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Hoang AT, Nguyen PA, Phan TP, Do GT, Nguyen HD, Chiu IJ, Chou CL, Ko YC, Chang TH, Huang CW, Iqbal U, Hsu YH, Wu MS, Liao CT. Personalised prediction of maintenance dialysis initiation in patients with chronic kidney disease stages 3-5: a multicentre study using the machine learning approach. BMJ Health Care Inform 2024; 31:e100893. [PMID: 38677774 PMCID: PMC11057266 DOI: 10.1136/bmjhci-2023-100893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 04/16/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Optimal timing for initiating maintenance dialysis in patients with chronic kidney disease (CKD) stages 3-5 is challenging. This study aimed to develop and validate a machine learning (ML) model for early personalised prediction of maintenance dialysis initiation within 1-year and 3-year timeframes among patients with CKD stages 3-5. METHODS Retrospective electronic health record data from the Taipei Medical University clinical research database were used. Newly diagnosed patients with CKD stages 3-5 between 2008 and 2017 were identified. The observation period spanned from the diagnosis of CKD stages 3-5 until the maintenance dialysis initiation or a maximum follow-up of 3 years. Predictive models were developed using patient demographics, comorbidities, laboratory data and medications. The dataset was divided into training and testing sets to ensure robust model performance. Model evaluation metrics, including area under the curve (AUC), sensitivity, specificity, positive predictive value, negative predictive value and F1 score, were employed. RESULTS A total of 6123 and 5279 patients were included for 1 year and 3 years of the model development. The artificial neural network demonstrated better performance in predicting maintenance dialysis initiation within 1 year and 3 years, with AUC values of 0.96 and 0.92, respectively. Important features such as baseline estimated glomerular filtration rate and albuminuria significantly contributed to the predictive model. CONCLUSION This study demonstrates the efficacy of an ML approach in developing a highly predictive model for estimating the timing of maintenance dialysis initiation in patients with CKD stages 3-5. These findings have important implications for personalised treatment strategies, enabling improved clinical decision-making and potentially enhancing patient outcomes.
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Affiliation(s)
- Anh Trung Hoang
- Nephro-Urology and Dialysis Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Phung-Anh Nguyen
- Clinical Data Center, Office of Data Science, Taipei Medical University, Taipei, Taiwan
- Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Research Center of Health Care Industry Data Science, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Thanh Phuc Phan
- International PhD program of Biotech and Healthcare Management,College of Management, Taipei Medical University, Taipei, Taiwan
- University Medical Center, Ho Chi Minh City, Vietnam
| | - Gia Tuyen Do
- Nephro-Urology and Dialysis Center, Bach Mai Hospital, Hanoi, Vietnam
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Huu Dung Nguyen
- Nephro-Urology and Dialysis Center, Bach Mai Hospital, Hanoi, Vietnam
| | - I-Jen Chiu
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- TMU-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
| | - Chu-Lin Chou
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- TMU-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Hsin Kuo Min Hospital, Taipei Medical University, Taoyuan City, Taiwan
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Chen Ko
- Division of Cardiovascular Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Tzu-Hao Chang
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Chih-Wei Huang
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- International Center for Health Information Technology, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Usman Iqbal
- School of Population Health, Faculty of Medicine and Health, University of New South Wales (UNSW), Sydney, New South Wales, Australia
- Global Health & Health Security Department, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Yung-Ho Hsu
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- TMU-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Hsin Kuo Min Hospital, Taipei Medical University, Taoyuan City, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- TMU-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
| | - Chia-Te Liao
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- TMU-Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
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Ramakrishnan C, Widjaja N, Malhotra C, Finkelstein E, Khan BA, Ozdemir S. Unravelling complex choices: multi-stakeholder perceptions on dialysis withdrawal and end-of-life care in kidney disease. BMC Nephrol 2024; 25:6. [PMID: 38172719 PMCID: PMC10765633 DOI: 10.1186/s12882-023-03434-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/10/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND For patients on dialysis with poor quality of life and prognosis, dialysis withdrawal and subsequent transition to palliative care is recommended. This study aims to understand multi-stakeholder perspectives regarding dialysis withdrawal and identify their information needs and support for decision-making regarding withdrawing from dialysis and end-of-life care. METHODS Participants were recruited through purposive sampling from eight dialysis centers and two public hospitals in Singapore. Semi-structured in-depth interviews were conducted with 10 patients on dialysis, 8 family caregivers, and 16 renal healthcare providers. They were held in-person at dialysis clinics with patients and caregivers, and virtually via video-conferencing with healthcare providers. Interviews were audio-recorded, transcribed, and thematically analyzed. The Ottawa Decision Support Framework's decisional-needs manual was used as a guide for data collection and analysis, with two independent team members coding the data. RESULTS Four themes reflecting perceptions and support for decision-making were identified: a) poor knowledge and fatalistic perceptions; b) inadequate resources and support for decision-making; c) complexity of decision-making, unclear timing, and unpreparedness; and d) internal emotions of decisional conflict and regret. Participants displayed limited awareness of dialysis withdrawal and palliative care, often perceiving dialysis withdrawal as medical abandonment. Patient preferences regarding decision-making ranged from autonomous control to physician or family-delegated choices. Cultural factors contributed to hesitancy and reluctance to discuss end-of-life matters, resulting in a lack of conversations between patients and providers, as well as between patients and their caregivers. CONCLUSIONS Decision-making for dialysis withdrawal is complicated, exacerbated by a lack of awareness and conversations on end-of-life care among patients, caregivers, and providers. These findings emphasize the need for a culturally-sensitive tool that informs and prepares patients and their caregivers to navigate decisions about dialysis withdrawal and the transition to palliative care. Such a tool could bridge information gaps and stimulate meaningful conversations, fostering informed and culturally aligned decisions during this critical juncture of care.
