Home haemodialysis—international trends and variation

Low-Volume Home Haemodialysis and In-Centre Haemodialysis: Comparison of Dialysis Adequacy in Obese Individuals

Background Although frequent low-flow, low-volume haemodialysis using the NxStage System One is now well-established as an option for home therapy of end-stage chronic kidney disease, its ability to deliver adequate dialysis in people with high BMI remains questionable. This doubt may lead to obese individuals being denied the potential benefits of this modality. To establish if this doubt is justified, we compared dialysis adequacy in two groups of obese individuals; one receiving standard thrice-weekly in-centre haemodialysis and the other receiving frequent haemodialysis at home using the NxStage System One. Methods This is a retrospective observational cohort study of 105 adult dialysis patients with obesity (BMI ≥ 30 kg/m2). All had been on dialysis for at least six months. Fifty-five patients receiving in-centre haemodialysis were compared with 50 patients receiving home haemodialysis using NxStage System One. Dialysis adequacy (standard Kt/V calculated by the Daugirdas equation) was compared between the two groups. The clinical characteristics, laboratory test results, and treatment regimens of each group were also compared. Results The in-centre haemodialysis group was older (63.6 ± 12.8 years vs. 58.5 ± 10.9 years, p=0.033) and had a higher Charlson comorbidity score (5.9 ± 2.1 vs. 4.5 ± 2.5, p=0.003). Standard Kt/V was significantly higher in the home haemodialysis group (2.4 ± 0.5) than in the in-centre haemodialysis group (2.2 ± 0.2) (p = 0.006). The mean serum inorganic phosphate was significantly lower in the home haemodialysis group than in the in-centre haemodialysis group (1.6 ± 0.4 mmol/l vs. 1.8 ± 0.5 mmol/l, p = 0.010). There were no statistically significant differences in the usage of antihypertensives, phosphate binders, or erythropoiesis-stimulating agents between the two groups. Conclusions In this study, dialysis adequacy (expressed as standard Kt/V) was superior to that of standard thrice-weekly in-center haemodialysis delivered by frequent low-volume home haemodialysis using the NxStage System One. Hesitancy about recommending frequent low-volume home haemodialysis to obese individuals is therefore unjustified.

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.

Data Challenges in Addressing Chronic Kidney Disease in Low- and Lower-Middle-Income Countries

The burden of chronic kidney disease (CKD) is growing globally, particularly in low- and lower-middle-income countries (LLMICs) where access to treatment is poor and the largest increases in disease burden will occur. The individual and societal costs of kidney disease are well recognized, especially in developed health care systems where treatments for the advanced stages of CKD are more readily available. The consequences of CKD are potentially more catastrophic in developing health care systems where such resources are often lacking. Central to addressing this challenge is the availability of data to understand disease burden and ensure that investments in treatments and health resources are effective at a local level. Use of routinely collected administrative data is helpful in this regard, however, the barriers to developing a more systematic focus on data collection should not be underestimated. This article reviews the current tools that have been used to measure the burden of CKD and considers limitations regarding their use in LLMICs. A review of the literature investigating the use of registries, disease specific databases and administrative data to identify populations with CKD in LLMICs, which indicate these to be underused resources, is included. Suggestions regarding the potential use of administrative data for measuring CKD burden in LLMICs are explored.

COVID-19 pandemic era: is it time to promote home dialysis and peritoneal dialysis?

The novel coronavirus, called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic in March 2020 by the World Health Organization. Older individuals and patients with comorbid conditions such as hypertension, heart disease, diabetes, lung disease, chronic kidney disease (CKD) and immunologic diseases are at higher risk of contracting this severe infection. In particular, patients with advanced CKD constitute a vulnerable population and a challenge in the prevention and control of the disease. Home-based renal replacement therapies offer an opportunity to manage patients remotely, thus reducing the likelihood of infection due to direct human interaction. Patients are seen less frequently, limiting the close interaction between patients and healthcare workers who may contract and spread the disease. However, while home dialysis is a reasonable choice at this time due to the advantage of isolation of patients, measures must be assured to implement the program. Despite its logistical benefits, outpatient haemodialysis also presents certain challenges during times of crises such as the coronavirus disease 2019 (COVID-19) pandemic and potentially future ones.

Systematic Evaluation of a Provincial Initiative to Improve Transition to Home Dialysis Therapies

Background:

The transition from choosing to initiating home dialysis therapies (HDTs) is not clearly standardized for patients and staff, causing increased anxiety and suboptimal self-management for chronic kidney disease (CKD) patients. At BC Renal, a “Transition to HDTs” guidebook (the Guide) was designed, outlining a step-wise approach to transitioning to HDTs for patients, to help address some of these concerns.

Objective:

We used the Logic Model evaluation framework to assess the value of the Guide to improve patient and staff experience with transitioning to HDTs.

Design:

This is a prospective cohort quality improvement study.

Setting:

This study took place at home dialysis programs in British Columbia, Canada, with 2 pilot sites and 2 control sites.

Patients:

Patients above age 18 who attended kidney care clinics and identified HDT as their renal replacement treatment of choice were included in this study.

Measurements:

Patient demographics were obtained from British Columbia Renal Patient Records and Outcomes Management Information System, with differences analyzed using Mann-Whitney U test and chi-square test where applicable. Patient surveys were based on Likert rating scales, analyzed using Cochran-Armitage trend test. All tests were 2-sided, with P < .05 considered significant.

Methods:

The study enrolled patients from December 2018 to April 2019 at 2 pilot and 2 control sites. Patients were followed up for 8 months. The intervention strategies included (1) training of front-line staff to use the Guide and (2) dissemination of the guide to patients. Evaluation tools measuring data at baseline and at the 8-month point included (1) qualitative and quantitative patient surveys, (2) qualitative staff surveys, (3) structured feedback session with renal care staff, and (4) transition rate and time between choosing and starting a HDT.

