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Hussein WF, Chen S, Bennett PN, Atwal J, Abra G, Weinhandl E, Zheng S, Pravoverov L, Schiller B. Description and outcomes of a staff-assisted peritoneal dialysis program in the United States. Perit Dial Int 2024:8968608241259607. [PMID: 38881397 DOI: 10.1177/08968608241259607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Staff-assisted peritoneal dialysis (PD) can help overcome barriers to self-care but is not yet available in the United States (US). We developed and implemented a staff-assisted PD program that fits within current regulatory and cost restraints in the US healthcare environment. METHODS Patient care technicians (PCTs) were trained on PD procedures and troubleshooting common problems. The program expanded from two centers in August 2020 to sixteen by October 2022. We described the logistic elements of program delivery, and patient and treatment outcomes for patients discharged by end of April 2023, with a cohort follow up until October 2023. RESULTS A total of 121 patients were referred to the program. The most common indications for referral were physical function limitations, cognitive impairment, and psychosocial challenges. Staff assistance was provided for 73 patients. Mean age was 72 (standard deviation 14) years. A total of 604 visits were delivered, with a median 5 (interquartile range [IQR] 3-10, range: 1-49) visits per patient. Median duration of assistance was 8 (IQR: 2-21, range: 1-84) days. Assistance was most frequently needed for PD treatment setup and for observing and directing the technique. No peritonitis events or exit-site infections were reported. Sixty-eight patients (93%) were discharged on PD without staff assistance. The 6- and 12-month survival of PD without assistance was 71% and 57%, respectively. CONCLUSIONS Staff-assisted PD for limited time periods is operationally feasible with PCTs in the US and can support transitioning and maintaining patients on PD.ClinicalTrials.gov Identifier: NCT04319185.
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Affiliation(s)
- Wael F Hussein
- Satellite Healthcare, San Jose, CA, USA
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Paul N Bennett
- School of Nursing and Midwifery, Griffith University, Brisbane, Australia
| | | | - Graham Abra
- Satellite Healthcare, San Jose, CA, USA
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Eric Weinhandl
- Satellite Healthcare, San Jose, CA, USA
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN, USA
| | - Sijie Zheng
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, The Permanente Medical Group, Oakland, CA, USA
| | - Leonid Pravoverov
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, The Permanente Medical Group, Oakland, CA, USA
| | - Brigitte Schiller
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
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2
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Desbiens LC, Bargman JM, Chan CT, Nadeau-Fredette AC. Integrated home dialysis model: facilitating home-to-home transition. Clin Kidney J 2024; 17:i21-i33. [PMID: 38846416 PMCID: PMC11151120 DOI: 10.1093/ckj/sfae079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Indexed: 06/09/2024] Open
Abstract
Peritoneal dialysis (PD) and home hemodialysis (HHD) are the two home dialysis modalities offered to patients. They promote patient autonomy, enhance independence, and are generally associated with better quality of life compared to facility hemodialysis. PD offers some advantages (enhanced flexibility, ability to travel, preservation of residual kidney function, and vascular access sites) but few patients remain on PD indefinitely due to peritonitis and other complications. By contrast, HHD incurs longer and more intensive training combined with increased upfront health costs compared to PD, but is easier to sustain in the long term. As a result, the integrated home dialysis model was proposed to combine the advantages of both home-based dialysis modalities. In this paradigm, patients are encouraged to initiate dialysis on PD and transfer to HHD after PD termination. Available evidence demonstrates the feasibility and safety of this approach and some observational studies have shown that patients who undergo the PD-to-HHD transition have clinical outcomes comparable to patients who initiate dialysis directly on HHD. Nevertheless, the prevalence of PD-to-HHD transfers remains low, reflecting the multiple barriers that prevent the full uptake of home-to-home transitions, notably a lack of awareness about the model, home-care "burnout," clinical inertia after a transfer to facility HD, suboptimal integration of PD and HHD centers, and insufficient funding for home dialysis programs. In this review, we will examine the conceptual advantages and disadvantages of integrated home dialysis, present the evidence that underlies it, identify challenges that prevent its success and finally, propose solutions to increase its adoption.
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Affiliation(s)
- Louis-Charles Desbiens
- Department of Medicine, Université de Montréal, Montreal, Canada
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Montreal, Canada
| | - Joanne M Bargman
- Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Christopher T Chan
- Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Annie-Claire Nadeau-Fredette
- Department of Medicine, Université de Montréal, Montreal, Canada
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Montreal, Canada
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3
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Virtanen J, Heiro M, Koivuviita N, Löyttyniemi E, Järvisalo MJ, Tertti R, Metsärinne K, Hellman T. Survival, cumulative hospital days and infectious complications in urgent-start PD compared with urgent-start HD. Perit Dial Int 2024:8968608241244939. [PMID: 38661183 DOI: 10.1177/08968608241244939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Urgent-start peritoneal dialysis (PD) carries a similar efficacy and safety profile compared to urgent-start haemodialysis (HD) but is only sparsely applied due to resource issues and concerns of complication risks. Furthermore, few data exist on adverse outcomes associated with central venous catheter (CVC) insertions in urgent-start HD patients. Thus, we sought to compare patient and dialysis-related outcomes in patients undergoing urgent-start PD or HD. METHODS All patients initiating urgent-start PD in a tertiary research hospital in 2005-2018 were included in this retrospective, single-centre, comparative study and matched with urgent-start HD patients of similar age and chronic kidney disease aetiology. All urgent-start PDs were initiated within 72 h after catheter insertion, and urgent-start HDs were performed via a CVC. All analyses were performed at 3 months and at 1 year of follow-up, respectively. RESULTS Thirty-three patients who commenced urgent-start PD and 58 matched urgent-start HD control patients were included. Altogether, 26 patients (29%; PD: 36%, HD 24%) died within the 1-year follow-up, and patient survival was similar at 3 months (hazard ratio (HR): 1.15, 95% confidence interval (CI): 0.35-3.81, p = 0.82) and at 1 year of follow-up (HR: 0.64, 95% CI: 0.30-1.39, p = 0.26) between the study groups. There were no differences in the total kidney replacement therapy (KRT)-related infection rate (p = 0.66) or cumulative first-year hospital care days (p = 0.43) between the treatment groups. Altogether, 139 CVCs were inserted during the 1-year follow-up. The number of CVCs per patient was associated with the emergence of blood culture-positive bacteraemia and increased cumulative first-year hospital care days. CONCLUSIONS Patient survival, cumulative first-year hospital care days and total KRT-related infection rate at 3 months and 1-year follow-up are similar between urgent-start PD and urgent-start HD patients. Furthermore, CVC insertion rate is associated with incident blood culture-positive bacteraemia and increased cumulative first-year hospital care days.
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Affiliation(s)
- Jonna Virtanen
- Kidney Center, Department of Internal Medicine, Turku University Hospital and University of Turku, Finland
| | - Maija Heiro
- Department of Internal Medicine, Vaasa Central Hospital and University of Turku, Vaasa, Finland
| | - Niina Koivuviita
- Kidney Center, Department of Internal Medicine, Turku University Hospital and University of Turku, Finland
| | - Eliisa Löyttyniemi
- Department of Biostatistics, University of Turku and Turku University Hospital, Finland
| | - Mikko J Järvisalo
- Kidney Center, Department of Internal Medicine, Turku University Hospital and University of Turku, Finland
- Department of Internal Medicine, Satakunta Central Hospital, Pori, Finland
| | - Risto Tertti
- Department of Internal Medicine, Vaasa Central Hospital and University of Turku, Vaasa, Finland
| | - Kaj Metsärinne
- Kidney Center, Department of Internal Medicine, Turku University Hospital and University of Turku, Finland
| | - Tapio Hellman
- Kidney Center, Department of Internal Medicine, Turku University Hospital and University of Turku, Finland
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4
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Viecelli AK, Teixeira-Pinto A, Valks A, Baer R, Cherian R, Cippà PE, Craig JC, DeSilva R, Jaure A, Johnson DW, Kiriwandeniya C, Kopperschmidt P, Liu WJ, Lee T, Lok C, Madhan K, Mallard AR, Oliver V, Polkinghorne KR, Quinn RR, Reidlinger D, Roberts M, Sautenet B, Hooi LS, Smith R, Snoeijs M, Tordoir J, Vachharajani TJ, Vanholder R, Vergara LA, Wilkie M, Yang B, Yuo TH, Zou L, Hawley CM. Study protocol for Vascular Access outcome measure for function: a vaLidation study In hemoDialysis (VALID). BMC Nephrol 2022; 23:372. [PMCID: PMC9675211 DOI: 10.1186/s12882-022-02987-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 10/24/2022] [Indexed: 11/21/2022] Open
Abstract
Background A functioning vascular access (VA) is crucial to providing adequate hemodialysis (HD) and considered a critically important outcome by patients and healthcare professionals. A validated, patient-important outcome measure for VA function that can be easily measured in research and practice to harvest reliable and relevant evidence for informing patient-centered HD care is lacking. Vascular Access outcome measure for function: a vaLidation study In hemoDialysis (VALID) aims to assess the accuracy and feasibility of measuring a core outcome for VA function established by the international Standardized Outcomes in Nephrology (SONG) initiative. Methods VALID is a prospective, multi-center, multinational validation study that will assess the accuracy and feasibility of measuring VA function, defined as the need for interventions to enable and maintain the use of a VA for HD. The primary objective is to determine whether VA function can be measured accurately by clinical staff as part of routine clinical practice (Assessor 1) compared to the reference standard of documented VA procedures collected by a VA expert (Assessor 2) during a 6-month follow-up period. Secondary outcomes include feasibility and acceptability of measuring VA function and the time to, rate of, and type of VA interventions. An estimated 612 participants will be recruited from approximately 10 dialysis units of different size, type (home-, in-center and satellite), governance (private versus public), and location (rural versus urban) across Australia, Canada, Europe, and Malaysia. Validity will be measured by the sensitivity and specificity of the data acquisition process. The sensitivity corresponds to the proportion of correctly identified interventions by Assessor 1, among the interventions identified by Assessor 2 (reference standard). The feasibility of measuring VA function will be assessed by the average data collection time, data completeness, feasibility questionnaires and semi-structured interviews on key feasibility aspects with the assessors. Discussion Accuracy, acceptability, and feasibility of measuring VA function as part of routine clinical practice are required to facilitate global implementation of this core outcome across all HD trials. Global use of a standardized, patient-centered outcome measure for VA function in HD research will enhance the consistency and relevance of trial evidence to guide patient-centered care. Trial registration Clinicaltrials.gov: NCT03969225. Registered on 31st May 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02987-1.