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Affiliation(s)
- Chandrika Ramakrishnan
- Duke-NUS Medical School, Lien Centre for Palliative Care, Programme in Health Services and Systems Research, Singapore, Singapore
- Duke NUS Medical School, Signature Programme in Health Services and Research, Singapore, Singapore
| | - Nathan Widjaja
- Duke-NUS Medical School, Lien Centre for Palliative Care, Programme in Health Services and Systems Research, Singapore, Singapore
- Nanyang Technological University, Singapore, Singapore
| | - Chetna Malhotra
- Duke-NUS Medical School, Lien Centre for Palliative Care, Programme in Health Services and Systems Research, Singapore, Singapore
- Duke NUS Medical School, Signature Programme in Health Services and Research, Singapore, Singapore
| | - Eric Finkelstein
- Duke-NUS Medical School, Lien Centre for Palliative Care, Programme in Health Services and Systems Research, Singapore, Singapore
- Duke NUS Medical School, Signature Programme in Health Services and Research, Singapore, Singapore
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Behram Ali Khan
- Division of Nephrology, National University Health System, Singapore, Singapore
- National Kidney Foundation, Singapore, Singapore
| | - Semra Ozdemir
- Duke-NUS Medical School, Lien Centre for Palliative Care, Programme in Health Services and Systems Research, Singapore, Singapore.
- Duke NUS Medical School, Signature Programme in Health Services and Research, Singapore, Singapore.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.
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Chang JH, Kim YC, Song SH, Kim S, Jo MW, Kim S. Shared Decision Making for Choosing renAl Replacement Therapy in Chronic Kidney Disease Patients (SDM-ART trial): study protocol for randomized clinical trial. Kidney Res Clin Pract 2023; 42:751-761. [PMID: 37098669 DOI: 10.23876/j.krcp.22.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/04/2022] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) should be educated about their condition so that they can initiate dialysis at the optimal time and make an informed choice between dialysis modalities. Shared decision-making (SDM) empowers patients to select their own treatment and improves patient outcomes. This study aimed to evaluate whether SDM affects the choice of renal replacement therapy among CKD patients. METHODS This is a multicenter, open-label, randomized, pragmatic clinical trial. A total of 1,194 participants with CKD who are considering renal replacement therapy were enrolled. The participants will be randomized into three groups in a 1:1:1 ratio: the conventional group, extensive informed decision-making group, and SDM group. Participants will be educated twice at months 0 and 2. Videos and leaflets will be provided to all patients. Patients in the conventional group will receive 5 minutes of education at each visit. The extensive informed decision-making group will receive more informed and detailed education using intensive learning materials for 10 minutes each visit. Patients in the SDM group will be educated for 10 minutes each visit according to illness perception and item-based analysis. The primary endpoint is the ratio of hemodialysis to peritoneal dialysis and kidney transplantation among the groups. Secondary outcomes include unplanned dialysis, economic efficiency, patient satisfaction, patient evaluation of the process, and patient adherence. DISCUSSION The SDM-ART is an ongoing clinical study to investigate the effect of SDM on the choice of renal replacement therapy in patients with CKD.