Results:

In total, 108 patients were enrolled: 43 patients at pilot sites and 65 in control sites. Twenty-three of 65 in control vs 18 of 43 in pilot transitioned to a HDT by 8-month follow-up. Transition time was 80 vs 89 days in pilot vs control group, but it was not statistically different (P = .37). The proportion of patients that transitioned to a HDT was 42% vs 35% in pilot vs control group (P = .497). Patients’ anxiety, illness knowledge, and activation of resources were not significantly different between patients who successfully transitioned at control and pilot sites. During interviews, patients confirmed that the Guide was effective and helped retain knowledge. The staff felt that the intervention did not increase their workload and that the Guide was a good communication tool, but was used inconsistently.

Limitations:

We had a small sample size and limited number of patients enrolled who chose home hemodialysis, with none in the control group. The results are therefore more applicable to peritoneal dialysis.

Conclusions:

The Logic Model was useful to evaluate our multi-intervention strategy. While there were no statistically significant differences in transition time, rate, and patient anxiety with or without the Guide, qualitative opinions from patients indicate that the Guide was a useful supplement. In addition, feedback from renal care staff suggested that the Guide served as a framework for communicating the transition process with patients, and was perceived as a useful tool. Future work is required to standardize the Guide’s utilization.

Trial registration:

As this is a quality improvement evaluation study, trial registration is not applicable.

Targeted Education ApproaCH to improve Peritoneal Dialysis Outcomes (TEACH-PD): A feasibility study

BACKGROUND

There is substantial variation in peritonitis rates across peritoneal dialysis (PD) units globally. This may, in part, be related to the wide variability in the content and delivery of training for PD nurse trainers and patients.

AIM

The aim of this study was to test the feasibility of implementing the Targeted Education ApproaCH to improve Peritoneal Dialysis Outcomes (TEACH-PD) curriculum in real clinical practice settings.

METHODS

This study used mixed methods including questionnaires and semi-structured interviews (pretraining and post-training) with nurse trainers and patients to test the acceptability and usability of the PD training modules implemented in two PD units over 6 months. Quantitative data from the questionnaires were analysed descriptively. Interviews were analysed using thematic analysis.

RESULTS

Ten PD trainers and 14 incident PD patients were included. Mean training duration to complete the modules were 10.9 h (range 6-17) and 24.9 h (range 15-35), for PD trainers and patients, respectively. None of the PD patients experienced PD-related complications at 30 days follow-up. Three (21%) patients were transferred to haemodialysis due to non-PD-related complications. Ten trainers and 14 PD patients participated in the interviews. Four themes were identified including use of adult learning principles (trainers), comprehension of online modules (trainers), time to complete the modules (trainers) and patient usability of the manuals (patient).

CONCLUSION

This TEACH-PD study has demonstrated feasibility of implementation in a real clinical setting. The outcomes of this study have informed refinement of the TEACH-PD modules prior to rigorous evaluation of its efficacy and cost-effectiveness in a large-scale study.

Is replacement modality choice knowledge important in the non-renal multidisciplinary team? Experience from a single UK centre

Dialysis remains the mainstay treatment for patients with end stage renal disease. In the UK, there has been a significant decline in home dialysis despite its benefits and cost effectiveness. Patients with chronic kidney disease (CKD) are often known to other specialties who they may continue to consult when approaching dialysis. We wished to assess the knowledge of the non-renal multidisciplinary team (MDT) regarding home dialysis and establish whether further education was warranted. This was assessed using an online survey sent to specialties likely to deal with CKD patients. In total, 364 questionnaires were sent out with a 26.4% response rate. According to the survey responses, 81.5% of non-renal MDTs lack confidence in discussing home dialysis options with patients and 74.55% feel that they need further education about home dialysis. Targeted education may increase home dialysis uptake by multimorbid CKD patients who have a consistent message delivered by all relevant healthcare teams about the benefits of home dialysis.

Gender differences in the dialysis treatment of Indigenous and non-Indigenous Australians

OBJECTIVE

Access to dialysis treatment and the types of treatments employed in Australia differs by Indigenous status. We examined whether dialysis treatment utilisation in Indigenous and non-Indigenous Australians also differs by gender.

METHODS

Using registry data we evaluated 21,832 incident patients (aged ≥18 years) commencing dialysis, 2001-2013. Incidence rates were calculated and multivariate regression modelling used to examine differences in dialysis treatment (modality, location and vascular access creation) by race and gender.

RESULTS

Dialysis incidence was consistently higher in Indigenous women compared to all other groups. Compared to Indigenous women, both non-Indigenous women and men were more likely to receive peritoneal dialysis as their initial treatment (non-Indigenous women RR=1.91, 95%CI 1.55-2.35; non-Indigenous men RR=1.73, 1.40-2.14) and were more likely to commence initial treatment at home (non-Indigenous women RR=2.07, 1.66-2.59; non-Indigenous men RR=1.95, 1.56-2.45). All groups were significantly more likely than Indigenous women to receive their final treatment at home.

CONCLUSIONS

Contemporary dialysis treatment in Australia continues to benefit the dominant non-Indigenous population over the Indigenous population, with non-Indigenous men being particularly advantaged. Implications for Public Health: Treatment guidelines that incorporate a recognition of gender-based preferences and dialysis treatment options specific to Indigenous Australians may assist in addressing this disparity.

The anticipated and the lived experience of home and in-centre haemodialysis: Is there a disconnect?

