Transfers from home to facility-based dialysis: comparisons of HHD, assisted PD and autonomous PD

Background

Home dialysis therapies such as peritoneal dialysis (PD) and home hemodialysis (HHD) are beneficial for quality of life and patient empowerment. The short technique survival time partly explains their low prevalence. We aimed to assess the risk of transfer to facility-based hemodialysis in patients treated with autonomous PD, assisted PD and HHD.

Methods

This was a retrospective study using data from the REIN registry of patients starting home dialysis in France from 2002 to 2019. The risks of transfer to facility-based hemodialysis (HD) were compared between three modalities of home dialysis (HHD, nurse-assisted PD, autonomous PD) using survival models with a propensity score (PS)-matched and unmatched cohort of patients.

Results

The study included 17 909 patients: 628 in the HHD group, 10 214 in the autonomous PD group, and 7067 in the assisted PD group. During the follow-up period, there were 5347 transfers to facility-based HD. The observed number of transfers was 2458 (13.7%) at 1 year and 5069 (28.3) at 5 years after the start of home dialysis, including 3272 (32%) on autonomous PD, 1648 (23.3%) on assisted PD, and 149 (23.7) on HHD. Owing to clinical characteristics differences, only 38% of HHD patients could be matched to patients from the others group. In the PS-matched cohort, the adjusted Cox model showed no difference in the risk of transfer for assisted PD (cs-HR 1.04, 95% CI 0.75-1.44) or HHD (cs-HR 1.07, 95% CI 0.77-1.48) compared with autonomous PD.

Conclusions

Unlike results from other countries, where nurse assistance is not fully available for PD-associated care, there was no difference in technique survival between autonomous PD, nurse-assisted PD, and HHD in France. This discrepancy may be attributed to our inclusion of a broader spectrum of patients who derive significant benefits from assisted PD.

Nephrologists' Perspectives of the Potential Utilization of Home Hemodialysis in Saudi Arabia

Home hemodialysis (HD) is an attractive renal replacement modality that has been shown to provide several benefits to the patient and health-care system. However, home HD programs have not been well-established in Saudi Arabia. We aimed to explore the perspectives of adult nephrology consultants in Saudi Arabia about the potential utilization of home HD via a survey-based cross-sectional study. The survey was distributed via email to all adult nephrology consultants practicing in Saudi Arabia and registered in the Saudi Society of Nephrology and Transplantation. Out of 236 invited consultants, 151 (64%) participated in the study. Half of the participants defined home HD as a trained patient who can independently perform his/her HD sessions at home. Eighty-one (54%) consultants have never managed a patient on home HD during their nephrology training period. More than 70% of participants believed that home HD provides advantages over in-center HD, and that its utilization in Saudi Arabia would be feasible. Although 40% of participants worked in centers with no accredited nephrology training program, most of the remaining participants believed that the local training program did not provide enough teaching about home HD to trainees. Patients' refusal, the nephrologists' lack of motivation and experience, a lack of administrative support, and the lack of infrastructure and nursing support were identified by most participants as the major barriers to the utilization of home HD in Saudi Arabia. Addressing these barriers would be the first step to facilitate initiatives aiming to establish home HD programs in this country.

Characteristics and technical survival of home hemodialysis in the Valencian Community (1976-2020)

INTRODUCTION

Home hemodialysis (HDD) is implemented in the Valencian Community with a higher prevalence than to the rest of the national territory, with a prevalence of 13.4 patients pmp in December 2018. We carried out an assessment of the patients characteristics and the overall and technical survival in HDD depending on the historical moment of onset and its origin.

MATERIAL AND METHODS

We conducted a retrospective and descriptive study including patients of the Valencian Registry of Renal Patients from the beginning of data reported until December 2020. We calculated overall survival (combined event death-technical failure, censoring transplantation) and technical survival (event technical failure, censoring exitus and transplantation). Comparing technical survival according to the starting era: ancient (1976-2000) vs modern (2001-2020) and according to the modality of origin. We performed univariate and multivariate Cox regression in the total series for both overall and technical survival.

