Early referral and selection of peritoneal dialysis as a treatment modality

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

Background

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

Methods

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

Results

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

Conclusion

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

Effect of patient- and center-level characteristics on uptake of home dialysis in Australia and New Zealand: a multicenter registry analysis

BACKGROUND

Home-based dialysis therapies, home hemodialysis (HHD) and peritoneal dialysis (PD) are underutilized in many countries and significant variation in the uptake of home dialysis exists across dialysis centers. This study aimed to evaluate the patient- and center-level characteristics associated with uptake of home dialysis.

METHODS

The Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry was used to include incident dialysis patients in Australia and New Zealand from 1997 to 2017. Uptake of home dialysis was defined as any HHD or PD treatment reported to ANZDATA within 6 months of dialysis initiation. Characteristics associated with home dialysis uptake were evaluated using mixed effects logistic regression models with patient- and center-level covariates, era as a fixed effect and dialysis center as a random effect.

RESULTS

Overall, 54 773 patients were included. Uptake of home-based dialysis was reported in 24 399 (45%) patients but varied between 0 and 87% across the 76 centers. Patient-level factors associated with lower uptake included male sex, ethnicity (particularly indigenous peoples), older age, presence of comorbidities, late referral to a nephrology service, remote residence and obesity. Center-level predictors of lower uptake included small center size, smaller proportion of patients with permanent access at dialysis initiation and lower weekly facility hemodialysis hours. The variation in odds of home dialysis uptake across centers increased by 3% after adjusting for the era and patient-level characteristics but decreased by 24% after adjusting for center-level characteristics.

CONCLUSION

Center-specific factors are associated with the variation in uptake of home dialysis across centers in Australia and New Zealand.

Patient and caregiver preferences for home dialysis-the home first study: a protocol for qualitative interviews and discrete choice experiments

INTRODUCTION

The number of patients requiring dialysis continues to increase worldwide imposing a substantial social and economic burden on patients, their families and healthcare systems. Compared with facility-based dialysis, dialysis performed by the patient at home is associated with higher quality of life, freedom, survival and reduced healthcare costs. International guidelines recommend suitable patients are offered a choice of dialysis modality, including home-based dialysis. Predialysis education and offering patients choice increase home dialysis uptake, yet the factors that patients and families are willing to trade off in making decisions about dialysis location are not well understood. The Home First study will explore patients' and caregivers' beliefs, attitudes and preferences regarding dialysis education and decision-making with regards to dialysis options; to identify key attributes which influence their decision-making, and to quantify the relative value of these attributes.

METHODS AND ANALYSIS

This study will use a mixed-methods approach to describe patient and caregiver preferences and views about the factors that influence their choice of home or facility-based dialysis. Face-to-face, semistructured interviews will be conducted with 30-40 patients and 10-15 caregivers. Thematic analysis of interview transcripts will be conducted. Additional to providing information on the perspectives and experiences of patients and caregivers, these analyses will also inform the design of discrete choice experiments (DCEs). We will undertake DCEs with approximately 150 patients and 150 caregivers to quantify preferences for home and facility dialysis.

ETHICS AND DISSEMINATION

The Hawke's Bay, Counties Manukau, and Capital Coast District Health Board Research Ethics Committees approved the study. Findings will be presented in national/international conferences and peer-reviewed journals. Dissemination to patients will take the form of presentations, newsletters and reports to support and community groups. Reports will be disseminated to funders and participating renal units and to the New Zealand Ministry of Health.

TRIAL REGISTRATION NUMBER

ACTRN12615000314527.

Increasing the uptake of peritoneal dialysis in New Zealand: a national survey

BACKGROUND

Peritoneal dialysis (PD) has been shown to offer a high quality of life and independence to patients. New Zealand (NZ) is a world leader in home dialysis, yet over the last decade, rates of PD have been steadily decreasing for unknown reasons.

OBJECTIVES

This paper reports on the findings of a national survey which explored the clinicians' perspectives on key factors that influence the rate of PD.

DESIGN

Ten multi-answer questions were asked of several groups of dialysis health professionals to assess factors that are barriers and enablers to PD, including patient choice of dialysis modality, information about PD and pre-dialysis education delivery. All NZ nephrologists, pre-dialysis and PD nurses were invited to complete an anonymous online survey. Responses were analysed to identify perceived barriers and enablers influencing the rate of PD uptake amongst incident dialysis patients.

RESULTS

Completed surveys were received from 52% of nephrologists, 100% of pre-dialysis nurses and 50% of PD nurses in NZ. In NZ, patients are offered a choice of dialysis modality with pre-dialysis nurses delivering the majority of education. The most frequently identified barriers to uptake of PD were lack of information about PD, established misconceptions about PD and late referrals to dialysis. Important enablers were early and frequent pre-dialysis education. The only two factors which were reported as very important contraindications to PD were dexterity and decreased cognitive function.

CONCLUSION

Early and frequent pre-dialysis education encourages patients to choose PD and enables early identification and resolution of barriers to the uptake of PD.