This qualitative study aimed to explore home haemodialysis and in-centre haemodialysis patients’ experience, to illuminate barriers and facilitators in the uptake and maintenance of home haemodialysis. Thirty-two semi-structured interviews with patients receiving home haemodialysis or in-centre haemodialysis were analysed using framework analysis. Four themes emerged: ‘perceptions of self’; ‘impact of haemodialysis on family’; ‘perceived advantages and disadvantages of home haemodialysis and in-centre haemodialysis’ and ‘practical issues and negotiating haemodialysis’. The lived experience of home haemodialysis was in contrast to the lived experience of in-centre haemodialysis and to the anticipated experience of home haemodialysis, highlighting patient factors that contributed to under-usage of home haemodialysis.

Present Status of Renal Replacement Therapy in Asian Countries

BACKGROUND

Asia is a huge and populous continent with diverse economies where the status of renal replacement therapy varies among different countries.

SUMMARY

The penetration of dialysis is poor among low income countries like India and China. A lack of trained nephrologists and limited numbers of dialysis facilities plague South Asian countries. Most of the hemodialysis centers are in the private sector; the few centers that are government-run or run by charitable organizations cannot meet growing needs. China has shown that twice-a-week hemodialysis can be feasible in female patients with small build. Peritoneal dialysis (PD) has less penetration among the developing countries than the developed countries in Asia. Novel schemes in India including the 'once-in-a-lifetime payment' scheme and an insurance scheme for peritonitis are attracting more patients to PD. New biocompatible PD solutions and home care facilities have brought down the peritonitis rates. The PD-first policy in Thailand alongside the domestic manufacture of PD fluids has decreased the cost of PD there. Iran has shown drastic changes in its PD policy (from 0 to 1,150 recruitments in 5 years) in spite of its high transplantation rate. Home hemodialysis is practiced in mostly affluent countries like Japan, where again it accounts for only 0.1% of all hemodialysis.

KEY MESSAGES

Developing countries should have more budgetary allocation for chronic ailments such as chronic kidney disease that can be utilized for training programs and establishing dialysis units, and thus meet the growing demands for renal replacement therapy. PD should be encouraged and adopted as first modality of renal replacement therapy considering its ease and economy.

Home dialysis-an international perspective

Background. There is strong evidence from a range of long-term conditions of improved outcomes where patients are involved in self-management. Against this background, the international trend for home dialysis continues to decline, with centre-based haemodialysis continuing its dominance.

Methods. An opinion-based commentary exploring practice patterns and drivers for home dialysis internationally. Data are drawn from a number of sources including the 2010 United States Renal Data System report.

Results. Drivers behind the use of home dialysis are complex including factors relating to the patient and their carers, health care team, health care system, geography and cultural factors. There are important examples where local champions or public health initiatives have had a positive impact on the use of home dialysis; however, in many settings significant barriers remain. Better systems for giving patient information, shared decision making and involving patients in their own care may have the potential to act as a driver for change.

Conclusion. Centre-based haemodialysis continues to dominate renal replacement therapy internationally with notable exceptions. Such dominance suggests that most patients worldwide do not get much choice when it comes to modality selection.

The perspectives of Aboriginal patients and their health care providers on improving the quality of hemodialysis services: a qualitative study

Chronic kidney disease has a higher prevalence in Indigenous populations globally. The incidence of end-stage kidney disease in Australian Aboriginal people is eight times higher than non-Aboriginal Australians. Providing services to rural and remote Aboriginal people with chronic disease is challenging because of access and cultural differences. This study aims to describe and analyze the perspectives of Aboriginal patients' and health care providers' experience of renal services, to inform service improvement for rural Aboriginal hemodialysis patients. We conducted a thematic analysis of interviews with Aboriginal patients (n = 18) receiving hemodialysis in rural Australia and health care providers involved in their care (n = 29). An overarching theme of avoiding the “costly” crisis encompassed four subthemes: (1) Engaging patients earlier (prevent late diagnosis, slow disease progression); (2) flexible family-focused care (early engagement of family, flexibility to facilitate family and cultural obligations); (3) managing fear of mainstream services (originating in family dialysis experiences and previous racism when engaging with government organizations); (4) service provision shaped by culture (increased home dialysis, Aboriginal support and Aboriginal-led cultural education). Patients and health care providers believe service redesign is required to meet the needs of Aboriginal hemodialysis patients. Participants identified early screening and improving the relationship of Aboriginal people with health systems would reduce crisis entry to hemodialysis. These strategies alongside improving the cultural competence of staff would reduce patients' fear of mainstream services, decrease the current emotional and family costs of care, and increase efficiency of health expenditure on a challenging and increasingly unsustainable treatment system.

Technique survival in home haemodialysis: a composite success rate and its risk predictors in a prospective longitudinal cohort from a tertiary renal network programme

BACKGROUND

Resurgence of interest in home haemodialysis (HHD) is, in part, due to emerging evidence of the benefits of extended HD regimens, which are most feasibly provided in the home setting. Although specific HHD therapy established at home such as nocturnal HD (NHD) has been reported from individual programmes, little is known about overall HHD success.

METHODS

The study included 166 patients who were accepted in the Manchester (UK) HHD training programme through liberal selection criteria. All patients were followed up prospectively until a switch to alternative modality, to include 4528 patient-months of follow-up and about 81 508 HHD sessions during an 8-year period (January 2004-December 2011). Twenty-four patients switched to an alternative modality during the period. Combined technique survival (HHDc) as a composite of training (HHDtr) and at home (HHDhome) was analysed and clinical predictors of HHD modality failure since the commencement of the programme were calculated using Cox regression analysis. Technology-related interruptions to dialysis over a 12-month period and patient-reported reasons for quitting the programme were analysed.