RESULTS

236 patients on HDD (611.4 patient-years of follow-up), mean age 49.7±16.3 years; median time of prior renal replacement therapy 0.2 years. The ratio of transplantation, death, and technical failure were 13.2, 4.4, and 7 events per 100 patient-years, respectively. In the comparison by ancient (n=57) vs modern (n=179) eras, age (37.5 vs 53.5 years), DM (3.5 vs 13.4%) and chronic tubuleinterstitial nephropathy (24.6 vs 8.9%) as a cause of chronic kidney disease were statistically significant. The probability of coming from outpatient consultation (33.3 vs 48.6%) and peritoneal dialysis (1.8 vs 12.8%) were higher in modern era with statistical significance. In the ancient era a single hospital centralized 57.9% of the patients, and in the modern era between two hospitals centralized 55.8% of the patients. Overall survival in the ancient era was 83.7% at 1year, 77.4% at 2 years, and 61% at 5 years; and in the modern era 87.3% per year, 83% 2 years and 47.8% 5 years (Log Rank 0.521). Technical survival in the ancient era was 85.4% at 1year, 79% 2 years, and 64.1% 5 years; and in the modern era 91.4% per year, 88.5% 2 years and 74.5% 5 years (Log Rank 0.195). There were no statistical differences in the comparison based on technical of provenance. In the Cox regression it was statistically significant for overall survival: the age and being diagnosed with heart disease, vascular disease or active neoplasia and for technical survival liver disease or social problem, both in univariate and multivariate.

CONCLUSIONS

In the modern era there is a considerable increase in HDD patients in the Valencian Community. There was a center effect in the development of HDD programs, most of the patients depended on few healthcare centers. The patients were older and had greater comorbidity in the modern era, despite this without affecting the technical and overall survival of the HDD.

Main Barriers to the Introduction of a Home Haemodialysis Programme in Poland: A Review of the Challenges for Implementation and Criteria for a Successful Programme

Introduction: Home dialysis in Poland is restricted to the peritoneal dialysis (PD) modality, with the majority of dialysis patients treated using in-centre haemodialysis (ICHD). Home haemodialysis (HHD) is an additional home therapy to PD and provides an attractive alternative to ICHD that combines dialysis with social distancing; eliminates transportation needs; and offers clinical, economic, and quality of life benefits. However, HHD is not currently provided in Poland. This review was performed to provide an overview of the main barriers to the introduction of a HHD programme in Poland. Main findings: The main high-level barrier to introducing HHD in Poland is the absence of specific health legislation required for clinician prescribing of HHD. Other barriers to overcome include clear definition of reimbursement, patient training and education (including infrastructure and experienced personnel), organisation of logistics, and management of complications. Partnering with a large care network for HHD represents an alternative option to payers for the provision of a new HHD service. This may reduce some of the barriers which need to be overcome when compared with the creation of a new HHD service and its supporting network due to the pre-existing infrastructure, processes, and staff of a large care network. Conclusions: Provision of HHD is not solely about the provision of home treatment, but also the organisation and definition of a range of support services that are required to deliver the service. HHD should be viewed as an additional, complementary option to existing dialysis modalities which enables choice of modality best suited to a patient’s needs.

Characteristics and technical survival of home hemodialysis in the Valencian Community (1976-2020)

INTRODUCTION

Home hemodialysis (HDD) is implemented in the Valencian Community with a higher prevalence than to the rest of the national territory, with a prevalence of 13.4 patients' pmp in December 2018. We carried out an assessment of the patients' characteristics and the overall and technical survival in HDD depending on the historical moment of onset and its origin.

MATERIAL AND METHODS

We conducted a retrospective and descriptive study including patients of the Valencian Registry of Renal Patients from the beginning of data reported until December 2020. We calculated overall survival (combined event death-technical failure, censoring transplantation) and technical survival (event technical failure, censoring exitus and transplantation). Comparing technical survival according to the starting era: ancient (1976-2000) vs modern (2001-2020) and according to the modality of origin. We performed univariate and multivariate Cox regression in the total series for both overall and technical survivals.

RESULTS

236 patients on HDD (611.4 patient-years of follow-up), mean age 49.7±16.3 years; median time of prior renal replacement therapy 0.2 years. The ratio of transplantation, death, and technical failure were 13.2, 4.4, and 7 events per 100 patient-years, respectively. In the comparison by ancient (n=57) vs modern (n=179) eras, age (37.5 vs 53.5 years), DM (3.5 vs 13.4%) and chronic tubuleinterstitial nephropathy (24.6 vs 8.9%) as a cause of chronic kidney disease were statistically significant. The probability of coming from outpatient consultation (33.3 vs 48.6%) and peritoneal dialysis (1.8 vs 12.8%) were higher in modern era with statistical significance. In the ancient era a single hospital centralized 57.9% of the patients, and in the modern era between two hospitals centralized 55.8% of the patients. Overall survival in the ancient era was 83.7% at 1 year, 77.4% at 2 years, and 61% at 5 years; and in the modern era 87.3% per year, 83% 2 years and 47.8% 5 years (Log Rank 0.521). Technical survival in the ancient era was 85.4% at 1 year, 79% 2 years, and 64.1% 5 years; and in the modern era 91.4% per year, 88.5% 2 years and 74.5% 5 years (Log Rank 0.195). There were no statistical differences in the comparison based on technical of provenance. In the Cox regression it was statistically significant for overall survival: the age and being diagnosed with heart disease, vascular disease or active neoplasia and for technical survival liver disease or social problem, both in univariate and multivariate.