Outcome of the sub-optimal dialysis starter on peritoneal dialysis. Report from the French Language Peritoneal Dialysis Registry (RDPLF)

BACKGROUND

This study was carried out to examine the association of sub-optimal dialysis initiation of peritoneal dialysis (PD) with all the possible outcomes on PD using survival analysis in the presence of competing risks.

METHODS

This was a retrospective cohort study based on the data of the French Language Peritoneal Dialysis Registry. We analysed 8527 incident patients starting PD between January 2002 and December 2010. The end of the observation period was 01 June 2011. Times from the start of PD to death, transplantation, transfer to haemodialysis (HD) and first peritonitis episode were calculated. The sub-optimal dialysis initiation was defined by a period of <30 days on HD before PD initiation.

RESULTS

Among 8527 patients, there were 568 patients who started PD after <30 days on HD. There were 6562 events: 3078 deaths, 2136 transfers to HD, 1348 renal transplantations. When using a Fine and Gray model, sub-optimal dialysis start, early peritonitis and transplant failure were associated with a higher sub-distribution relative hazard of technique failure. There was no association between the sub-optimal dialysis start and the sub-distribution hazard of death or transplantation. In the multivariate analysis using a Fine and Gray regression model, the sub-optimal dialysis start was not associated with a higher sub distribution relative hazard of peritonitis.

CONCLUSIONS

Sub-optimal dialysis initiation is neither associated with a higher risk of death nor with a lower risk of renal transplantation. Sub-optimal PD patients had a higher risk of transfer to HD.

Balancing Fistula First With Catheters Last

The success of Fistula First nationwide has been accompanied by an unplanned increase in hemodialysis catheters. Complications related to prolonged hemodialysis catheter use include increased morbidity, mortality, and cost. We hypothesize that the national focus on increasing fistulas may have inadvertently diverted attention away from initiatives to decrease dependence on hemodialysis catheters. Based on a synthesis of guidelines, reviews, published evidence, and the authors' opinions, we propose that the national vascular access initiative be revised to have a dual goal of Fistula First and "Catheters Last." These goals are not mutually exclusive, but rather complementary. We recommend a systematic refocus on interventions that not only increase fistulas, but help avoid extended catheter use. Clearly, the ideal practice for hemodialysis vascular access remains early placement of fistulas with enough maturation time such that they can be used for initiating long-term hemodialysis therapy when the need arises. To effect this change, a reimbursement policy covering the costs associated with permanent access placement before the need for dialysis is essential. Individualized patient management strategies may consider such innovative approaches as initiating patients on peritoneal dialysis therapy or using nonautogenous grafts as bridge accesses in lieu of catheters. For patients who are dialyzing using catheters, immediate active planning for permanent access placement and removal of the catheter is necessary. In the same vein as Fistula First, the renal community should once again be galvanized in working together toward controlling the catheter epidemic in our dialysis population.

Late referral of patients with chronic kidney disease: no time to waste

The prevalence of patients with chronic kidney disease (CKD) in the US population is approximately 11%, and because of the increase in life expectancy and in diabetic nephropathy incidence, an exponential increase is predicted for the next decades. During the past decade, evidence that the progression of CKD can be attenuated by a multifactorial therapeutic approach has been increasing. However, a substantial percentage of patients with CKD will have progression to CKD stage V (ie, need for renal replacement therapy). Late referral of these patients (ie, <1 to 6 months before the start of renal replacement therapy) has been shown to be associated with higher mortality, morbidity, and costs. However, up to 64% of patients with CKD are still referred late. This review presents the available data on the epidemiology, causes, and consequences of late patient referral. Furthermore, it offers information to prevent late referral, improve CKD patient care, and change clinical practice.

Quality of life of patients having renal replacement therapy

AIM

This paper reports a study to compare the quality of life and its correlates for patients undergoing various types of renal replacement therapy.

BACKGROUND

Patients with end stage renal disease need renal replacement therapy as a substitute for their original kidneys. Different renal replacement therapies have different levels of impact on physical, psychological and social health. Quality of life as perceived by patients with end-stage renal disease is an important measure of patient outcome.

METHODS

A cross-sectional, descriptive, correlational study was carried out in 2002. A total of 240 patients were recruited from two medical centres in northern Taiwan. These patients were currently undergoing one of following types of renal replacement therapies: haemodialysis, continuous ambulatory peritoneal dialysis or transplantation. The study instrument used was the WHOQOL-BREF-TAIWAN. Data were analysed using descriptive and inferential statistics.

RESULTS

The scores for quality of life of transplantation patients were higher than those for both haemodialysis and continuous ambulatory peritoneal dialysis patients. The lowest scores for all three groups were in the psychological domain. The mean age for haemodialysis and continuous ambulatory peritoneal dialysis patients was significantly higher than that for transplant patients. The educational level, proportion of single people, and employment status of transplant patients were significantly higher than those of haemodialysis and continuous ambulatory peritoneal dialysis patients. Perception of economic status as 'balanced' or 'proficient' for transplant patients was significantly higher than for continuous ambulatory peritoneal dialysis and haemodialysis patients.