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Affiliation(s)
- Andrea K. Viecelli
- grid.412744.00000 0004 0380 2017Department of Nephrology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102 Australia ,grid.489335.00000000406180938The Translational Research Institute, Brisbane, Australia ,grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Armando Teixeira-Pinto
- grid.1013.30000 0004 1936 834XCentre for Kidney Research, School of Public Health, The University of Sydney, Sydney, Australia
| | - Andrea Valks
- grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Richard Baer
- grid.416528.c0000 0004 0637 701XMater Hospital Brisbane, Brisbane, Queensland Australia
| | - Roy Cherian
- grid.460765.60000 0004 0430 0107Mackay Base Hospital, Mackay, Australia
| | - Pietro E. Cippà
- grid.469433.f0000 0004 0514 7845Division of Nephrology, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Jonathan C. Craig
- grid.1014.40000 0004 0367 2697Flinders University, Adelaide, Australia
| | - Ranil DeSilva
- grid.21925.3d0000 0004 1936 9000University of Pittsburgh, Pittsburgh, PA USA
| | - Allison Jaure
- grid.1013.30000 0004 1936 834XThe University of Sydney, Sydney, Australia
| | - David W. Johnson
- grid.412744.00000 0004 0380 2017Department of Nephrology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102 Australia ,grid.489335.00000000406180938The Translational Research Institute, Brisbane, Australia ,grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Charani Kiriwandeniya
- grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | | | - Wen-J Liu
- grid.413461.50000 0004 0621 7083Sultanah Aminah, Johor Bahru, Malaysia
| | - Timmy Lee
- grid.280808.a0000 0004 0419 1326Veterans Affairs Medical Center, Birmingham, AL USA
| | - Charmaine Lok
- grid.17063.330000 0001 2157 2938University of Toronto, Toronto, Ontario Canada
| | | | - Alistair R. Mallard
- grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Veronica Oliver
- grid.412744.00000 0004 0380 2017Department of Nephrology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102 Australia
| | - Kevan R. Polkinghorne
- grid.416060.50000 0004 0390 1496Department of Nephrology, Monash Medical Centre, Monash Health, Clayton, VIC Australia ,grid.1002.30000 0004 1936 7857Department of Medicine, Monash University, Clayton, VIC Australia ,grid.1002.30000 0004 1936 7857Department of Epidemiology & Preventive Medicine, Monash University, Clayton, VIC Australia
| | - Rob R. Quinn
- grid.22072.350000 0004 1936 7697Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Donna Reidlinger
- grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Matthew Roberts
- grid.1002.30000 0004 1936 7857Eastern Health Clinical School, Monash University, Melbourne, Australia
| | | | - Lai Seong Hooi
- grid.413461.50000 0004 0621 7083Sultanah Aminah, Johor Bahru, Malaysia
| | - Rob Smith
- grid.240634.70000 0000 8966 2764Patient Partner, Royal Darwin Hospital, Darwin, Australia
| | - Maarten Snoeijs
- grid.412966.e0000 0004 0480 1382Maastricht University Medical Center, Maastricht, Netherlands
| | - Jan Tordoir
- grid.412966.e0000 0004 0480 1382Maastricht University Medical Center, Maastricht, Netherlands
| | - Tushar J. Vachharajani
- grid.239578.20000 0001 0675 4725Department of Kidney Medicine, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, USA ,grid.254293.b0000 0004 0435 0569Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | | | - Liza A. Vergara
- grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
| | - Martin Wilkie
- grid.31410.370000 0000 9422 8284Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Bing Yang
- grid.411634.50000 0004 0632 4559Peking University People’s Hospital, Beijing, China
| | - Theodore H. Yuo
- grid.21925.3d0000 0004 1936 9000University of Pittsburgh, Pittsburgh, PA USA
| | - Li Zou
- grid.411634.50000 0004 0632 4559Peking University People’s Hospital, Beijing, China
| | - Carmel M. Hawley
- grid.412744.00000 0004 0380 2017Department of Nephrology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102 Australia ,grid.489335.00000000406180938The Translational Research Institute, Brisbane, Australia ,grid.1003.20000 0000 9320 7537Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia
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5
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Okpechi IG, Jha V, Cho Y, Ye F, Ijezie CI, Jindal K, Klarenbach S, Makusidi MA, Okpechi-Samuel US, Okwuonu C, Shah N, Thompson S, Tonelli M, Johnson DW, Bello AK. The case for Increased Peritoneal Dialysis Utilization in Low- and Lower-Middle-Income Countries. Nephrology (Carlton) 2022; 27:391-403. [PMID: 35060223 DOI: 10.1111/nep.14024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/03/2022] [Accepted: 01/13/2022] [Indexed: 11/30/2022]
Abstract
Peritoneal dialysis (PD) has several advantages compared to hemodialysis (HD), but there is evidence showing underutilization globally, especially in low-income and lower-middle-income countries (LLMICs) where kidney replacement therapies (KRT) are often unavailable, inaccessible, and unaffordable. Only 11% of all dialysis patients worldwide use PD, more than 50% of whom live in China, the United States of America, Mexico, or Thailand. Various barriers to increased PD utilization have been reported worldwide including patient preference, low levels of education, and lower provider reimbursement. However, unique but surmountable barriers are applicable to LLMICs including the excessively high cost of providing PD (related to PD fluids in particular), excessive cost of treatment borne by patients (relative to HD), lack of adequate PD training opportunities for doctors and nurses, low workforce availability for kidney care, and challenges related to some PD outcomes (catheter-related infections, hospitalizations, mortality, etc.). This review discusses some known barriers to PD use in LLMICs and leverages data that show a global trend in reducing rates of PD-related infections, reducing rates of modality switches from HD, and improving patient survival in PD to discuss how PD use can be increased in LLMICs. We therefore, challenge the idea that low PD use in LLMICs is unavoidable due to these barriers and instead present opportunities to improve PD utilization in LLMICs.
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Affiliation(s)
- Ikechi G Okpechi
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada.,Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa.,Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales (UNSW), New Delhi, India.,School of Public Health, Imperial College, London, United Kingdom.,Manipal Academy of Higher Education, Manipal, India
| | - Yeoungjee Cho
- Australasian Kidney Trials Network, University of Queensland, Brisbane, QLD, Australia.,Translational Research Institute, Brisbane, QLD, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Feng Ye
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Chukwuonye I Ijezie
- Division of Renal Medicine, Department of Internal Medicine, Umuahia, Nigeria
| | - Kailash Jindal
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Scott Klarenbach
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Muhammad A Makusidi
- Department of Medicine, College of Health Sciences, Usmanu Danfodiyo University, Renal Centre, Sokoto State, Nigeria
| | | | - Chimezie Okwuonu
- Division of Renal Medicine, Department of Internal Medicine, Umuahia, Nigeria
| | - Nikhil Shah
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Stephanie Thompson
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - David W Johnson
- Translational Research Institute, Brisbane, QLD, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Centre for Kidney Disease Research, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Aminu K Bello
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
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6
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Ding X, Gao W, Guo Y, Cai Q, Bai Y. Comparison of mortality and complications between urgent-start peritoneal dialysis and urgent-start hemodialysis: A systematic review and meta-analysis. Semin Dial 2021; 35:207-214. [PMID: 34435394 DOI: 10.1111/sdi.13001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/25/2021] [Accepted: 06/20/2021] [Indexed: 11/28/2022]
Abstract
The advantages of urgent-start peritoneal dialysis (PD) vis-à-vis urgent-start hemodialysis (HD) are not clear. We performed a systematic review and meta-analysis of studies comparing the two modalities. Databases of PubMed, Embase, Ovoid, and Google Scholar were searched up to November 1, 2020. The primary outcome was mortality, and secondary outcomes were dialysis-related infectious complications and mechanical complications. Risk ratios (RRs) were calculated for all outcomes. Seven studies were included. The pooled analysis revealed a statistically significant reduced risk of all-cause mortality in patients undergoing urgent-start PD as compared to urgent-start HD (RR: 0.61, 95% confidence interval [CI] [0.40, 0.94], I2 = 56.34%). A meta-analysis of dialysis-related infectious complications indicated no statistically significant difference between the two modalities (RR: 0.66, 95% CI [0.29, 1.50], I2 = 69.62%). Our analysis revealed a statistically significant reduced risk of mechanical complications in patients undergoing urgent-start PD (RR: 0.54, 95% CI [0.40, 0.73], I2 = 0%). To conclude, unadjusted data from observational studies are indicative of lower mortality and lower risk of mechanical complications with urgent-start PD versus urgent-start HD. The risk of infectious complications was not different between the two groups. Further studies with a larger sample size using propensity-matched cohorts are needed to strengthen current evidence.