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Affiliation(s)
- Jae Hyun Chang
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang Heon Song
- Department of Internal Medicine and BioMedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Soojin Kim
- Division of Communication and Media, Ewha Womans University, Seoul, Republic of Korea
| | - Min-Woo Jo
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Salas-Gama K, Onakpoya IJ, Coronado Daza J, Perera R, Heneghan CJ. Recommendations of high-quality clinical practice guidelines related to the process of starting dialysis: A systematic review. PLoS One 2022; 17:e0266202. [PMID: 35696388 PMCID: PMC9191707 DOI: 10.1371/journal.pone.0266202] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/16/2022] [Indexed: 11/19/2022] Open
Abstract
Background
The optimal time for initiation of dialysis and which modality to choose as the starting therapy is currently unclear. This systematic review aimed to assess the recommendations across high-quality clinical practice guidelines (CPGs) related to the start of dialysis.
Methods
We systematically searched MEDLINE, EMBASE, Web of Science, LILACS, and databases of organisations that develop CPGs between September 2008 to August 2021 for CPGs that addressed recommendations on the timing of initiation of dialysis, selection of dialysis modality, and interventions to support the decision-making process to select a dialysis modality. We used the Appraisal of Guidelines for Research and Evaluation instrument to assess the methodological quality of the CPGs and included only high-quality CPGs. This study is registered in PROSPERO, number CRD42018110325.
Results
We included 12 high-quality CPGs. Six CPGs addressed recommendations related to the timing of initiating dialysis, and all agreed on starting dialysis in the presence of symptoms or signs. Six CPGs addressed recommendations related to the selection of modality but varied greatly in their content. Nine CPGs addressed recommendations related to interventions to support the decision-making process. Eight CPGs agreed on recommended educational programs that include information about dialysis options. One CPG considered using patient decision aids a strong recommendation.
Limitations
We could have missed potentially relevant guidelines since we limited our search to CPGs published from 2008, and we set up a cut-off point of 60% in domains of the rigour of development and editorial independence.
Conclusion
High-quality CPGs related to the process of starting dialysis were consistent in initiating dialysis in the presence of symptoms or signs and offering patients education at the point of decision-making. There was variability in how CPGs addressed the issue of dialysis modality selection. CPGs should improve strategies on putting recommendations into practice and the quality of evidence to aid decision-making for patients.
Registration
The protocol of this systematic review has been registered in the international prospective register of systematic reviews (PROSPERO) under the registration number: CRD CRD42018110325.
https://clinicaltrials.gov/ct2/show/CRD42018110325.
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Affiliation(s)
- Karla Salas-Gama
- Quality, Process and Innovation Direction, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Health Services Research Group, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Hospital Universitari, Barcelona, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health–CIBERESP, Barcelona, Spain
- * E-mail:
| | - Igho J. Onakpoya
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Rafael Perera
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Carl J. Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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5
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Khou V, De La Mata NL, Morton RL, Kelly PJ, Webster AC. Cause of death for people with end-stage kidney disease withdrawing from treatment in Australia and New Zealand. Nephrol Dial Transplant 2021; 36:1527-1537. [PMID: 32750144 DOI: 10.1093/ndt/gfaa105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Withdrawal from renal replacement therapy is common in patients with end-stage kidney disease (ESKD), but end-of-life service planning is challenging without population-specific data. We aimed to describe mortality after treatment withdrawal in Australian and New Zealand ESKD patients and evaluate death-certified causes of death. METHODS We performed a retrospective cohort study on incident patients with ESKD in Australia, 1980-2013, and New Zealand, 1988-2012, from the Australian and New Zealand Dialysis and Transplant registry. We estimated mortality rates (by age, sex, calendar year and country) and summarized withdrawal-related deaths within 12 months of treatment modality change. Certified causes of death were ascertained from data linkage with the Australian National Death Index and New Zealand Mortality Collection database. RESULTS Of 60 823 patients with ESKD, there were 8111 treatment withdrawal deaths and 26 207 other deaths over 381 874 person-years. Withdrawal-related mortality rates were higher in females and older age groups. Rates increased between 1995 and 2013, from 1142 (95% confidence interval 1064-1226) to 2706/100 000 person-years (95% confidence interval 2498-2932), with the greatest increase in 1995-2006. A third of withdrawal deaths occurred within 12 months of treatment modality change. The national death registers reported kidney failure as the underlying cause of death in 20% of withdrawal cases, with other causes including diabetes (21%) and hypertensive disease (7%). Kidney disease was not mentioned for 18% of withdrawal patients. CONCLUSIONS Treatment withdrawal represents 24% of ESKD deaths and has more than doubled in rate since 1988. Population data may supplement, but not replace, clinical data for end-of-life kidney-related service planning.