CONCLUSION

Information about the quality of life of patients having various types of renal replacement therapy will assist physicians, nurses, patients and their families to make decisions on treatment selection. There is a need to establish support groups for patients having renal replacement therapy in order to enhance their quality of life, especially in the psychological domain.

Influence of a Pre-Dialysis Education Programme (PDEP) on the mode of renal replacement therapy

BACKGROUND

The distribution of renal replacement therapy (RRT) modalities among patients varies from country to country, and is often influenced by non-medical factors. In our department, patients progressing towards end-stage renal disease (ESRD) go through a structured Pre-Dialysis Education Programme (PDEP). The goals of the programme, based on both individualized information session(s) given by an experienced nurse to the patient and family and the use of in-house audio-visual tapes, are to inform on all modalities of RRT, in order to decrease anxiety and promote self-care RRT modalities.

METHODS

To evaluate the influence of our PDEP on the choice of RRT modalities, we retrospectively reviewed the modalities chosen by all consecutive patients starting a first RRT in our institution between December 1994 and March 2000.

RESULTS

Two hundred and forty-two patients started a first RRT during the study period. Fifty-seven patients, median age 66 (24-80) years, were directed towards in-centre haemodialysis (HD) for medical or psycho-social reasons (seven of whom were not involved in the PDEP); the remaining 185 patients, median age 53 (7-81) years, with no major medical complications, went through our PDEP. Eight of them (4%) received a pre-emptive renal transplantation. The therapeutic options of the other 177 patients were as follows: 75 (40%) patients, median age 65 (20-81) years opted for in-centre HD, while 102 patients opted for a self-care modality; 55 (31%) patients, median age 56 (7-77) years, chose peritoneal dialysis, 30 (16%) patients, median age 49 (21-68) years, chose to perform self-care HD in our satellite unit, and 17 (9%) patients, median age 46 (19-70) years, opted for home HD. Interestingly, in the whole cohort of patients, the cause of ESRD was associated with the RRT modality: the proportion of patients with chronic glomerulonephritis or chronic interstitial nephritis on self-care therapy was significantly higher than that of patients with nephrosclerosis, diabetic nephropathy or unknown cause of ESRD.

CONCLUSION

In our centre offering all treatment RRT modalities, a high percentage of patients exposed to a structured PDEP start with a self-care RRT modality. This leaves in-centre HD for patients needing medical and nursing care, or for patients refusing to participate in their treatment. Additional large studies, preferably with a randomized design, should delineate the cost-benefit of such a PDEP on the final choice of a RRT modality.

The role of comprehensive renal clinic in chronic kidney disease stabilization and management: The Northwestern experience

In this article, we maintain that the management of patients with chronic kidney disease (CKD) is best provided in a clinic setting that integrates nephrologic expertise, patient education, and comprehensive supportive services. Our experience with a CKD clinic in an urban academic setting is described. As a way to assess and quantify the impact of our clinic on clinical outcomes, we have analyzed our results in terms of 2 variables: presence of permanent access at the time of dialysis initiation and impact on renal function as assessed by calculated glomerular filtration rate (GFR). The number of clinic visits was taken as an index of comprehensive renal care before dialysis initiation. Individuals who started dialysis with a functioning permanent access had been seen in our clinic more frequently than those seen less frequently (20 +/- 3.5 and 4.4 +/- 2.1 visits, respectively, P <.005). The impact on renal function was analyzed in a group of 80 unselected patients stratified into 3 stages based on the recently published National Kidney Foundation Disease Outcomes Quality Initiative (K/DOQI) guidelines: stage III (mean GFR 39 +/- 1.5 mL/min, n = 21), stage IV (mean GFR 21 +/- 0.6 mL/min, n = 46), and stage V (mean GFR 12 +/-.76 mL/min, n = 13). Provision of comprehensive renal care in conjunction with anemia management using weekly injections of erythropoietin subcutaneously resulted in stabilization of GFR in patients with stages IV and V over a period of 15 months of follow-up evaluation. In patients with stage III CKD, GFR decreased over the initial period of follow-up evaluation (first few months), and to a lesser extent by the end of follow-up evaluation (15 mo). Further studies are underway to discern the factor(s) underlying the overall clinic effect versus a beneficial effect of anemia correction on GFR. Our data suggests that stabilization of GFR is a goal that can be accomplished with comprehensive renal care provided in an organized clinic setting.

An update on the referral pattern of patients with end-stage renal disease

This article first describes the epidemiology and reasons of late referal to the nephrologist of patients suffering from end-stage renal disease (ESRD). Depending on the definition, between 25 and 50% of worldwide ESRD patients are referred very late. Second, the relation of late referral to the quality of pre-ESRD care, its impact on the selection of dialysis modality, on the time of start of dialysis and on the use of an adequate vascular access, are discussed. Finally, the economic aspects of late referral are described and ways to improve the referral pattern are proposed.