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Affiliation(s)
- Xinyu Ding
- Department of Nephropathy, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Wenfeng Gao
- Department of Urology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yingbo Guo
- Department of Nephropathy, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Qian Cai
- Department of Nephropathy, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yu Bai
- Department of Nephropathy, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
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7
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Smith B, Mirhaidari S, Shoemaker A, Douglas D, Dan AG. Outcomes of Laparoscopic Peritoneal Dialysis Catheter Placement Using an Optimal Placement Technique. JSLS 2021; 25:JSLS.2020.00115. [PMID: 33879992 PMCID: PMC8035820 DOI: 10.4293/jsls.2020.00115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Peritoneal dialysis (PD) is a widely employed renal replacement modality. A prospective study was conducted to determine the short-term and midterm outcomes and complication rates associated with a standardized optimal laparoscopic peritoneal dialysis catheter placement technique. Methods: All patients undergoing laparoscopic PD catheter placement by one surgeon using our standardized method over a 5-year period were entered into a prospective database. Patients were evaluated preoperatively and postoperatively through office visits. Development of complications was assessed using follow up telephone or mail surveys. Results: A total of 100 patients with a mean age of 56 years underwent laparoscopic PD catheter placement over the 5-year study period. In total, 103 laparoscopic PD catheter placement attempts were made in 100 patients. Placement was successful in 98 (95.1%) attempts and no placement required conversion to an open operation. Omentopexy was performed in 82 (83.7%) patients. There was no mortality reported within 30 days of the index operation. For patients who successfully underwent laparoscopic PD placement, early complications developed in 9 (9.2%) patients, of which 6 (6.1%) complications were directly related to the PD catheter. Midterm complications developed in 25 (25.5%) patients. Complication-related catheter repositioning was required for 12 (12.2%) catheters and catheter-related complication removal was required for 18 (18.4%) catheters. Conclusion: Laparoscopic placement of PD catheters can be successfully performed using a combination of described standardized laparoscopic maneuvers for optimal placement resulting in acceptable perioperative and short and midterm complication rates with negligible mortality rates.
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Affiliation(s)
- Brandon Smith
- Department of Surgery, Summa Health Akron City Hospital, Akron, Ohio USA
| | - Shayda Mirhaidari
- Department of Surgery, Summa Health Akron City Hospital, Akron, Ohio USA
| | - Ashley Shoemaker
- Department of Surgery, Summa Health Akron City Hospital, Akron, Ohio USA
| | - Deborah Douglas
- Department of Surgery, Summa Health Akron City Hospital, Akron, Ohio USA
| | - Adrian G Dan
- Department of Surgery, Summa Health Akron City Hospital, Akron, Ohio USA
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8
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Quinn RR, Mohamed F, Pauly R, Schwartz T, Scott-Douglas N, Morrin L, Kozinski A, Manns BJ, Klarenbach S, Clarke A, Fox DE, Oliver MJ. Starting Dialysis on Time, At Home on the Right Therapy (START): Description of an Intervention to Increase the Safe and Effective Use of Peritoneal Dialysis. Can J Kidney Health Dis 2021; 8:20543581211003764. [PMID: 33868692 PMCID: PMC8020238 DOI: 10.1177/20543581211003764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/16/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Most of the patients with end-stage kidney failure are treated with dialysis. Jurisdictions around the world are actively promoting peritoneal dialysis (PD) because it is equivalent to hemodialysis in terms of clinical outcomes, but is less costly. Unfortunately, PD penetration remains low. Objectives: The Starting dialysis on Time, At Home, on the Right Therapy (START) Project had 2 overarching goals: (1) to provide information that would help programs increase the safe and effective use of PD, and (2) to reduce inappropriate, early initiation of dialysis in patients with kidney failure. In this article, we focus on the first objective and describe the rationale for START and the methods employed. Design: The START Project was a comprehensive, province-wide quality improvement intervention. Setting: The START project was implemented in both Alberta Kidney Care (AKC)-South and AKC-North, including all 7 renal programs in the province. Patients: The project included all patients who commenced maintenance dialysis between October 1, 2015, and March 31, 2018, in Alberta, Canada who met our inclusion criteria. Measurements: We reported baseline characteristics of incident dialysis patients overall, and by site. Our key performance indicator was the proportion of patients who received PD for any period of time within 180 days of the first dialysis treatment. Reports also included detailed metrics pertaining to the 6 steps in the process of modality selection and we had the capacity to provide more granular data on an as-needed basis. To understand loss of PD patients, we reported the numbers of incident patients who recovered kidney function, experienced technique failure, received a transplant, were lost to follow-up, transferred to another program, or died. Methods: START provided dialysis programs with a conceptual framework for understanding the drivers of PD utilization. High-quality, detailed data were collected using a tool that was custom-built for this purpose, and were mapped to steps in the process of care that drove the outcomes of interest. This allowed sites to identify gaps in care, develop action plans, and implement local interventions to address them. The process was supported by an Innovation Learning Collaborative consisting of 3 learning sessions that brought frontline staff together from across the province to share strategies and learnings. Ongoing data collection allowed teams to determine whether their interventions were effective at each subsequent learning session, and to revisit their interventions if required (the “Plan-Do-Study-Act Cycle”). Results: Future work will report on the impact of the START project on incident PD utilization at a provincial and regional level. Limitations: The time required to design and implement interventions in practice, as well as the need for multiple PDSA (Plan-Do-Study-Act) cycles to see results, meant that the true potential may not be realized during a relatively short intervention period. Change required buy-in and support from local and provincial leadership and frontline staff. In the absence of accountability for local performance, we relied on the goodwill of participating programs to use the information and resources provided to effect change. Finally, the burden of documentation and data collection for frontline staff was high at baseline. We anticipated that adding supplemental data collection would be difficult. Conclusions: The START project was a comprehensive, province-wide initiative to maximize the safe and effective use of PD in Alberta, Canada. It standardized the management of incident dialysis patients, leveraged high-quality data to facilitate the reporting of metrics mapped to steps in the process of care that drove incident PD utilization, and helped programs to identify gaps in care and target them for improvement. Future work will report on the impact of the program on incident utilization at the provincial and regional level.
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Affiliation(s)
- Robert R Quinn
- Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | | | - Robert Pauly
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | | | | | | | - Braden J Manns
- Cumming School of Medicine, University of Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, AB, Canada
| | - Scott Klarenbach
- Department of Medicine, University of Alberta, Edmonton, Canada.,Institute of Health Economics, Edmonton, Canada
| | - Alix Clarke
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - Danielle E Fox
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - Matthew J Oliver
- Department of Medicine, Division of Nephrology, University of Toronto, ON, Canada
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9
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MacRae JM, Clarke A, Ahmed SB, Elliott M, Quinn RR, James M, King-Shier K, Hiremath S, Oliver MJ, Hemmelgarn B, Scott-Douglas N, Ravani P. Sex differences in the vascular access of hemodialysis patients: a cohort study. Clin Kidney J 2020; 14:1412-1418. [PMID: 33959269 PMCID: PMC8087139 DOI: 10.1093/ckj/sfaa132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 05/18/2020] [Indexed: 11/14/2022] Open
Abstract
Background We describe differences for probability of receiving a fistula attempt, achieving fistula use, remaining catheter-free and the rate of access-related procedures as a function of sex. Methods Prospectively collected vascular access data on incident dialysis patients from five Canadian programs using the Dialysis Measurement Analysis and Reporting System to determine differences in fistula-related outcomes between women and men. The probability of receiving a fistula attempt and the probability of fistula use were determined using binary logistic regression. Catheter and fistula procedure rates were described using Poisson regression. We studied time to fistula attempt and time to fistula use, accounting for competing risks. Results We included 1446 (61%) men and 929 (39%) women. Men had a lower body mass index (P < 0.001) and were more likely to have coronary artery disease (P < 0.001) and peripheral vascular disease (p < 0.001). A total of 688 (48%) men and 403 (43%) women received a fistula attempt. Women were less likely to receive a fistula attempt by 6 months {odds ratio [OR] 0.64 [95% confidence interval (CI) 0.52-0.79]} and to achieve catheter-free use of their fistula by 1 year [OR 0.38 (95% CI 0.27-0.53)]. At an average of 2.30 access procedures per person-year, there is no difference between women and men [incidence rate ratio (IRR) 0.97 (95% CI 0.87-1.07)]. Restricting to those with a fistula attempt, women received more procedures [IRR 1.16 (95% CI 1.04-1.30)] attributed to increased catheter procedures [IRR 1.50 (95% CI 1.27-1.78)]. There was no difference in fistula procedures [IRR women versus men 0.96 (95% CI 0.85-1.07)]. Conclusion Compared with men, fewer women undergo a fistula attempt. This disparity increases after adjusting for comorbidities. Women have the same number of fistula procedures as men but are less likely to successfully use their fistula.
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Affiliation(s)
- Jennifer M MacRae
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Alix Clarke
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sofia B Ahmed
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Meghan Elliott
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Rob R Quinn
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Matthew James
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kathryn King-Shier
- Faculty of Nursing and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Matthew J Oliver
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Brenda Hemmelgarn
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nairne Scott-Douglas
- Division of Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Pietro Ravani
- Libin Cardiovascular Institute, Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
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10
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Wang D, Calabro-Kailukaitis N, Mowafy M, Kerns ES, Suvarnasuddhi K, Licht J, Ahn SH, Hu SL. Urgent-start peritoneal dialysis results in fewer procedures than hemodialysis. Clin Kidney J 2020; 13:166-171. [PMID: 32296520 PMCID: PMC7147319 DOI: 10.1093/ckj/sfz053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/08/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Peritoneal dialysis (PD) is an underutilized modality for hospitalized patients with an urgent need to start renal replacement therapy in the USA. Most patients begin hemodialysis (HD) with a tunneled central venous catheter (CVC). METHODS We examined the long-term burden of dialysis modality-related access procedures with urgent-start PD and urgent-start HD in a retrospective cohort of 73 adults. The number of access-related (mechanical and infection-related) procedures for each modality was compared in the first 30 days and cumulatively through the duration of follow-up. RESULTS Fifty patients underwent CVC placement for HD and 23 patients underwent PD catheter placement for urgent-start dialysis. Patients were followed on average >1 year. The PD group was significantly younger, with less diabetes, with a higher pre-dialysis serum creatinine and more likely to have a planned dialysis access. The mean number of access-related procedures per patient in the two groups was not different at 30 days; however, when compared over the duration of follow-up, the number of access-related procedures was significantly higher in the HD group compared with the PD group (4.6 ± 3.9 versus 0.61 ± 0.84, P < 0.0001). This difference persisted when standardized to procedures per patient-month (0.37 ± 0.57 versus 0.081 ± 0.18, P = 0.019). Infection-related procedures were similar between groups. Findings were the same even after case-matching was performed for age and diabetes mellitus with 18 patients in each group. CONCLUSIONS Urgent-start PD results in fewer invasive access procedures compared with urgent-start HD long term, and should be considered for urgent-start dialysis.