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Affiliation(s)
- Victor Khou
- Sydney Medical School, University of Sydney, Sydney, Australia.,Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Nicole L De La Mata
- Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Patrick J Kelly
- Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Angela C Webster
- Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia.,Centre for Renal and Transplant Research, Westmead Hospital, Sydney, Australia
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6
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Werida RH, Abou-Madawy S, Abdelsalam M, Helmy MW. Omega 3 fatty acids effect on the vascular calcification biomarkers fetuin A and osteoprotegerin in hemodialysis patients. Clin Exp Med 2021; 22:301-310. [PMID: 34286397 DOI: 10.1007/s10238-021-00740-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/26/2021] [Indexed: 11/25/2022]
Abstract
Chronic renal failure patients on dialysis are at a high risk of death due to vascular calcification. This study aimed at investigating the effect of omega-3 fatty acids on the vascular calcification biomarkers fetuin-A and osteoprotegerin (OPG) in patients with chronic renal failure who are undergoing hemodialysis. This prospective, open-label, controlled, parallel study included 60 hemodialysis patients who were randomized to receive either omega-3 fatty acids capsule along with their standard care of treatment (omega-3 group) or their standard care of treatment only (control group). Serum levels of fetuin-A, OPG, calcium, phosphorus, hemoglobin, parathyroid hormone, blood urea nitrogen (BUN), albumin, serum creatinine (SCr), and serum triglycerides (TG) were measured at baseline and after six months of intervention and follow-up of both groups. Significantly increased levels of fetuin-A and OPG (p < 0.001) were observed in the omega-3 group six months after the intervention compared with the control group. Levels of TG, albumin, SCr, BUN, phosphorous, calcium, hemoglobin, and parathyroid hormone were not significantly different in the omega-3 group compared with the control group after six months of intervention. Our study concluded that omega-3 may have a clinically beneficial effect in decreasing cardiovascular events by increasing the levels of the protective vascular calcification inhibitors fetuin-A and osteoprotegerin in chronic renal failure patients who are undergoing hemodialysis.
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Affiliation(s)
- Rehab H Werida
- Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Damanhour University, Damanhour, 22514, Egypt.
| | - Sohaila Abou-Madawy
- Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Damanhour University, Damanhour, 22514, Egypt
| | - Mohamed Abdelsalam
- Nephrology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Maged W Helmy
- Pharmacology and Toxicology, Faculty of Pharmacy, Damanhour University, Damanhour, 22514, Egypt
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7
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Pyart R, Aggett J, Goodland A, Jones H, Prichard A, Pugh J, Thomas N, Roberts G. Exploring the choices and outcomes of older patients with advanced kidney disease. PLoS One 2020; 15:e0234309. [PMID: 32520955 PMCID: PMC7286495 DOI: 10.1371/journal.pone.0234309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 05/24/2020] [Indexed: 02/08/2023] Open
Abstract
A lack of data on patient choices and outcomes at the time of pre-dialysis planning limits meaningful shared decision making, particularly in older frailer patients. In this large retrospective cohort study of patients aged over 70 seen by the pre-dialysis clinic (2004–2016) of a large single centre in the United Kingdom (1,216 patients), age, sex, comorbidity, poverty and frailty were used to predict choice of renal replacement therapy (RRT) over maximum conservative management (MCM). The impact of patient choice of RRT versus MCM was used to predict survival from the time of choice using multivariable Cox proportional hazards regression. Older age, female sex, greater poverty and greater frailty were associated with choosing MCM, whilst comorbidity had no significant impact on choice. At 5 years of follow up, 49% of all patients had died without receiving RRT. Over 70% of the patients choosing MCM died with better kidney function than the median level at which those starting RRT initiated treatment. Frailty and age were better predictors of survival than comorbidity and in patients with at least moderate frailty, RRT offered no survival benefit over MCM. In conclusion, analysing outcomes from the time of choice may improve shared decision making. Frailty should be routinely assessed and collected and further work may help predict which patients are unlikely to survive or progress to end stage renal disease and may not need to be burdened with making a pre-dialysis choice.
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Affiliation(s)
- Rhodri Pyart
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, United Kingdom
- * E-mail:
| | - Justine Aggett
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, United Kingdom
| | - Annwen Goodland
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, United Kingdom
| | - Hayley Jones
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, United Kingdom
| | - Alison Prichard
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, United Kingdom
| | - Julia Pugh
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, United Kingdom
| | - Nerys Thomas
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, United Kingdom
| | - Gareth Roberts
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, United Kingdom
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Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, Flowers K, Fotheringham J, Andrea Fox RN, Franklin G, Gardiner C, Martin Gerrish RN, Greenwood S, Hothi D, Khares A, Koufaki P, Levy J, Lindley E, Macdonald J, Mafrici B, Mooney A, Tattersall J, Tyerman K, Villar E, Wilkie M. Renal Association Clinical Practice Guideline on Haemodialysis. BMC Nephrol 2019; 20:379. [PMID: 31623578 PMCID: PMC6798406 DOI: 10.1186/s12882-019-1527-3] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 12/15/2022] Open
Abstract
This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.