RESULTS

Technique survival at 1, 2 and 5 years was 90.2, 87.4, 81.5% (HHDc) and 98.4, 95.4 and 88.9% (HHDhome) when censored for training phase exits, death and transplantation. The combined HHDc modality switch rate is 1 in 192 patient-months of dialysis follow-up. Age >60 years, diabetes, cardiac failure, unit decrease in Hb and increasing score of age-adjusted Charlson--comorbidity index were significantly associated with technique failure. Significant clinical predictors of HHD technique failure in a multivariate model were diabetes (P = 0.002) and cardiac failure (P = 0.05). The majority (61%) switched to an alternative modality for non-medical reasons. The composite of operator error and mechanical breakdown resulting in temporary HHD technique failure was 0.7% per year.

CONCLUSIONS

HHD training and technique failure rate are low. Technical errors are infrequent too. Diabetes and cardiac failure are associated with significant risk of technique failure. Although absolute rates are low, training failure is proportionally quite significant, highlighting the importance of reporting the composite technique failure rate (to include early HHD training phase) in HHD programmes.

The HOME network: an Australian national initiative for home therapies

BACKGROUND

Longer, more frequent dialysis at home can improve life expectancy for patients with chronic kidney disease. Increased use of home dialysis therapies also benefits the hospital system, allowing for more efficient allocation of clinic resources. However, the Australian and New Zealand Data Registry statistics highlight the low uptake of home haemodialysis and peritoneal dialysis across Australia.

OBJECTIVE

In August 2009, the Australia's HOME Network was established as a national initiative to engage and empower healthcare professionals working in the home dialysis specialty. The aim was to develop solutions to advocate for and ultimately increase the use of home therapies. This paper describes the development, achievement and future plan of the Australian HOME Network.

ACHIEVEMENTS

Achievements to date include: a survey of HOME Network members to assess the current state of patient and healthcare professional-targeted education resources; development of two patient case studies and activities addressing how to overcome the financial burden experienced by patients on home dialysis. Future projects aim to improve patient and healthcare professional education, and advocacy for home dialysis therapies.

CONCLUSION

The HOME Network is supporting healthcare professionals working in the home dialysis specialty to develop solutions and tools that will help to facilitate greater utilisation of home dialysis therapies.

Service providers' perspectives, attitudes and beliefs on health services delivery for Aboriginal people receiving haemodialysis in rural Australia: a qualitative study

OBJECTIVE

Providing services to rural dwelling minority cultural groups with serious chronic disease is challenging due to access to care and cultural differences. This study aimed to describe service providers' perspectives on health services delivery for Aboriginal people receiving haemodialysis for end-stage kidney disease in rural Australia.

DESIGN

Semistructured interviews, thematic analysis

SETTING

A health district in rural New South Wales, Australia

PARTICIPANTS

Using purposive sampling, 29 renal and allied service providers were recruited, including nephrologists, renal nurses, community nurses, Aboriginal health workers, social workers and managers. Six were Aboriginal and 23 non-Aboriginal.

RESULTS

Improving cultural understanding within the healthcare system was central to five themes identified: rigidity of service design (outreach, inevitable home treatment failures, pressure of system overload, limited efficacy of cultural awareness training and conflicting priorities in acute care); responding to social complexities (respecting but challenged by family obligations, assumptions about socioeconomic status and individualised care); promoting empowerment, trust and rapport (bridging gaps in cultural understanding, acknowledging the relationship between land, people and environment, and being time poor); distress at late diagnosis (lost opportunities and prioritise prevention); and contending with discrimination and racism (inherent judgement of lifestyle choices, inadequate cultural awareness, pervasive multilevel institutionalised racism and managing patient distrust).

CONCLUSIONS

Service providers believe current services are not designed to address cultural needs and Aboriginality, and that caring for Aboriginal patients receiving haemodialysis should be family focused and culturally safer. An Aboriginal-specific predialysis pathway, building staff cultural awareness and enhancing cultural safety within hospitals are the measures recommended. Increasing patient support for home haemodialysis may improve health and the quality of care outcomes.

Barriers to successful implementation of care in home haemodialysis (BASIC-HHD):1. Study design, methods and rationale

Background

Ten years on from the National Institute of Health and Clinical Excellence’ technology appraisal guideline on haemodialysis in 2002; the clinical community is yet to rise to the challenge of providing home haemodialysis (HHD) to 10-15% of the dialysis cohort. The renal registry report, suggests underutilization of a treatment type that has had a lot of research interest and several publications worldwide on its apparent benefit for both physical and mental health of patients. An understanding of the drivers to introducing and sustaining the modality, from organizational, economic, clinical and patient perspectives is fundamental to realizing the full benefits of the therapy with the potential to provide evidence base for effective care models. Through the BASIC-HHD study, we seek to understand the clinical, patient and carer related psychosocial, economic and organisational determinants of successful uptake and maintenance of home haemodialysis and thereby, engage all major stakeholders in the process.

Design and methods

We have adopted an integrated mixed methodology (convergent, parallel design) for this study. The study arms include a. patient; b. organization; c. carer and d. economic evaluation. The three patient study cohorts (n = 500) include pre-dialysis patients (200), hospital haemodialysis (200) and home haemodialysis patients (100) from geographically distinct NHS sites, across the country and with variable prevalence of home haemodialysis. The pre-dialysis patients will also be prospectively followed up for a period of 12 months from study entry to understand their journey to renal replacement therapy and subsequently, before and after studies will be carried out for a select few who do commence dialysis in the study period. The process will entail quantitative methods and ethnographic interviews of all groups in the study. Data collection will involve clinical and biomarkers, psychosocial quantitative assessments and neuropsychometric tests in patients. Organizational attitudes and dialysis unit practices will be studied together with perceptions of healthcare providers on provision of home HD. Economic evaluation of home and hospital haemodialysis practices will also be undertaken and we will apply scenario ("what … if") analysis using system dynamics modeling to investigate the impact of different policy choices and financial models on dialysis technology adoption, care pathways and costs. Less attention is often given to the patient’s carers who provide informal support, often of a complex nature to patients afflicted by chronic ailments such as end stage kidney disease. Engaging the carers is fundamental to realizing the full benefits of a complex, home-based intervention and a qualitative study of the carers will be undertaken to elicit their fears, concerns and perception of home HD before and after patient’s commencement of the treatment. The data sets will be analysed independently and the findings will be mixed at the stage of interpretation to form a coherent message that will be informing practice in the future.