CONCLUSION

In the modern era there is a considerable increase in HDD patients in the Valencian Community. There was a center effect in the development of HDD programs, most of the patients depended on few healthcare centers. The patients were older and had greater comorbidity in the modern era, despite this without affecting the technical and overall survival of the HDD.

Risk of hospitalization, technique failure, and death with increased training duration in 3-days-a-week home hemodialysis

INTRODUCTION

Quality training is a core component of successful home hemodialysis (HHD) and training duration varies significantly between dialysis centers as well as at the patient level. This study aimed to assess the adverse outcomes associated with HHD training duration.

METHODS

All HHD patients successfully trained in a single dialysis center between January 2005 and July 2017 were included. A multivariable multiple-events (Andersen-Gill) survival model was built to evaluate the association between training time and main adverse events, including hospitalizations, technique failure, and death on HHD. Potential confounding factors were defined a priori (age, diabetes, coronary artery disease, and year of training start). Adjusted risk of vascular interventions (arteriovenous fistula angioplasties and central venous catheter replacements) was assessed as the secondary outcome in a negative binomial regression.

FINDINGS

Forty-eight patients were included in the study. Median HHD training duration was 86 (67-108) days, using a thrice weekly training schedule. Over a follow-up median time of 2.0 (0.7-3.3) years, three patients died while on HHD, 10 had a definitive transfer to HD, and 18 experienced a least 1 hospitalization (38 hospitalizations in total). Training duration was associated with a higher risk of hospitalization, technique failure, and death in unadjusted (hazard ratio [HR] 1.16 per month, 95% confidence interval [CI] 1.08-1.24) and adjusted multiple events model (HR 1.21, 95% CI 1.04-1.43). Risk of vascular access intervention was also significantly higher with increased training time (adjusted incidence rate ratio 1.31, 95% CI 1.03-1.64, per training month).

DISCUSSION

In this single-center observational study, HHD training duration was associated with a higher risk of adverse events including, death, technique failure, hospitalizations, and vascular access intervention. Enhanced clinical follow-up and home support should be offered to these more vulnerable patients to mitigate this heightened risk.

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

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

Physical Infrastructure and Integrated Governance Structure for Home Hemodialysis

In view of the growing enthusiasm for home dialysis use, new dialysis centers may build or expend their home hemodialysis program in the next few years. This review will discuss the main challenges faced by small and large home hemodialysis programs in terms of physical spaces, human resource, training considerations, and overall governance. We will elaborate on the inclusion of home hemodialysis in the kidney replacement therapy care continuum, with a specific interest for collaboration and transition between peritoneal dialysis and home hemodialysis programs.

The use of virtual physician mentoring to enhance home dialysis knowledge and uptake

Home dialysis therapies are flexible kidney replacement strategies with documented clinical benefits. While the incidence of end-stage kidney disease continues to increase globally, the use of home dialysis remains low in most developed countries. Multiple barriers to providing home dialysis have been noted in the published literature. Among known challenges, gaps in clinician knowledge are potentially addressable with a focused education strategy. Recent national surveys in the United States and Australia have highlighted the need for enhanced home dialysis knowledge especially among nephrologists who have recently completed training. Traditional in-person continuing professional educational programmes have had modest success in promoting home dialysis and are limited by scale and the present global COVID-19 pandemic. We hypothesize that the use of a 'Hub and Spoke' model of virtual home dialysis mentorship for nephrologists based on project ECHO would support home dialysis growth. We review the home dialysis literature, known educational gaps and plausible educational interventions to address current limitations in physician education.

Complications and challenges of home hemodialysis: A historical review

Home hemodialysis (HHD) has evolved as a preferred and safe kidney replacement modality over the past six decades. Despite advances in technological aspects of HHD, potential complications still pose a challenge to health care givers, patients, and their families. In this narrative review, we describe vascular access and cannulation, anticoagulation, nutritional, residual kidney function, psychosocial, technique failure, and machine/procedural-related complications. Addressing these problems is essential for favorable patient outcomes.