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Affiliation(s)
- Delin Wang
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Medicine, Aspirus Nephrology Clinic, Wausau, WI, USA
| | - Nathan Calabro-Kailukaitis
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Mahmoud Mowafy
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Eric S Kerns
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Khetisuda Suvarnasuddhi
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Jonah Licht
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Providence Access Care, Providence, RI, USA
| | - Sun H Ahn
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Radiology, Rhode Island Hospital, Providence, RI, USA
| | - Susie L Hu
- Division of Kidney Diseases and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Li M, Yan J, Zhang H, Wu Q, Wang J, Liu J, Xing C, Zhou Y. Analysis of outcome and factors correlated with maintenance peritoneal dialysis. J Int Med Res 2019; 47:4683-4690. [PMID: 31446816 PMCID: PMC6833380 DOI: 10.1177/0300060519862091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Objectives This study aimed to analyze the outcome and factors correlated with maintenance peritoneal dialysis (PD) to provide guidance for improving prognosis, and prolonging the catheterization and survival times of patients on PD with end-stage renal disease. Methods Clinical data of patients at The Third Xiangya Hospital of Central South University were retrospectively analyzed. We compared the survival and technique survival rates of patients, and analyzed relevant factors. Results A total of 510 cases of PD were included. Two hundred thirty-nine patients continued to receive PD treatment, 73 received kidney transplants, 72 transferred to hemodialysis, and 126 died. The main reasons of death were cardiovascular (27.00%) and cerebrovascular diseases (23.80%). The main reasons of transfer to HD were peritonitis and inadequate dialysis. The survival rates at 1, 2, 3, 5, and 7 years were 95.75%, 90.34%, 82.35%, 66.21%, and 54.32%, respectively. The technique survival rates at 1, 2, 3, 5, and 7 years were 93.22%, 86.76%, 77.91%, 63.16%, and 47.67%, respectively. Female sex and older age were protective factors that affected patients’ withdrawal from PD and survival time. Conclusions Death is the primary reason for withdrawal from PD. Female sex and older age affect patients’ withdrawal from PD and survival.
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Affiliation(s)
- Min Li
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Jin Yan
- Department of Nursing, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Hao Zhang
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Qiongying Wu
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Jianwen Wang
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Jishi Liu
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Chengling Xing
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Yuqiong Zhou
- Department of Nephrology, The Third Xiangya Hospital of Central South University, Changsha, Hunan Province, China
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12
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Wojtaszek E, Grzejszczak A, Grygiel K, Małyszko J, Matuszkiewicz-Rowińska J. Urgent-Start Peritoneal Dialysis as a Bridge to Definitive Chronic Renal Replacement Therapy: Short- and Long-Term Outcomes. Front Physiol 2019; 9:1830. [PMID: 30662408 PMCID: PMC6328466 DOI: 10.3389/fphys.2018.01830] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 12/06/2018] [Indexed: 01/28/2023] Open
Abstract
Background: The peritoneal dialysis (PD) urgent-start pathway, without typical 2-week break-in period, was meant for late-referral patients able and prone to join PD-first program, with its main advantages such as: keeping the vascular system intact, preserving their residual renal function and retaining life-style flexibility. We compared the short- and long-term outcomes of consecutive 35 patients after urgent- and 94 patients after the planned start of PD as the first choice. Methods: The study included all incident end-stage renal disease patients starting PD program between January 2005 and December 2015, classified into two groups: those with urgent (unplanned) and those with elective (planned) start. Urgent PD was initiated as an overnight automatic procedure (APD) with dwell volume gradually increased, and after 2–3 weeks, target PD method was established. Results: The mean time between catheter implantation and PD start was 3.5 ± 2.3 in urgent and 16.2 ± 1.7 days in planned-start groups (p < 0.00001). 51% of the patients in the urgent-start group required PD during first 48 h after catheter insertion. Mean follow-up of 17.6 ± 11.09 months (median: 19.0) was in the urgent-start group and 28.6 ± 26.6 months (median: 19.5) in the planned-start group. The early mechanical complications were observed more often in the urgent-start group (29 vs. 4%, p = 0.00005). The only significant predictors of early mechanical complications were serum albumin (p = 0.02) and time between the catheter insertion and PD start. The first year patient survival and technique survival censored for death and kidney transplantation were not significantly different between groups. In Cox proportional analysis the independent risk factors for patient survival as well as for method and patient survival appeared Charlson Comorbidity Index CCI (HR 1.4; p = 0.01 and 1.24; p = 0.02) and time from catheter implantation to PD start with HR 5.11; p = 0.03 and 4.29; p = 0.04 for <2 days, while time >14 days lost its predictive value (p = 0.07). Conclusion: Peritoneal dialysis may be a feasible and safe alternative to HD in patients who need to start dialysis urgently without established dialysis access, with an acceptable complications rates, as well as patient and technique survival.
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Affiliation(s)
- Ewa Wojtaszek
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - Agnieszka Grzejszczak
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - Katarzyna Grygiel
- Department of General, Vascular and Transplant Surgery, Warsaw Medical University, Warsaw, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warsaw, Poland
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13
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Kamar F, Quinn RR, Oliver MJ, Viecelli AK, Hiremath S, MacRae J, Miller L, Blake P, Moist L, Garg AX, Lam NN, Kabani R, Clarke A, Liu P, Gillespie B, Ravani P. Outcomes of the First and Second Hemodialysis Fistula: A Cohort Study. Am J Kidney Dis 2018; 73:62-71. [PMID: 30122545 DOI: 10.1053/j.ajkd.2018.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 06/11/2018] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Fistulas are the preferred form of hemodialysis access; however, many fistulas fail to mature into usable accesses after creation. Data for outcomes after placement of a second fistula are limited. STUDY DESIGN Cohort study. SETTING & PARTICIPANTS People who initiated hemodialysis therapy in any of 5 Canadian dialysis programs (2004-2012) and had at least 1 hemodialysis fistula placed. PREDICTOR Second versus initial fistula; receipt of 2 versus 1 fistula; second versus first fistula in recipients of 2 fistulas. OUTCOMES Catheter-free fistula use during 1 year following initiation of hemodialysis therapy or following fistula creation, if created after hemodialysis therapy start; proportion of time with catheter-free use; time to catheter free use; time of functional patency. ANALYTICAL APPROACH Logistic regression; fractional regression. RESULTS Among the 1,091 study participants (mean age, 64±15 [SD] years; 63% men; 59% with diabetes), 901 received 1 and 190 received 2 fistulas. 38% of second fistulas versus 46% of first fistulas were used catheter free at least once. Average percentages of time that second and initial fistulas were used catheter free were 34% and 42%, respectively (OR, 0.72; 95% CI, 0.54-0.94). Compared with people who received 1 fistula, those who received 2 fistulas were less likely to achieve catheter-free use (26% vs 56%) and remain catheter free (23% vs 49% of time; OR, 0.30, 95% CI, 0.24-0.39). Among people who received 2 fistulas, the proportion of time that the second fistula was used catheter free was 11% higher with each 10% greater proportion of time that the first fistula was used catheter free (95% CI, 1%-22%). Model discrimination was modest (C index, 0.69). LIMITATIONS Unknown criteria for patient selection for 1 or 2 fistulas; unknown reasons for prolonged catheter use. CONCLUSIONS Outcomes of a second fistula may be inferior to outcomes of the initial fistula. First and second fistula outcomes are weakly correlated and difficult to predict based on clinical characteristics.
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Affiliation(s)
- Fareed Kamar
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Robert R Quinn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Matthew J Oliver
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrea K Viecelli
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, The University of Ottawa, Ottawa, ON, Canada
| | - Jennifer MacRae
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lisa Miller
- Division of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Blake
- Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada; Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Louise Moist
- Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada; Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Amit X Garg
- Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada; Division of Nephrology, Department of Medicine, Western University, London, ON, Canada; Institute for Clinical Evaluative Sciences, ON, Canada
| | - Ngan N Lam
- University of Alberta, Edmonton, AB, Canada
| | - Rameez Kabani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alix Clarke
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ping Liu
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Brenda Gillespie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Pietro Ravani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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14
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Nayak KS, Subhramanyam SV, Pavankumar N, Antony S, Sarfaraz Khan MA. Emergent Start Peritoneal Dialysis for End-Stage Renal Disease: Outcomes and Advantages. Blood Purif 2018; 45:313-319. [PMID: 29393132 DOI: 10.1159/000486543] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 12/29/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Initiating renal replacement therapy in late referred patients with central venous catheter (CVC) hemodialysis (HD) causes serious complications. In urgent start peritoneal dialysis, initiating peritoneal dialysis (PD) within 14 days of catheter insertion still needs HD with CVC. We initiated Emergent start PD (ESPD) with Automated PD (APD) at our center within 48 h from the time of presentation. METHODS A prospective, case-controlled, intention-to-treat study with 56 patients was conducted between March 2016 and August 2017. Group A (24 patients) underwent conventional PD 14 days after catheter insertion. Group B (32 patients), underwent ESPD with APD. Exit site leak (ESL), catheter blockage, and peritonitis at 90 days were primary outcomes. Technique survival was secondary outcome. RESULTS Baseline characteristics were similar with 3 episodes of ESLs (9.4%) in the study group and none in the control group (p = 0.123). Catheter blockage (16.7%-Group A, 25%-Group B) and peritonitis (none vs. 9.4% in study group) were similar in terms of statistical details just as technique survival (95%-Group A, 88.2%-Group B at 90 days). CONCLUSION ESPD with APD in the unplanned patient is an appropriate approach.
