of the caregivers has been incompletely characterized.

STUDY DESIGN

Systematic review of quantitative studies of quality of life and burden to caregivers.

SETTING & STUDY POPULATION

Caregivers of adults receiving maintenance dialysis.

SELECTION CRITERIA FOR STUDIES

The Cochrane Library, Embase, PsycINFO, CINAHL, PubMed, and MEDLINE were systematically searched from inception until December 2016 for quantitative studies of caregivers. Pediatric and non-English language studies were excluded. Study quality was assessed using a modified Newcastle-Ottawa scale.

DATA EXTRACTION

2 independent reviewers selected studies and extracted data using a prespecified extraction instrument.

ANALYTICAL APPROACH

Descriptive reports of demographics, measurement scales, and outcomes. Quantitative meta-analysis using random effects when possible.

RESULTS

61 studies were identified that included 5,367 caregivers from 21 countries and assessed the impact on caregivers using 70 different scales. Most (85%) studies were cross-sectional. The largest identified group of caregivers was female spouses who cared for recipients of facility-based hemodialysis (72.3%) or peritoneal dialysis (20.6%). Caregiver quality of life was poorer than in the general population, mostly comparable with caregivers of people with other chronic diseases, and often better than experienced by the dialysis patients cared for. Caregiver quality of life was comparable across dialysis modalities.

LIMITATIONS

Heterogeneity in study design and outcome measures made comparisons between studies difficult and precluded quantitative meta-analysis. Study quality was generally poor.

CONCLUSIONS

Quality of life of caregivers of dialysis recipients is poorer than in the general population and comparable to that of caregivers of individuals with other chronic diseases. The impact of caring for recipients of home hemodialysis or changes in the impact of caring over time have not been well studied. Further research is needed to optimally inform dialysis programs how to educate and support caregivers.

A Discrete Choice Study of Patient Preferences for Dialysis Modalities

BACKGROUND AND OBJECTIVES

Improved knowledge about factors that influence patient choices when considering dialysis modality could facilitate health care interventions to increase rates of home dialysis. We aimed to quantify the attributes of dialysis care and the tradeoffs that patients consider when making decisions about dialysis modalities.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a prospective, discrete choice experiment survey with random parameter logit analysis to quantify preferences and tradeoffs for attributes of dialysis treatment in 143 adult patients with CKD expected to require RRT within 12 months (predialysis). The attributes included schedule flexibility, patient out of pocket costs, subsidized transport services, level of nursing support, life expectancy, dialysis training time, wellbeing on dialysis, and dialysis schedule (frequency and duration). We reported outcomes using β-coefficients with corresponding odds ratios and 95% confidence intervals for choosing home-based dialysis (peritoneal dialysis or hemodialysis) compared with facility hemodialysis.

RESULTS

Home-based therapies were significantly preferred with the following attributes: longer survival (odds ratio per year, 1.63; 95% confidence interval, 1.25 to 2.12), increased treatment flexibility (odds ratio, 9.22; 95% confidence interval, 2.71 to 31.3), improved wellbeing (odds ratio, 210; 95% confidence interval, 15 to 2489), and more nursing support (odds ratio, 87.3; 95% confidence interval, 3.8 to 2014). Respondents were willing to accept additional out of pocket costs of approximately New Zealand $400 (United States $271) per month (95% confidence interval, New Zealand $333 to $465) to receive increased nursing support. Patients were willing to accept out of pocket costs of New Zealand $223 (United States $151) per month (95% confidence interval, New Zealand $195 to $251) for more treatment flexibility.

CONCLUSIONS

Patients preferred home dialysis over facility-based care when increased nursing support was available and when longer survival, wellbeing, and flexibility were expected. Sociodemographics, such as age, ethnicity, and income, influenced patient choice.