Intensive Home Hemodialysis Survival Comparable to Deceased Donor Kidney Transplantation

Introduction

Kidney transplantation (KT) remains the treatment of choice for end-stage kidney disease (ESKD), but access to transplantation is limited by a disparity between supply and demand for suitable organs. This organ shortfall has resulted in the use of a wider range of donor kidneys and, in parallel, a reexamination of potential alternative renal replacement therapies. Previous studies comparing Canadian intensive home hemodialysis (IHHD) with deceased donor (DD) KT in the United States reported similar survival, suggesting IHHD might be a plausible alternative.

Methods

Using data from the Scientific Registry of Transplant Recipients and an experienced US-based IHHD program in Lynchburg, VA, we retrospectively compared mortality outcomes of a cohort of IHHD patients with transplant recipients within the same geographic region between October 1997 and June 2014.

Results

We identified 3073 transplant recipients and 116 IHHD patients. Living donor KT (n = 1212) had the highest survival and 47% reduction in risk of death compared with IHHD (hazard ratio [HR]: 0.53; 95% confidence interval [CI]: 0.34–0.83). Survival of IHHD patients did not statistically differ from that of DD transplant recipients (n = 1834) in adjusted analyses (HR: 0.96; 95% CI: 0.62–1.48) or when exclusively compared with marginal (Kidney Donor Profile Index >85%) transplant recipients (HR: 1.35; 95% CI: 0.84–2.16).

Conclusion

Our study showed comparable overall survival between IHHD and DD KT. For appropriate patients, IHHD could serve as bridging therapy to transplant and a tenable long-term renal replacement therapy.

Exploring Barriers and Potential Solutions in Home Dialysis: An NKF-KDOQI Conference Outcomes Report

Home dialysis therapy, including home hemodialysis and peritoneal dialysis, is underused as a modality for the treatment of chronic kidney failure. The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative sponsored a home dialysis conference in late 2017 that was designed to identify the barriers to starting and maintaining patients on home dialysis therapy. Clinical, operational, policy, and societal barriers were identified that need to be overcome to ensure that dialysis patients have the freedom to choose their treatment modality. Education of patients and patient partners, as well as health care providers, about home dialysis therapy, if offered at all, is often provided in a cursory manner. Lack of exposure to home dialysis therapies perpetuates a lack of familiarity and thus a hesitancy to refer patients to home dialysis therapies. Patient and care partner support, both psychosocial and financial, is also critical to minimize the risk for burnout leading to dropout from a home dialysis modality. Thus, the facilitation of home dialysis therapy will require a systematic change in chronic kidney disease education and the approach to dialysis therapy initiation, the creation of additional incentives for performing home dialysis, and breakthroughs to simplify the performance of home dialysis modalities. The home dialysis work group plans to develop strategies to overcome these barriers to home dialysis therapy, which will be presented at a follow-up home dialysis conference.

CE: Improving Outcomes for Patients with Chronic Kidney Disease: Part 2

: Coping with chronic kidney disease (CKD) is challenging for many people, since symptoms often don't appear until the disease is advanced and the patient is close to requiring dialysis. This two-part article aims to provide nurses with the basic information necessary to assess and manage patients with CKD. Part 1, which appeared last month, offered an overview of the disease, described identification and etiology, and discussed ways to slow disease progression. Part 2 addresses disease complications and treatment for kidney failure.

Clinical study on low-molecular weight heparin infusion as anticoagulation for nocturnal home haemodialysis

AIM

This study was conducted to evaluate low-molecular weight heparin (LMWH) as anticoagulation for nocturnal home haemodialysis (NHHD). While its longer half-life may cause drug accumulation in frequent dialysis, the essential need of a supplementary intra-dialytic bolus for the sleeping patients also renders LMWH's use impractical.

METHODS

The recruited patients, who were on alternate-day 8 h haemodialysis, were randomized to receive either nadroparin or unfractionated heparin (UFH) for a week. They underwent crossover to receive the alternate anticoagulant in the next week. A nadroparin infusion regimen was adopted to enhance its practicability, which consisted of a loading dose of 35 IU/kg and a continuous infusion of 10 IU/kg per hour for 6 h.