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15
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Gill S, Quinn R, Oliver M, Kamar F, Kabani R, Devoe D, Mysore P, Pannu N, MacRae J, Manns B, Hemmelgarn B, James M, Tonelli M, Lewin A, Liu P, Ravani P. Multi-Disciplinary Vascular Access Care and Access Outcomes in People Starting Hemodialysis Therapy. Clin J Am Soc Nephrol 2017; 12:1991-1999. [PMID: 28912248 PMCID: PMC5718268 DOI: 10.2215/cjn.03430317] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/19/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Fistulas, the preferred form of hemodialysis access, are difficult to establish and maintain. We examined the effect of a multidisciplinary vascular access team, including nurses, surgeons, and radiologists, on the probability of using a fistula catheter-free, and rates of access-related procedures in incident patients receiving hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined vascular access outcomes in the first year of hemodialysis treatment before (2004-2005, preteam period) and after the implementation of an access team (2006-2008, early-team period; 2009-2011, late-team period) in the Calgary Health Region, Canada. We used logistic regression to study the probability of fistula creation and the probability of catheter-free fistula use, and negative binomial regression to study access-related procedure rates. RESULTS We included 609 adults (mean age, 65 [±15] years; 61% men; 54% with diabetes). By the end of the first year of hemodialysis, 102 participants received a fistula in the preteam period (70%), 196 (78%) in the early-team period (odds ratios versus preteam, 1.47; 95% confidence interval, 0.92 to 2.35), and 139 (66%) in the late-team period (0.85; 0.54 to 1.35). Access team implementation did not affect the probability of catheter-free use of the fistula (odds ratio, 0.87; 95% confidence interval, 0.52 to 1.43, for the early; and 0.89; 0.52 to 1.53, for the late team versus preteam period). Participants underwent an average of 4-5 total access-related procedures during the first year of hemodialysis, with higher rates in women and in people with comorbidities. Catheter-related procedure rates were similar before and after team implementation; relative to the preteam period, fistula-related procedure rates were 40% (20%-60%) and 30% (10%-50%) higher in the early-team and late-team periods, respectively. CONCLUSION Introduction of a multidisciplinary access team did not increase the probability of catheter-free fistula use, but resulted in higher rates of fistula-related procedures.
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Affiliation(s)
| | - Robert Quinn
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Oliver
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | | | | | - Daniel Devoe
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Priyanka Mysore
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Neesh Pannu
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Braden Manns
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew James
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Adriane Lewin
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ping Liu
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Departments of Medicine and
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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16
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Javaid MM, Lee E, Khan BA, Subramanian S. Description of an Urgent-Start Peritoneal Dialysis Program in Singapore. Perit Dial Int 2017; 37:500-502. [DOI: 10.3747/pdi.2016.00308] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Muhammad M. Javaid
- Division of Nephrology University Medicine Cluster, National University Hospital Singapore
- Yong Loo Lin School of Medicine National University of Singapore, Singapore
| | - Evan Lee
- Division of Nephrology University Medicine Cluster, National University Hospital Singapore
- Yong Loo Lin School of Medicine National University of Singapore, Singapore
| | - Behram A. Khan
- Division of Nephrology University Medicine Cluster, National University Hospital Singapore
- Yong Loo Lin School of Medicine National University of Singapore, Singapore
| | - Srinivas Subramanian
- Division of Nephrology University Medicine Cluster, National University Hospital Singapore
- Yong Loo Lin School of Medicine National University of Singapore, Singapore
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17
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Walton SM, Basu A, Mullahy J, Hong S, Schumock GT. Measuring the Value of Pharmaceuticals in the US Health System. PHARMACOECONOMICS 2017; 35:1-4. [PMID: 27785770 PMCID: PMC6590687 DOI: 10.1007/s40273-016-0463-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Surrey M Walton
- Department of Pharmacy Systems Outcomes and Policy, College of Pharmacy, University of Illinois, 833 S. Wood Street (M/C 871) rm 287, Chicago, IL, 60612, USA.
| | - Anirban Basu
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, USA
| | - John Mullahy
- Department of Population Health Sciences, University of Wisconsin, Madison, USA
| | - Samuel Hong
- College of Pharmacy, University of Illinois, Chicago, USA
| | - Glen T Schumock
- Department of Pharmacy Systems Outcomes and Policy, College of Pharmacy, University of Illinois, Chicago, IL, USA
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18
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Quinn R, Ravani P. ACCESS HD pilot: A randomised feasibility trial Comparing Catheters with fistulas in Elderly patientS Starting haemodialysis. BMJ Open 2016; 6:e013081. [PMID: 27884849 PMCID: PMC5168520 DOI: 10.1136/bmjopen-2016-013081] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION The selection of the type of vascular access for haemodialysis is an important intervention question. However, only observational studies are available to inform decision-making in this area, and they are at high risk of selection bias. While a clinical trial comparing the effects of the 2 most frequently chosen strategies for haemodialysis access (fistulas and catheters) on patient important and 'hard' clinical end points is needed, the feasibility of such a trial is uncertain. METHODS AND ANALYSIS This open-label pilot randomised controlled trial will test the feasibility and safety of randomising elderly people (≥65 years) who start haemodialysis with a central venous catheter (the most common initial type of haemodialysis access), and are eligible to receive a fistula, to a catheter-based strategy (comparator) or to a fistula-based strategy (intervention). We will enrol 100 patients at 10 centres across Canada. Participants assigned to the catheter-strategy arm will continue to use catheters; participants assigned to the fistula-strategy arm will receive a surgical attempt at fistula creation. The inclusion criteria are designed to minimise the risk of protocol violation and attrition. The primary outcome is feasibility, which we will assess by measuring: (1) the proportion of participants deemed eligible for the trial who consent to randomisation; and (2) the proportion of participants randomised to the intervention who receive the fistula surgery within 90 days of randomisation. Secondary outcomes will include safety outcomes, the reasons people and healthcare providers may not accept randomisation, and the reasons sites may not adhere to the trial protocol. ETHICS AND DISSEMINATION The Conjoint Health Research Ethics Board at the University of Calgary approved the study protocol. We will submit the results of this feasibility study in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02675569, Pre-results.
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Affiliation(s)
- Robert Quinn
- Cumming School of Medicine/Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine/O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Ravani
- Cumming School of Medicine/Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine/O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
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Oliver MJ, Al-Jaishi AA, Dixon SN, Perl J, Jain AK, Lavoie SD, Nash DM, Paterson JM, Lok CE, Quinn RR. Hospitalization Rates for Patients on Assisted Peritoneal Dialysis Compared with In-Center Hemodialysis. Clin J Am Soc Nephrol 2016; 11:1606-1614. [PMID: 27464838 PMCID: PMC5012487 DOI: 10.2215/cjn.10130915] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 05/21/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Assisted peritoneal dialysis is a treatment option for individuals with barriers to self-care who wish to receive home dialysis, but previous research suggests that this treatment modality is associated with a higher rate of hospitalization. The objective of our study was to determine whether assisted peritoneal dialysis has a different rate of hospital days compared to in-center hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a multicenter, retrospective cohort study by linking a quality assurance dataset to administrative health data in Ontario, Canada. Subjects were accrued between January 1, 2004 and July 9, 2013. Individuals were grouped into assisted peritoneal dialysis (family or home care assisted) or in-center hemodialysis on the basis of their first outpatient dialysis modality. Inverse probability of treatment weighting using a propensity score was used to create a sample in which the baseline covariates were well balanced. RESULTS The study included 872 patients in the in-center hemodialysis group and 203 patients in the assisted peritoneal dialysis group. Using an intention to treat approach, patients on assisted peritoneal dialysis had a similar hospitalization rate of 11.1 d/yr (95% confidence interval, 9.4 to 13.0) compared with 12.9 d/yr (95% confidence interval, 10.3 to 16.1) in the hemodialysis group (P=0.19). Patients on assisted peritoneal dialysis were more likely to be hospitalized for dialysis-related reasons (admitted for 2.4 d/yr [95% confidence interval, 1.8 to 3.2] compared with 1.6 d/yr [95% confidence interval, 1.1 to 2.3] in the hemodialysis group; P=0.04). This difference was partly explained by more hospital days because of peritonitis. Modality switching was associated with high rates of hospital days per year. CONCLUSIONS Assisted peritoneal dialysis was associated with similar rates of all-cause hospitalization compared with in-center hemodialysis. Patients on assisted peritoneal dialysis who experienced peritonitis and technique failure had high rates of hospitalization.