Discussion

The BASIC-HHD study is designed to assemble pivotal information on dialysis modality choice and uptake, investigating users, care-givers and care delivery processes and study their variation in a multi-layered analytical approach within a single health care system. The study results would define modality specific service and patient pathway redesign.

Study Registration

This study has been reviewed and approved by the Greater Manchester West Health Research Authority National Research Ethics Service (NRES) The study is on the NIHR (CLRN) portfolio.

Needs, Concerns, Strategies, and Advice of Daily Home Hemodialysis Caregivers

Improved patient outcomes have led to increased international interest in daily home hemodialysis as a kidney replacement therapy. Daily home hemodialysis often requires the assistance of a caregiver during and between treatments. Understanding the needs and concerns of caregivers of persons on daily home hemodialysis will inform the design of supportive interventions to improve caregiver retention and maintain their health and well-being. Using a descriptive qualitative design, the purpose of this study was to identify and describe the needs, concerns, strategies, and advice of family caregivers. Twenty-one caregivers were interviewed; five of these individuals were former caregivers of patients who had returned to outpatient hemodialysis. Data were collected via audio-recorded telephone interviews following a semistructured interview guide with five open-ended questions. A content analysis approach was used to code and analyze the data. Caregivers described needs, concerns, and strategies and offered advice in five predetermined major categories. Major findings included a need for respite services and a need for interventions to manage the emotional responses to caregiving. This study provides valuable information about relevant areas to consider when developing an intervention program for daily home hemodialysis caregivers.

Determinants of training and technique failure in home hemodialysis

Home hemodialysis (HHD) has clinical and economic advantages compared with in-center conventional hemodialysis. Many health systems wish to broaden the population to which this modality can be successfully offered. However, determinants of successful HHD training and technique survival are unknown. We hypothesize that both medical and social factors play a role when patients fail to successfully adopt HHD. We examined characteristics of consecutive patients who initiated training for HHD between 2003 and 2011. Patients were classified as "failure" if they failed to complete HHD training or experienced technique failure (TF) within the first year of treatment. Remaining patients were classified as "success." One hundred seventy-seven patients initiated HHD training. In the "failure" group (n = 32), 24 did not finish training and 8 had TF. In the "success" group (n = 145), 65 (45%) patients remained on NHD, 49 (34%) discontinued HHD because of renal transplantation and 21 (14%) because of death, while only 10 (7%) eventually transferred to another dialysis modality. In a multivariable logistic regression analysis, the strongest predictors of "failure" were end-stage renal disease because of diabetes (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.4-10.3, P = 0.008) and use of rental housing (OR 3.1, 95% CI 1.3-6.0, P = 0.01). Both medical and social factors are associated with failure to adopt HHD. Enhanced supports or a customized education strategy for these vulnerable patients should be considered.

The beliefs and expectations of patients and caregivers about home haemodialysis: an interview study

OBJECTIVES

To explore the beliefs and expectations of patients and their caregivers about home haemodialysis in Italy where the prevalence of home haemodialysis is low.

DESIGN

Semistructured, qualitative interview study with purposive sampling and thematic analysis.

SETTING

Four dialysis centres in Italy without home haemodialysis services (Bari, Marsala, Nissoria and Taranto).

PARTICIPANTS

22 patients receiving in-centre haemodialysis and 20 of their identified caregivers.

RESULTS

We identified seven major themes that were central to patient and caregiver perceptions of home haemodialysis in regions without established services. Three positive themes were: flexibility and freedom (increased autonomy, minimised wasted time, liberation from strict dialysis schedules and gaining self-worth); comfort in familiar surroundings (family presence and support, avoiding the need for dialysis in hospital) and altruistic motivation to do home haemodialysis as an exemplar for other patients and families. Four negative themes were: disrupting sense of normality; family burden (an onerous responsibility, caregiver uncertainty and panic and visually confronting); housing constraints; healthcare by 'professionals' not 'amateurs' (relinquishing security and satisfaction with in-centre services) and isolation from peer support.

CONCLUSIONS

Patients without direct experience or previous education about home haemodialysis and their caregivers recognise the autonomy of home haemodialysis but are very concerned about the potential burden and personal sacrifice home haemodialysis will impose on caregivers and feel apprehensive about accepting the medical responsibilities of dialysis. To promote acceptance and uptake of home haemodialysis among patients and caregivers who have no experience of home dialysis, effective strategies are needed that provide information about home haemodialysis to patients and their caregivers, assure access to caregiver respite, provide continuous availability of medical and technical advice and facilitate peer patient support.

Caregiver burden among nocturnal home hemodialysis patients

Recent studies have suggested improvements in quality of life (QOL) in patients on quotidian dialysis compared with conventional hemodialysis. Few studies have focused on the burden and QOL in caregivers of patients with end-stage renal disease (ESRD) on nocturnal home hemodialysis (NHD). We aim to assess the caregivers' burden, QOL, and depressive symptoms and to compare these parameters with their patients' counterparts. Cross-sectional surveys were sent to 61 prevalent NHD patients and their caregivers. Surveys assessed demographics, general self-perceived health using the 12-Item Short Form Health Survey (SF-12) and the presence of depression using the Beck Depression Inventory. Subjective burden on caregivers was assessed by the Caregiver Burden scale and was compared with perceived burden by the patients. Thirty-six patients and 31 caregivers completed the survey. The majority of caregivers were female (66%), spouse (81%) with no comorbid illness (72%). Their mean age was 51 ± 11 years. Patients were mostly male (64%) with a median ESRD vintage of 60 months (interquartile range [IQR], 18-136 months) and a mean age of 52 ± 10 years. Compared to caregivers, patients had lower perceived physical health score but had similar mental health score. Depression criteria were present in 47% of patients and 25% of caregivers. Total global burden perceived by either caregivers or patients is relatively low. Although there is a relatively low global burden perceived by caregivers and patients undergoing NHD, a significant proportion of both groups fulfilled criteria for depression. Further innovative approaches are needed to support caregivers and patients performing NHD to reduce the intrusion of caring for a chronic illness and the risk of developing depression.