RESULTS

A total of 12 NHHD patients were recruited. With nadroparin infusion, the mean anti-Xa levels at the 2^nd , 4^th , 6^th and 8^th hours of dialysis were 0.46 ± 0.11, 0.55 ± 0.14, 0.61 ± 0.15 and 0.45 ± 0.15 IU/mL respectively. Comparing to UFH, which offered satisfactory anticoagulation according to the activated partial thromboplastin time, nadroparin-treated dialysis achieved similar thrombus scores and dialyser urea/creatinine clearances at the end of haemodialysis. During the post-dialysis period, one patient demonstrated residual LMWH effect (anti-Xa level 0.09 IU/mL) on the next day, whereas none had detectable anti-Xa activities 2 days afterwards upon next dialysis.

CONCLUSIONS

Low-molecular weight heparin infusion is practical and effective as anticoagulation for NHHD. It can be safely used in an alternate-day haemodialysis schedule. A close monitoring for LMWH accumulation is recommended if long dialysis is performed daily.

Clinical, patient-related, and economic outcomes of home-based high-dose hemodialysis versus conventional in-center hemodialysis

Despite technological advances in renal replacement therapy, the preservation of health and quality of life for individuals on dialysis still remains a challenge. The high morbidity and mortality in dialysis warrant further research and insight into the clinical domains of the technique and practice of this therapy. In the last 20 years, the focus of development in the field of hemodialysis (HD) has centered around adequate removal of urea and other associated toxins. High-dose HD offers an opportunity to improve mortality, morbidity, and quality of life of patients with end-stage kidney disease. However, the uptake of this modality is low, and the risk associated with the therapy is not fully understood. Recent studies have highlighted the evidence base and improved our understanding of this technique of dialysis. This article provides a review of high-dose and home HD, its clinical impact on patient outcome, and the controversies that exist.

Adrenal insufficiency presenting as unexplained hypotension in nocturnal home hemodialysis

Adrenal insufficiency is a complication of chronic corticosteroid therapy. Unexplained hypotension may be a manifestation of an adrenal insufficient state in patients with a history of corticosteroid therapy on hemodialysis. We present a series of five cases of patients on nocturnal home hemodialysis with hypotension as the main manifestation of adrenal insufficiency. Unexplained hypotension in patients with a history of corticosteroid therapy should prompt the managing clinician to consider adrenal insufficiency as a possible cause.

Pregnancy in advanced chronic kidney disease and end-stage renal disease

PURPOSE OF REVIEW

This article reviews the available literature about the incidence, outcomes, and the management of pregnancy in women with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) who require renal replacement therapy.

RECENT FINDINGS

Pregnancy in women with advanced CKD and ESRD can result in serious adverse maternal and fetal outcomes, but improved outcomes have been noted in recent years, likely secondary to intensified dialysis regimens. More intensive dialysis allows for the gentle removal of water, solutes, and uremic toxins, which theoretically results in near-normal maternal renal physiology, an improvement in placental blood flow, and therefore a better environment for fetal growth and development. As management remains complex, a close joint collaboration between the high-risk obstetrical team and nephrology is essential.

SUMMARY

Pregnancy on dialysis is becoming a viable option for women with advanced CKD and ESRD who do not have immediate access to transplantation.

The Global Forum for Home Hemodialysis: a new open-source practical manual

Encouraging clinical outcomes from observational and randomized controlled data in the forms of frequent hemodialysis (HD) has renewed interest in home HD. However, given its benefits, home HD is relatively underutilized throughout the world. The Global Forum for Home Hemodialysis, an independent panel comprised of internationally recognized nephrologists, home HD nurses, administrators, patient advocates, and a long-time home HD patient, has convened with the intention of creating an open-source, comprehensive, practical manual that provides useful information to clinicians who are interested in implementing home HD.

Home Hemodialysis Dose: Balancing Patient Needs and Preferences

<b><i>Background:</i></b> The aim in defining the dose of HHD is to provide sufficient dialysis required to possibly ‘normalize' all abnormalities associated with renal failure in order improve patient survival and quality of life. Much progress has been made in defining the dose required to accomplish this goal, but the evidence is still far from robust. The main limitations are incomplete understanding of uremic toxins, their relative importance in causing uremic symptoms, and our inability to comprehensively assess dry weight. <b><i>Summary:</i></b> This review provides guidance on realistic dosing of dialysis for the HHD patient based on the available evidence, where available, and alternative regimens that suit the individual's lifestyle and preferences. <b><i>Key Messages:</i></b> HHD can easily accommodate alternative, intensive HD prescriptions, including daily and nocturnal HD. HHD provides prescription flexibility to fulfill patient needs while taking their preferences into account.