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Affiliation(s)
- Matthew J. Oliver
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Nephrology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Ahmed A. Al-Jaishi
- Kidney, Dialysis and Transplantation Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Stephanie N. Dixon
- Kidney, Dialysis and Transplantation Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Jeffrey Perl
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Nephrology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Arsh K. Jain
- Kidney, Dialysis and Transplantation Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Division of Nephrology, London Health Sciences Center, London, Ontario, Canada
| | - Susan D. Lavoie
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Danielle M. Nash
- Kidney, Dialysis and Transplantation Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | | | - Charmaine E. Lok
- Division of Nephrology, University Health Network–Toronto General Hospital, Toronto, Ontario, Canada; and
| | - Robert R. Quinn
- Departments of Medicine and
- Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Poinen K, Oliver MJ, Ravani P, Van der Veer SN, Jager KJ, Van Biesen W, Polkinghorne KR, Rosenfeld A, Lewin AM, Dulai M, Quinn RR. Willingness to participate in a randomized trial comparing catheters to fistulas for vascular access in incident hemodialysis patients: an international survey of nephrologists. Can J Kidney Health Dis 2016; 3:33. [PMID: 27418966 PMCID: PMC4944245 DOI: 10.1186/s40697-016-0125-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 07/02/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Current guidelines favor fistulas over catheters as vascular access. Yet, the observational literature comparing fistulas to catheters has important limitations and biases that may be difficult to overcome in the absence of randomization. However, it is not clear if physicians would be willing to participate in a clinical trial comparing fistulas to catheters. OBJECTIVES We also sought to elicit participants' opinions on willingness to participate in a future trial regarding catheters and fistulas. DESIGN We created a three-part survey consisting of 19 questions. We collected demographic information, respondents' knowledge of the vascular access literature, appropriateness of current guideline recommendations, and their willingness to participate in a future trial. SETTING Participants were recruited from Canada, Europe, Australia, and New Zealand. PARTICIPANTS Participants include physicians and trainees who are involved in the care of end-stage renal disease patients requiring vascular access. MEASUREMENTS Descriptive statistics were used to describe baseline characteristics of respondents according to geographic location. We used logistic regression to model willingness to participate in a future trial. METHODS We surveyed nephrologists from Canada, Europe, Australia, and New Zealand to assess their willingness to participate in a randomized trial comparing fistulas to catheters in incident hemodialysis patients. RESULTS Our results show that in Canada, 86 % of respondents were willing to participate in a trial (32 % in all patients; 54 % only in patients at high risk of primary failure). In Europe and Australia/New Zealand, the willingness to participate in a trial that included all patients was lower (28 % in Europe; 25 % in Australia/New Zealand), as was a trial that included patients at high risk of primary failure (38 % in Europe; 39 % in Australia/New Zealand). Nephrologists who have been in practice for a few years, saw a larger volume of patients, or self-identified as experts in vascular access literature were more likely to participate in a trial. LIMITATIONS Survey distribution was limited to vascular access experts in participating European countries and ultimately led to a discrepancy in numbers of European to non-European respondents overall. Canadian views are likely over-represented in the overall outcomes. CONCLUSIONS Our survey results suggest that nephrologists believe there is equipoise surrounding the optimal vascular access strategy and that a randomized controlled study should be undertaken, but restricted to those individuals with a high risk of primary fistula failure.
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Affiliation(s)
- Krishna Poinen
- />Internal Medicine, University of Calgary, Calgary, Canada
| | | | - Pietro Ravani
- />Faculty of Medicine, University of Calgary, Calgary, Canada
- />Foothills Medical Centre, Cumming School of Medicine, University of Calgary, 1403 29th Street NW, Calgary, AB T2N 2T9 Canada
| | - Sabine N. Van der Veer
- />Institute of Population Health, Health e-Research Centre, University of Manchester, Manchester, UK
| | - Kitty J. Jager
- />Department Medical Informatics, Academic Medical Center, Amsterdam, Netherlands
| | | | | | - Aviva Rosenfeld
- />Australian and New Zealand Society of Nephrology, Melbourne, Australia
| | | | | | - Robert R. Quinn
- />Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
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Lok CE, Perazella MA, Choi MJ. American Society of Nephrology Quiz and Questionnaire 2015: ESRD/RRT. Clin J Am Soc Nephrol 2016; 11:1313-1320. [PMID: 27094608 PMCID: PMC4934831 DOI: 10.2215/cjn.01280216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
The Nephrology Quiz and Questionnaire remains an extremely popular session for attendees of the Annual Kidney Week Meeting of the American Society of Nephrology. During the 2015 meeting, the conference hall was once again overflowing with eager quiz participants. Topics covered by the experts included electrolyte and acid-base disorders, glomerular disease, ESRD and dialysis, and kidney transplantation. Complex cases representing each of these categories together with single best answer questions were prepared and submitted by the panel of experts. Before the meeting, training program directors of nephrology fellowship programs and nephrology fellows in the United States answered the questions through an internet-based questionnaire. During the live session, members of the audience tested their knowledge and judgment on the same series of case-oriented questions in a quiz. The audience compared their answers in real time using a cellphone application containing the answers of the nephrology fellows and training program directors. The results of the online questionnaire were displayed, and then, the quiz answers were discussed. As always, the audience, lecturers, and moderators enjoyed this highly educational session. This article recapitulates the session and reproduces selected content of educational value for the readers of the Clinical Journal of the American Society of Nephrology Enjoy the clinical cases and expert discussions.
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Affiliation(s)
- Charmaine E. Lok
- Division of Nephrology, Department of Medicine, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mark A. Perazella
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut; and
| | - Michael J. Choi
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
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22
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Urgent peritoneal dialysis or hemodialysis catheter dialysis. J Vasc Access 2016; 17 Suppl 1:S56-9. [PMID: 26951906 DOI: 10.5301/jva.5000535] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2016] [Indexed: 12/31/2022] Open
Abstract
Worldwide, there is a steady incident rate of patients with end-stage kidney disease (ESKD) who require renal replacement therapy. Of these patients, approximately one-third have an "unplanned" or "urgent" start to dialysis. This can be a very challenging situation where patients have either not had adequate time for education and decision making regarding dialysis modality and appropriate dialysis access, or a decision was made and plans were altered due to unforeseen circumstances. Despite such unplanned starts, clinicians must still consider the patient's ESKD "life-plan", which includes the best initial dialysis modality and access to suit the patient's individual goals and their medical, social, logistic, and facility circumstances. This paper will discuss the considerations of peritoneal dialysis and a peritoneal dialysis catheter access and hemodialysis and central venous catheter access in patients who require an urgent start to dialysis.
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23
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Shiff B, Pierrato A, Oliver MJ, Jain AK, McCormick B, Kandasamy G, Perl J. Knowledge, attitudes, and practices with regard to PD access: a report from the Peritoneal Dialysis Access Subcommittee of the Ontario Renal Network Committee on Independent Dialysis. Perit Dial Int 2015; 34:791-5. [PMID: 25520483 DOI: 10.3747/pdi.2013.00240] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Benjamin Shiff
- Division of Nephrology St. Michael's Hospital, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Toronto, Department of Medicine, Humber River Regional Hospital Toronto, Ontario, Canada Ontario Renal Network Toronto, Ontario, Canada Division of Nephrology London Health Sciences Centre, University of Western Ontario London, Ontario, Canada Division of Nephrology Sunnybrook Health Sciences Centre, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Ottawa Ottawa, Ontario, Canada
| | - Andreas Pierrato
- Division of Nephrology St. Michael's Hospital, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Toronto, Department of Medicine, Humber River Regional Hospital Toronto, Ontario, Canada Ontario Renal Network Toronto, Ontario, Canada Division of Nephrology London Health Sciences Centre, University of Western Ontario London, Ontario, Canada Division of Nephrology Sunnybrook Health Sciences Centre, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Ottawa Ottawa, Ontario, Canada Division of Nephrology St. Michael's Hospital, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Toronto, Department of Medicine, Humber River Regional Hospital Toronto, Ontario, Canada Ontario Renal Network Toronto, Ontario, Canada Division of Nephrology London Health Sciences Centre, University of Western Ontario London, Ontario, Canada Division of Nephrology Sunnybrook Health Sciences Centre, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Ottawa Ottawa, Ontario, Canada
| | - Matthew J Oliver
- Division of Nephrology St. Michael's Hospital, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Toronto, Department of Medicine, Humber River Regional Hospital Toronto, Ontario, Canada Ontario Renal Network Toronto, Ontario, Canada Division of Nephrology London Health Sciences Centre, University of Western Ontario London, Ontario, Canada Division of Nephrology Sunnybrook Health Sciences Centre, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Ottawa Ottawa, Ontario, Canada
| | - Arsh K Jain
- Division of Nephrology St. Michael's Hospital, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Toronto, Department of Medicine, Humber River Regional Hospital Toronto, Ontario, Canada Ontario Renal Network Toronto, Ontario, Canada Division of Nephrology London Health Sciences Centre, University of Western Ontario London, Ontario, Canada Division of Nephrology Sunnybrook Health Sciences Centre, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Ottawa Ottawa, Ontario, Canada
| | - Brendan McCormick
- Division of Nephrology St. Michael's Hospital, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Toronto, Department of Medicine, Humber River Regional Hospital Toronto, Ontario, Canada Ontario Renal Network Toronto, Ontario, Canada Division of Nephrology London Health Sciences Centre, University of Western Ontario London, Ontario, Canada Division of Nephrology Sunnybrook Health Sciences Centre, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Ottawa Ottawa, Ontario, Canada
| | - Gokulan Kandasamy
- Division of Nephrology St. Michael's Hospital, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Toronto, Department of Medicine, Humber River Regional Hospital Toronto, Ontario, Canada Ontario Renal Network Toronto, Ontario, Canada Division of Nephrology London Health Sciences Centre, University of Western Ontario London, Ontario, Canada Division of Nephrology Sunnybrook Health Sciences Centre, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Ottawa Ottawa, Ontario, Canada
| | - Jeffrey Perl
- Division of Nephrology St. Michael's Hospital, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Toronto, Department of Medicine, Humber River Regional Hospital Toronto, Ontario, Canada Ontario Renal Network Toronto, Ontario, Canada Division of Nephrology London Health Sciences Centre, University of Western Ontario London, Ontario, Canada Division of Nephrology Sunnybrook Health Sciences Centre, University of Toronto Toronto, Ontario, Canada Division of Nephrology University of Ottawa Ottawa, Ontario, Canada
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Overcoming the Underutilisation of Peritoneal Dialysis. BIOMED RESEARCH INTERNATIONAL 2015; 2015:431092. [PMID: 26640787 PMCID: PMC4658397 DOI: 10.1155/2015/431092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/20/2015] [Indexed: 11/23/2022]
Abstract
Peritoneal dialysis is troubled with declining utilisation as a form of renal replacement therapy in developed countries. We review key aspects of therapy evidenced to have a potential to increase its utilisation. The best evidence to repopulate PD programmes is provided for the positive impact of timely referral and systematic and motivational predialysis education: average odds ratio for instituting peritoneal dialysis versus haemodialysis was 2.6 across several retrospective studies on the impact of predialysis education. Utilisation of PD for unplanned acute dialysis starts facilitated by implantation of peritoneal catheters by interventional nephrologists may diminish the vast predominance of haemodialysis done by central venous catheters for unplanned dialysis start. Assisted peritoneal dialysis can improve accessibility of home based dialysis to elderly, frail, and dependant patients, whose quality of life on replacement therapy may benefit most from dialysis performed at home. Peritoneal dialysis providers should perform close monitoring, preventing measures, and timely prophylactic therapy in patients judged to be prone to EPS development. Each peritoneal dialysis programme should regularly monitor, report, and act on key quality indicators to manifest its ability of constant quality improvement and elevate the confidence of interested patients and financing bodies in the programme.