Choosing to live with home dialysis-patients' experiences and potential for telemedicine support: a qualitative study

BACKGROUND

This study examines the patients' need for information and guidance in the selection of dialysis modality, and in establishing and practicing home dialysis. The study focuses on patients' experiences living with home dialysis, how they master the treatment, and their views on how to optimize communication with health services and the potential of telemedicine.

METHODS

We used an inductive research strategy and conducted semi-structured interviews with eleven patients established in home dialysis. Our focus was the patients' experiences with home dialysis, and our theoretical reference was patients' empowerment through telemedicine solutions. Three informants had home haemodialysis (HHD); eight had peritoneal dialysis (PD), of which three had automated peritoneal dialysis (APD); and five had continuous ambulatory peritoneal dialysis (CAPD). The material comprises all PD-patients in the catchment area capable of being interviewed, and all known HHD-users in Norway at that time.

RESULTS

All of the interviewees were satisfied with their choice of home dialysis, and many experienced a normalization of daily life, less dominated by disease. They exhibited considerable self-management skills and did not perceive themselves as ill, but still required very close contact with the hospital staff for communication and follow-up. When choosing a dialysis modality, other patients' experiences were often more influential than advice from specialists. Information concerning the possibility of having HHD, including knowledge of how to access it, was not easily available. Especially those with dialysis machines, both APD and HHD, saw a potential for telemedicine solutions.

CONCLUSIONS

As home dialysis may contribute to a normalization of life less dominated by disease, the treatment should be organized so that the potential for home dialysis can be fully exploited. Pre-dialysis information should be unbiased and include access to other patients' experiences. Telemedicine may potentially facilitate a communication-based follow-up and improve safety within the home setting, making it easier to choose and live with home dialysis.

Clinician beliefs and attitudes about home haemodialysis: a multinational interview study

OBJECTIVES

To explore clinician beliefs and attitudes about home haemodialysis in global regions where the prevalence of home haemodialysis is low, and to identify barriers to developing home haemodialysis services and possible strategies to increase acceptance and uptake of home haemodialysis.

DESIGN

Semistructured interviews, thematic analysis.

SETTING

15 dialysis centres in Italy, Portugal, France, Germany, Sweden and Argentina.

PARTICIPANTS

28 nephrologists and 14 nurses caring for patients receiving in-centre haemodialysis.

RESULTS

We identified four major themes as being central to clinician beliefs about home haemodialysis in regions without established services: external structural barriers (ready access to dialysis centres, inadequate housing conditions, unstable economic environment); dialysis centre characteristics (availability of alternative treatments, competing service priorities, commercial interests); clinician responsibility and motivation (preserving safety and security, lack of awareness, knowledge and experience, potential to offer lifestyle benefits, professional interest and advancement); and cultural apprehension (an unrelenting imposition, carer burden, attachment to professional healthcare provision, limited awareness).

CONCLUSIONS

Despite recognising the potential benefits of home haemodialysis, clinicians practicing in Europe and South America felt apprehensive and doubted the feasibility of home haemodialysis programmes. Programmes that provide clinicians with direct experience of home haemodialysis could increase acceptance and motivation for home-based haemodialysis, as might service prioritisation and funding models that favour home haemodialysis.

International practice patterns and factors associated with non-conventional hemodialysis utilization

Background

The purpose of our study was to determine characteristics that influence the utilization of non-conventional hemodialysis (NCHD) therapies and its subtypes (nocturnal (NHD), short daily (SDHD), long conventional (LCHD) and conventional hemodialysis (CHD) as well as provider attitudes regarding the evidence for NCHD use.

Methods

An international cohort of subscribers of a nephrology education website http://www.nephrologynow.com was invited to participate in an online survey. Non-conventional hemodialysis was defined as any forms of hemodialysis delivered > 3 treatments per week and/or > 4 hours per session. NHD and SDHD included both home and in-centre. Respondents were categorized as CHD if their centre only offered conventional thrice weekly hemodialysis. Variables associated with NCHD and its subtypes were determined using multivariate logistic regression analysis. The survey assessed multiple domains regarding NCHD including reasons for initiating and discontinuing, for not offering and attitudes regarding evidence.

Results

544 surveys were completed leading to a 15.6% response rate. The final cohort was limited to 311 physicians. Dialysis modalities utilized among the respondents were as follows: NCHD194 (62.4%), NHD 83 (26.7%), SDHD 107 (34.4%), LCHD 81 (26%) and CHD 117 (37.6%). The geographic regions of participants were as follows: 11.9% Canada, 26.7% USA, 21.5% Europe, 6.1% Australia/New Zealand, 10% Africa/Middle East, 10.9% Asia and 12.9% South America. Variables associated with NCHD utilization included NCHD training (OR 2.47 CI 1.25-4.16), government physician reimbursement (OR 2.66, CI 1.11-6.40), practicing at an academic centre (OR 2.28 CI 1.25-4.16), higher national health care expenditure and number of ESRD patients per centre. Hemodialysis providers with patients on NCHD were significantly more likely to agree with the statements that NCHD improves quality of life, improves nutritional status, reduces EPO requirements and is cost effective. The most common reasons to initiate NCHD were driven by patient preference and the desire to improve volume control and global health outcomes.

Conclusion

Physician attitudes toward the evidence for NCHD differ significantly between NCHD providers and conventional HD providers. Interventions and health policy targeting these areas along with increased physician education and training in NCHD modalities may be effective in increasing its utilization.

Outcomes on home haemodialysis: registry challenges

Health care policy is encouraging expansion of home haemodialysis, aiming to improve patient outcomes and reduce cost. However, most patient outcome data derive from retrospective observational studies, with all their inherent weaknesses. Conventional thrice weekly home haemodialysis delivers a 22-51% reduction in mortality, but why should that be? Frequent and/or nocturnal haemodialysis reduces mortality by 36-66%, with comparable outcomes to deceased donor kidney transplantation. Approaches which might improve the quality of future observational studies are discussed. Patient-relevant outcomes other than mortality are also discussed.

An economic assessment model for in-center, conventional home, and more frequent home hemodialysis

More intensive and/or frequent hemodialysis may provide clinical benefits to patients with end-stage renal disease; however, these dialysis treatments are more convenient to the patients if provided in their homes. Here we created a standardized model, based on a systematic review of available costing literature, to determine the economic viability of providing hemodialysis in the home that arrays costs and common approaches for assessing direct medical and nonmedical costs. Our model was based on data from Australia, Canada, and the United Kingdom. The first year start-up costs for all hemodialysis modalities were higher than in subsequent years with modeled costs for conventional home hemodialysis lower than in-center hemodialysis in subsequent years. Modeled costs for frequent home hemodialysis was higher than both in-center and conventional home hemodialysis in the United Kingdom, but lower than in-center hemodialysis and higher than conventional home hemodialysis in Australia and Canada in subsequent years. The higher costs of frequent compared to conventional home hemodialysis were because of higher consumable usage due to dialysis frequency. Thus, our findings reinforce the conclusions of previous studies showing that home-based conventional and more frequent hemodialysis may provide clinical benefit at reasonable costs.

Effect of an in-hospital chronic kidney disease education program among patients with unplanned urgent-start dialysis

BACKGROUND AND OBJECTIVES

The effect of in-hospital education on the adoption of home dialysis (peritoneal dialysis [PD] and home hemodialysis [HHD]) after an unplanned dialysis start is unknown.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Clinical demographics of consecutive patients acutely initiating hemodialysis (HD) from January 2005 to December 2009 were abstracted using institutional electronic records. All patients received multimedia chronic kidney disease education by the same advanced care nurse practitioner before discharge from the hospital. Clinical characteristics of patients choosing home dialysis or staying on in-center HD were compared.

RESULTS

Between 2005 and 2009, 228 patients acutely started renal replacement therapy (RRT) at the center. Seventy-one patients chose home dialysis (49 patients adopted PD and 22 adopted HHD), 132 chose to remain on in-center HD, and 25 died before discharge from the hospital. Patients adopting home dialysis tended to be younger than in-center HD patients (55 ± 18 [home dialysis] versus 59 ± 16 [in center] years; P=0.09) and were similar in gender distribution (49% [home dialysis] versus 56% [in center] male; P=0.2). Patients adopting home dialysis were more likely to have a failed kidney transplant (24% [home dialysis] versus 12% [in center]; P=0.045) and less likely to have ischemic nephropathy (9% [home dialysis] versus 21% [in center]; P=0.03). The distribution of comorbid conditions was different between patients adopting home dialysis and in-center HD.

CONCLUSIONS

Home dialysis is feasible after urgent dialysis start. Education should be promoted among patient experiencing acute-start dialysis.

Recruitment and training for home hemodialysis: experience and lessons from the Nocturnal Dialysis Trial

BACKGROUND AND OBJECTIVES

We assessed perceived barriers and incentives to home hemodialysis and evaluated potential correlates with the duration of home hemodialysis training.

DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS

Surveys were sent to the principal investigator and study coordinator for each clinical center in the Frequent Hemodialysis Network Nocturnal Trial. Baseline data were obtained on medical comorbidities, cognitive and physical functioning, sessions required for home hemodialysis training, and costs of home renovations.

RESULTS

The most commonly perceived barriers included lack of patient motivation, unwillingness to change from in-center modality, and fear of self-cannulation. The most common incentives were greater scheduling flexibility and reduced travel time. The median costs for home renovations varied between $1191 and $4018. The mean number of home hemodialysis training sessions was 27.7 +/- 10.4 (11-59 days). Average training time was less for patients with experience in either self-care or both self-care and cannulation. The number of training sessions was unrelated to the score on the Modified Mini Mental Status or Trailmaking B tests or patient's education level. Training time also did not correlate with the SF-36 Physical Function subscale but did with the modified Charlson comorbidity score and older patient age.

CONCLUSIONS

Lack of patient or family motivation and fear of the dialysis process are surmountable barriers for accepting home hemodialysis as a modality for renal replacement therapy. Formal education and scores on cognitive function tests are not predictors of training time.

Dialysis modality choices among chronic kidney disease patients: identifying the gaps to support patients on home-based therapies

BACKGROUND

Home dialysis is a cost-effective renal replacement strategy, which provides improved quality of life compared to conventional in-center hemodialysis (CHD). To date, most studies support the use of multidisciplinary chronic kidney disease (CKD) clinics to facilitate timely initiation of dialysis. This is an observational cohort study examining 486 patients with CKD over the period of 2001-2007 to ascertain potential demographic differences among patients transitioned to in-center versus home dialysis.

SUBJECTS AND METHODS

From January 2001 to December 2007, 486 patients with CKD attended the multidisciplinary renal management clinic at the University Health Network in Toronto.