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25
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Lambie M, Davies SJ. Transition between home dialysis modalities: another piece in the jigsaw of the integrated care pathway. Nephrol Dial Transplant 2015. [PMID: 26199391 DOI: 10.1093/ndt/gfv279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Mark Lambie
- Health Services Research Unit, Institute for Science and Technology in Medicine, Keele University and University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Simon J Davies
- Health Services Research Unit, Institute for Science and Technology in Medicine, Keele University and University Hospital of North Midlands, Stoke-on-Trent, UK
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26
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Quinn RR, Ravani P, Zhang X, Garg AX, Blake PG, Austin PC, Zacharias JM, Johnson JF, Pandeya S, Verrelli M, Oliver MJ. Impact of modality choice on rates of hospitalization in patients eligible for both peritoneal dialysis and hemodialysis. Perit Dial Int 2014; 34:41-8. [PMID: 24525596 DOI: 10.3747/pdi.2012.00257] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED BACKGROUND Hospitalization rates are a relevant consideration when choosing or recommending a dialysis modality. Previous comparisons of peritoneal dialysis (PD) and hemodialysis (HD) have not been restricted to individuals who were eligible for both therapies. ♢ METHODS We conducted a multicenter prospective cohort study of people 18 years of age and older who were eligible for both PD and HD, and who started outpatient dialysis between 2007 and 2010 in four Canadian dialysis programs. Zero-inflated negative binomial models, adjusted for baseline patient characteristics, were used to examine the association between modality choice and rates of hospitalization. ♢ RESULTS The study enrolled 314 patients. A trend in the HD group toward higher rates of hospitalization, observed in the primary analysis, became significant when modality was treated as a time-varying exposure or when the population was restricted to elective outpatient starts in patients with at least 4 months of pre-dialysis care. Cardiovascular disease, infectious complications, and elective surgery were the most common reasons for hospital admission; only 23% of hospital stays were directly related to complications of dialysis or kidney disease. ♢ CONCLUSIONS Efforts to promote PD utilization are unlikely to result in increased rates of hospitalization, and efforts to reduce hospital admissions should focus on potentially avoidable causes of cardiovascular disease and infectious complications.
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Affiliation(s)
- Robert R Quinn
- Faculties of Medicine and Community Health Sciences1 and of Medicine,2 University of Calgary, Calgary, Alberta
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Liu FX, Ghaffari A, Dhatt H, Kumar V, Balsera C, Wallace E, Khairullah Q, Lesher B, Gao X, Henderson H, LaFleur P, Delgado EM, Alvarez MM, Hartley J, McClernon M, Walton S, Guest S. Economic evaluation of urgent-start peritoneal dialysis versus urgent-start hemodialysis in the United States. Medicine (Baltimore) 2014; 93:e293. [PMID: 25526471 PMCID: PMC4603112 DOI: 10.1097/md.0000000000000293] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients presenting late in the course of kidney disease who require urgent initiation of dialysis have traditionally received temporary vascular catheters followed by hemodialysis. Recent changes in Medicare payment policy for dialysis in the USA incentivized the use of peritoneal dialysis (PD). Consequently, the use of more expeditious PD for late-presenting patients (urgent-start PD) has received new attention. Urgent-start PD has been shown to be safe and effective, and offers a mechanism for increasing PD utilization. However, there has been no assessment of the dialysis-related costs over the first 90 days of care. The objective of this study was to characterize the costs associated with urgent-start PD, urgent-start hemodialysis (HD), or a dual approach (urgent-start HD followed by urgent-start PD) over the first 90 days of treatment from a provider perspective. A survey of practitioners from 5 clinics known to use urgent-start PD was conducted to provide inputs for a cost model representing typical patients. Model inputs were obtained from the survey, literature review, and available cost data. Sensitivity analyses were also conducted. The estimated per patient cost over the first 90 days for urgent-start PD was $16,398. Dialysis access represented 15% of total costs, dialysis services 48%, and initial hospitalization 37%. For urgent-start HD, total per patient costs were $19,352, and dialysis access accounted for 27%, dialysis services 42%, and initial hospitalization 31%. The estimated cost for dual patients was $19,400. Urgent-start PD may offer a cost saving approach for the initiation of dialysis in eligible patients requiring an urgent-start to dialysis.
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Affiliation(s)
- Frank Xiaoqing Liu
- From the Healthcare Economics International, Baxter Healthcare Corporation, Deerfield, IL 60015, USA (FXL); Division of Nephrology, University of Southern California, 2020 Zonal Ave, IRD 806, Los Angeles, CA 90033, USA (AG); Pharmerit International, 4350 East-West Highway, Suite 430, Bethesda, MD 20814, USA (HD); Southwest Kidney Institute, PLC, 2149 E Warner Road, Tempe, AZ 85284, USA (VK); Kidney Disease and High Blood Pressure Clinic, 510 Vonderburg Rd. Suite 208, Brandon, FL 33511, USA (CB); University of Alabama, 230 Paula Building, 728 Richard Arrington Blvd, Birmingham, AL 35294, USA (EW); St. Clair Specialty Physicians, 22201 Moross Road PB#2, Suite 150, Detroit, MI 48236, USA (QK); Pharmerit International, 4350 East-West Highway, Suite 430, Bethesda, MD 20814, USA (BL); Pharmerit International, 4350 East-West Highway, Suite 430, Bethesda, MD 20814, USA (XG); St. Clair Specialty Physicians, PC, 22201 Moross Road PB#2, Suite 150, Detroit, MI 48236, USA (HH); St. Clair Specialty Physicians, 22201 Moross Road PB#2 Suite 150, Detroit, MI 48236, USA (PL); DaVita USC Kidney Center, 2310 Alcazar St, Los Angeles, CA 90033, USA (EMD); DaVita USC Kidney Center, 2310 Alcazar St, Los Angeles, CA 90033, USA (MMA); Tempe Home Program, 2149 E Warner Rd Suite 109, Tempe, AZ 85284, USA (JH); Tempe Home Program, 2149 E Warner Rd, Suite 109, Tempe, AZ 85284, USA (MM); Department of Pharmacy Systems, Outcomes, and Policy, 833 S. Wood Street (M/C 871), Chicago, IL 60612, USA (SW); and Baxter Healthcare Corporation, Deerfield, IL 60015, USA (SG)
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28
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Ghaffari A, Kumar V, Guest S. Infrastructure requirements for an urgent-start peritoneal dialysis program. Perit Dial Int 2014; 33:611-7. [PMID: 24335123 DOI: 10.3747/pdi.2013.00017] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Patients with advanced chronic kidney disease nearing dialysis but without pre-established access almost uniformly initiate dialysis with a temporary central venous catheter. These catheters are associated with high rates of infection and flow disturbances, requiring removal and subsequent replacement. Many of these patients might be candidates for peritoneal dialysis (PD), but because of the absence of prior catheter placement, the default initial modality is hemodialysis. Recent reports, however, have demonstrated the feasibility of initiating PD urgently despite the late referral for access placement. Urgent-start PD clinical pathways require a unique infrastructure and treatment approach. This article reviews the salient features required to establish an urgent-start PD program.
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Affiliation(s)
- Arshia Ghaffari
- Division of Nephrology,1 Keck School of Medicine, University of Southern California, Los Angeles, California
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29
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Manns BJ, Scott-Douglas N, Tonelli M, Ravani P, LeBlanc M, Dorval M, Holden R, Moist L, Lok C, Zimmerman D, Au F, Hemmelgarn BR. An economic evaluation of rt-PA locking solution in dialysis catheters. J Am Soc Nephrol 2014; 25:2887-95. [PMID: 25012176 DOI: 10.1681/asn.2013050463] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
In a recent randomized trial, weekly recombinant tissue plasminogen activator (rt-PA), 1 mg per lumen, once per week, and twice-weekly heparin as a locking solution (rt-PA/heparin) resulted in lower risks of hemodialysis catheter malfunction and catheter-related bacteremia compared with thrice-weekly heparin (heparin alone). We collected detailed costs within this trial to determine how choice of locking solution would affect overall health care costs, including the cost of locking solutions and all other relevant medical costs over the course of the 6-month trial. Nonparametric bootstrap estimates were used to derive 95% confidence intervals (CIs) and mean cost differences between the treatment groups. The cost of the locking solution was higher in patients receiving rt-PA/heparin, but this was partially offset by lower costs for managing complications. Overall, the difference in unadjusted mean cost for managing patients with rt-PA/heparin versus heparin alone was Can$323 (95% CI, -$935 to $1581; P=0.62). When the costs were extrapolated over a 1-year time horizon using decision analysis, assuming ongoing rt-PA effectiveness, the overall costs of the strategies were similar. This finding was sensitive to plausible variation in the frequency and cost of managing patients with catheter-related bacteremia, and whether the benefit of rt-PA on catheter-related bacteremia was maintained in the long term. In summary, we noted no significant difference in the mean overall cost of an rt-PA/heparin strategy as a locking solution for catheters compared with thrice-weekly heparin. Cost savings due to a lower risk of hospitalization for catheter-related bacteremia partially offset the increased cost of rt-PA.
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Affiliation(s)
- Braden J Manns
- Department of Medicine, Department of Community Health Sciences, and Libin Cardiovascular Institute and Institute of Public Health, University of Calgary, Calgary, Alberta, Canada; Interdisciplinary Chronic Disease Collaboration, Calgary, Alberta, Canada;
| | | | - Marcello Tonelli
- Interdisciplinary Chronic Disease Collaboration, Calgary, Alberta, Canada; Alberta Kidney Disease Network, Calgary, Alberta, Canada; University of Alberta, Edmonton, Alberta, Canada
| | - Pietro Ravani
- Department of Medicine, Department of Community Health Sciences, and Libin Cardiovascular Institute and Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Martine LeBlanc
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Marc Dorval
- Dr.-Georges-L.-Dumont University Hospital Centre, Moncton, New Brunswick, Canada
| | - Rachel Holden
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Louise Moist
- Schulich School of Medicine, Western University, London, Ontario, Canada; Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada
| | - Charmaine Lok
- University Health Network, Toronto, Ontario, Canada; and
| | - Deborah Zimmerman
- Division of Nephrology, Kidney Research Centre of the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Brenda R Hemmelgarn
- Department of Medicine, Department of Community Health Sciences, and Libin Cardiovascular Institute and Institute of Public Health, University of Calgary, Calgary, Alberta, Canada; Interdisciplinary Chronic Disease Collaboration, Calgary, Alberta, Canada
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Abstract
Peritoneal dialysis is now a well established, mature treatment modality for advanced chronic kidney disease. The medium term (at least 5 year) survival of patients on peritoneal dialysis is currently equivalent to that of those on haemodialysis, and is particularly good in patients who are new to renal replacement therapy and have less comorbidity. Nevertheless the modality needs to keep pace with the constantly evolving challenges associated with the provision and delivery of health care. These challenges, which are gradually converging at a global level, include ageing of the population, multimorbidity of patients, containment of cost, increasing self care and environmental issues. In this context, peritoneal dialysis faces particular challenges that include multiple barriers to the therapy and unsatisfactory and poorly defined technique survival as well as limitations relating to intrinsic aspects of the therapy, such as peritoneal membrane longevity and hypoalbuminaemia. To move the therapy forward and favourably influence health-care policy, the peritoneal dialysis community needs to integrate their research effort more effectively by undertaking clinically meaningful studies-with a strong focus on technique survival--that are supported by multidisciplinary expertise in patient-centred outcomes, study design and analysis.
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Affiliation(s)
- Simon J Davies
- Department of Nephrology, University Hospital of North Staffordshire, Newcastle Road, Stoke on Trent, Staffordshire ST4 6QG, UK.
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Coentrão LA, Araújo CS, Ribeiro CA, Dias CC, Pestana MJ. Cost analysis of hemodialysis and peritoneal dialysis access in incident dialysis patients. Perit Dial Int 2013; 33:662-70. [PMID: 23455977 DOI: 10.3747/pdi.2011.00309] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Although several studies have demonstrated the economic advantages of peritoneal dialysis (PD) over hemodialysis (HD), few reports in the literature have compared the costs of HD and PD access. The aim of the present study was to compare the resources required to establish and maintain the dialysis access in patients who initiated HD with a tunneled cuffed catheter (TCC) or an arteriovenous fistula (AVF) and in patients who initiated PD. METHODS We retrospectively analyzed the 152 chronic kidney disease patients who consecutively initiated dialysis treatment at our institution in 2008 (HD-AVF, n = 65; HD-CVC, n = 45; PD, n = 42). Detailed clinical and demographic information and data on access type were collected for all patients. A comprehensive measure of total dialysis access costs, including surgery, radiology, hospitalization for access complications, physician costs, and transportation costs was obtained at year 1 using an intention-to-treat approach. All resources used were valued using 2010 prices, and costs are reported in 2010 euros. RESULTS Compared with the HD-AVF and HD-TCC modalities, PD was associated with a significantly lower risk of access-related interventions (adjusted rate ratios: 1.572 and 1.433 respectively; 95% confidence intervals: 1.253 to 1.891 and 1.069 to 1.797). The mean dialysis access-related costs per patient-year at risk were €1171.6 [median: €608.8; interquartile range (IQR): €563.1 - €936.7] for PD, €1555.2 (median: €783.9; IQR: €371.4 - €1571.7) for HD-AVF, and €4208.2 (median: €1252.4; IQR: €947.9 - €2983.5) for HD-TCC (p < 0.001). In multivariate analysis, total dialysis access costs were significantly higher for the HD-TCC modality than for either PD or HD-AVF (β = -0.53; 95% CI: -1.03 to -0.02; and β = -0.50; 95% CI: -0.96 to -0.04). CONCLUSIONS Compared with patients initiating HD, those initiating PD required fewer resources to establish and maintain a dialysis access during the first year of treatment.
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Affiliation(s)
- Luis A Coentrão
- Nephrology Research and Development Unit1 and Financial Management Unit,2 São João Hospital Centre, and Department of Health Information and Decision Sciences,3 Faculty of Medicine, University of Porto, Portugal
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Coentrão L, Santos-Araújo C, Dias C, Neto R, Pestana M. Effects of starting hemodialysis with an arteriovenous fistula or central venous catheter compared with peritoneal dialysis: a retrospective cohort study. BMC Nephrol 2012; 13:88. [PMID: 22916962 PMCID: PMC3476986 DOI: 10.1186/1471-2369-13-88] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 08/20/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although several studies have demonstrated early survival advantages with peritoneal dialysis (PD) over hemodialysis (HD), the reason for the excess mortality observed among incident HD patients remains to be established, to our knowledge. This study explores the relationship between mortality and dialysis modality, focusing on the role of HD vascular access type at the time of dialysis initiation. METHODS A retrospective cohort study was performed among local adult chronic kidney disease patients who consecutively initiated PD and HD with a tunneled cuffed venous catheter (HD-TCC) or a functional arteriovenous fistula (HD-AVF) in our institution in the year 2008. A total of 152 patients were included in the final analysis (HD-AVF, n = 59; HD-TCC, n = 51; PD, n = 42). All cause and dialysis access-related morbidity/mortality were evaluated at one year. Univariate and multivariate analysis were used to compare the survival of PD patients with those who initiated HD with an AVF or with a TCC. RESULTS Compared with PD patients, both HD-AVF and HD-TCC patients were more likely to be older (p<0.001) and to have a higher frequency of diabetes mellitus (p = 0.017) and cardiovascular disease (p = 0.020). Overall, HD-TCC patients were more likely to have clinical visits (p = 0.069), emergency room visits (p<0.001) and hospital admissions (p<0.001). At the end of follow-up, HD-TCC patients had a higher rate of dialysis access-related complications (1.53 vs. 0.93 vs. 0.64, per patient-year; p<0.001) and hospitalizations (0.47 vs. 0.07 vs. 0.14, per patient-year; p = 0.034) than HD-AVF and PD patients, respectively. The survival rates at one year were 96.6%, 74.5% and 97.6% for HD-AVF, HD-TCC and PD groups, respectively (p<0.001). In multivariate analysis, HD-TCC use at the time of dialysis initiation was the important factor associated with death (HR 16.128, 95%CI [1.431-181.778], p = 0.024). CONCLUSION Our results suggest that HD vascular access type at the time of renal replacement therapy initiation is an important modifier of the relationship between dialysis modality and survival among incident dialysis patients.
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Affiliation(s)
- Luis Coentrão
- Nephrology Research and Development Unit, Faculty of Medicine, University of Porto & São João Hospital Centre, Alameda Professor Hernani Monteiro, Porto, 4202-451, Portugal
| | - Carla Santos-Araújo
- Nephrology Research and Development Unit, Faculty of Medicine, University of Porto & São João Hospital Centre, Alameda Professor Hernani Monteiro, Porto, 4202-451, Portugal
| | - Claudia Dias
- Department of Health Information and Decision Sciences, Faculty of Medicine, University of Porto, Alameda Professor Hernani Monteiro, Porto, 4202-451, Portugal
| | - Ricardo Neto
- Nephrology Research and Development Unit, Faculty of Medicine, University of Porto & São João Hospital Centre, Alameda Professor Hernani Monteiro, Porto, 4202-451, Portugal
| | - Manuel Pestana
- Nephrology Research and Development Unit, Faculty of Medicine, University of Porto & São João Hospital Centre, Alameda Professor Hernani Monteiro, Porto, 4202-451, Portugal
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Optimizing renal replacement therapy in older adults: a framework for making individualized decisions. Kidney Int 2011; 82:261-9. [PMID: 22089945 DOI: 10.1038/ki.2011.384] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
It is often difficult to synthesize information about the risks and benefits of recommended management strategies in older patients with end-stage renal disease since they may have more comorbidity and lower life expectancy than patients described in clinical trials or practice guidelines. In this review, we outline a framework for individualizing end-stage renal disease management decisions in older patients. The framework considers three factors: life expectancy, the risks and benefits of competing treatment strategies, and patient preferences. We illustrate the use of this framework by applying it to three key end-stage renal disease decisions in older patients with varying life expectancy: choice of dialysis modality, choice of vascular access for hemodialysis, and referral for kidney transplantation. In several instances, this approach might provide support for treatment decisions that directly contradict available practice guidelines, illustrating circumstances when strict application of guidelines may be inappropriate for certain patients. By combining quantitative estimates of benefits and harms with qualitative assessments of patient preferences, clinicians may be better able to tailor treatment recommendations to individual older patients, thereby improving the overall quality of end-stage renal disease care.
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