RESULTS

One hundred and fifty-three of the 486 patients were initiated on renal replacement therapy [59 to center hemodialysis (CHD), 15 to home hemodialysis (HHD) and 79 to home peritoneal dialysis (PD)]. HHD patients were younger (48 ± 15 years) than those who selected CHD (62 ± 16 years) or PD (64 ± 16 years). Although the gender distribution was similar overall, the percentage of single males was higher in CHD versus home dialysis patients (29 vs. 15%, P < 0.05). There were no significant differences in other demographic, clinical and biochemical parameters at the time of dialysis initiation. Disinterest in home dialysis by patients and their families (25.4%) and lack of social support (12.1%) constituted the main barriers to home dialysis. Medical contraindications for home dialysis were present among 11% of the patients. Other less frequent barriers were inadequate space, communication barrier and inability to perform their own dialysis.

CONCLUSIONS

Sixty-one percent of patients requiring dialysis chose a home dialysis modality. Patients' and their families' disinterest in home dialysis and lack of support (either perceived or actual) represented the major overall barriers to adoption of home dialysis.

Novel Trends in Haemodialysis: Where Are We Heading?

The mortality and morbidity of end-stage renal failure patients undergoing conventional thrice weekly in-centre haemodialysis remain alarmingly high despite continuing advances in haemodialysis technologies and improvements in clinical care. Home haemodialysis continues to be under-utilised in many parts of the world despite the reported benefits. Alternative haemodialysis regimens including longer and/or more frequent dialysis (e.g. nocturnal haemodialysis and short daily haemodialysis), haemodiafiltration and the use of high flux dialysers have become more widespread in recent years as nephrologists struggle to improve the dismal survival figures. Whilst most of the encouraging data have come from observational studies, many randomised controlled trials which will provide more robust data are already underway. This review aims to provide a concise update of the recent and novel trends in haemodialysis. Key words: Haemodiafiltration, High flux dialysis, Home haemodialysis, Nocturnal haemodialysis, Short daily haemodialysis

Home haemodialysis in Australia - is the wheel turning full circle?

In the mid 1970s, home haemodialysis accounted for nearly half of all patients on dialysis, both in Australia and elsewhere. The advent of both peritoneal dialysis (itself a home therapy) and satellite haemodialysis resulted in a gradual attrition in the use of home haemodialysis. Since 2000, the introduction of nocturnal home haemodialysis has begun to change this pattern in Australia, with a sharp growth in the uptake of home haemodialysis. Home haemodialysis, which enables longer hours and more frequent treatments than facility-based (hospital or satellite centre) dialysis, appears to offer improved patient outcomes in observational studies; randomised studies are necessary to confirm these findings. Home haemodialysis is also a cheaper form of therapy than facility-based dialysis. As newer, simpler and more user-friendly equipment is emerging that will make home haemodialysis even more accessible and attractive to the consumer, we believe that this trend toward a greater uptake of home haemodialysis should and will continue.

The EVEREST study: an international collaboration

Rates of initiation of renal replacement therapy (RRT), use of home modalities of treatment and patient outcomes vary considerably between countries. This paper reports the methods and baseline characteristics of countries participating in the EVEREST study (n = 46), a global collaboration examining the association between medical and non-medical factors and RRT incidence, modality mix and survival. Numbers of incident and prevalent patients were collected for current (2003-05) and historic (1983-85, 1988-90, 1993-95 and 1998-2000) periods stratified, where available, by age, gender, treatment modality and cause of end stage renal disease (diabetic versus non-diabetic). General population age and health indicators and national-level macroeconomic data were collected from secondary data sources. National experts provided primary data on renal service funding, resources and organization. The median (inter quartile range) RRT incidence per million of the population (pmp) was 130 pmp (102-167 pmp). The general population life expectancy at 60 was 22.1 years (19.7-23.1 years) and 6.9% had diabetes mellitus (5.4-9.0%). Healthcare spending as a percentage of gross domestic product was 8.1% (5.6-9.3%). Countries averaged nine dialysis facilities pmp (4-12 pmp), with 69.0% (43.9-99.0%) owned by the public or private not-for-profit sector. The number of nephrologists ranged from 0.5 to 48 pmp (median 12 pmp). The heterogeneity of EVEREST countries will enable modelling to examine the independent association between medical and non-medical factors on RRT epidemiology.

The cost-effectiveness of increasing kidney transplantation and home-based dialysis

BACKGROUND

Renal replacement therapy (RRT) consumes sizable proportions of health budgets internationally, but there is considerable variability in choice of RRT modality among and within countries with major implications for health outcomes and costs. We aimed to quantify these implications for increasing kidney transplantation and improving the rate of home-based dialysis.

METHODS

A multiple cohort Markov model was used to assess costs and health outcomes of RRT for new end-stage kidney disease (ESKD) patients in Australia for 2005-2010, using a health-care funder perspective. Patient characteristics and current practice patterns were based on the ANZDATA Registry. Two proposed changes were modelled: (i) increasing kidney transplants by between 10% and 50% by 2010; and (ii) increasing home haemodialysis (HD) and peritoneal dialysis (PD) to the highest rates observed among Australian centres. We assessed costs (Australian dollars), survival and quality-adjusted survival, and cost-effectiveness.

RESULTS

The number of new ESKD patients in 2010 was estimated to be 2700, with annual RRT costs of about $A700 million; cumulative costs (2005-2010) were $A5 billion. Increasing transplants by 10-50% saves between $A5.8 and $A26.2 million, and increases quality-adjusted life years (QALYs) by 130-658 QALYs. Switching new patients from hospital HD to (i) home HD saves $A46.6 million by 2010; or (ii) PD saves $A122.1 million.

CONCLUSIONS

These clinical practice changes reduce costs, improve patient quality of life and, in the case of transplantation, increase survival. Planning for RRT services should incorporate efforts to maximize rates of transplantation and to encourage home-based over hospital-based dialysis to optimize cost-effectiveness in RRT service delivery.