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Affiliation(s)
- Damien Ashby
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England.
| | - Natalie Borman
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | - James Burton
- University Hospitals of Leicester NHS Trust, Leicester, England
| | - Richard Corbett
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | | | - Ken Farrington
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Katey Flowers
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | | | - R N Andrea Fox
- School of Nursing and Midwifery, University of Sheffield, Sheffield, England
| | - Gail Franklin
- East & North Hertfordshire NHS Trust, Stevenage, England
| | | | | | - Sharlene Greenwood
- Renal and Exercise Rehabilitation, King's College Hospital, London, England
| | | | - Abdul Khares
- Haemodialysis Patient, c/o The Renal Association, Bristol, UK
| | - Pelagia Koufaki
- School of Health Sciences, Queen Margaret University, Edinburgh, Scotland
| | - Jeremy Levy
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | - Elizabeth Lindley
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, England
| | - Jamie Macdonald
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | - Bruno Mafrici
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | - Kay Tyerman
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Enric Villar
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Martin Wilkie
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
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Bhachu HK, Cockwell P, Subramanian A, Nirantharakumar K, Kyte D, Calvert M. Cross-sectional observation study to investigate the impact of risk-based stratification on care pathways for patients with chronic kidney disease: protocol paper. BMJ Open 2019; 9:e027315. [PMID: 31182446 PMCID: PMC6561412 DOI: 10.1136/bmjopen-2018-027315] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) management in the UK is usually primary care based, with National Institute for Health and Care Excellence (NICE) guidelines defining criteria for referral to secondary care nephrology services. Estimated glomerular filtration rate (eGFR) is commonly used to guide timing of referrals and preparation of patients approaching renal replacement therapy. However, eGFR lacks sensitivity for progression to end-stage renal failure; as a consequence, the international guideline group, Kidney Disease: Improving Global Outcomes has recommended the use of a risk calculator. The validated Kidney Failure Risk Equation may enable increased precision for the management of patients with CKD; however, there is little evidence to date for the implication of its use in routine clinical practice. This study will aim to determine the impact of the Kidney Failure Risk Equation on the redesignation of patients with CKD in the UK for referral to secondary care, compared with NICE CKD guidance. METHOD AND ANALYSIS This is a cross-sectional population-based observational study using The Health Improvement Network database to identify the impact of risk-based designation for referral into secondary care for patients with CKD in the UK. Adult patients registered in primary care and active in the database within the period 1 January 2016 to 31 March 2017 with confirmed CKD will be analysed. The proportion of patients who meet defined risk thresholds will be cross-referenced with the current NICE guideline recommendations for referral into secondary care along with an evaluation of urinary albumin-creatinine ratio monitoring. ETHICS AND DISSEMINATION Approval was granted by The Health Improvement Network Scientific Review Committee (Reference number: 18THIN061). Study outcomes will inform national and international guidelines including the next version of the NICE CKD guideline. Dissemination of findings will also be through publication in a peer-reviewed journal, presentation at conferences and inclusion in the core resources of the Think Kidneys programme.
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Affiliation(s)
- Harjeet Kaur Bhachu
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Nephrology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Paul Cockwell
- Department of Nephrology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | - Derek Kyte
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Biomedical Research Centre (BRC) in Inflammatory Diseases, University of Birmingham, Birmingham, UK
| | - Melanie Calvert
- Centre for Patient Reported Outcomes Research and Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Baker RJ, Marks SD. Management of chronic renal allograft dysfunction and when to re-transplant. Pediatr Nephrol 2019; 34:599-603. [PMID: 30039433 PMCID: PMC6394652 DOI: 10.1007/s00467-018-4000-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 06/09/2018] [Accepted: 06/12/2018] [Indexed: 12/26/2022]
Abstract
Despite the advances in renal transplantation over the last decades, chronic allograft dysfunction remains the largest concern for patients, their families, clinicians and other members of the multi-disciplinary team. Although we have made progress in improving patient and renal allograft survival within the first year after transplantation, the rate of transplant failure with requirement for commencement of dialysis or re-transplantation has essentially remained unchanged. It is important that paediatric and adult nephrologists and transplant surgeons, not only manage their patients and their renal transplants but provide the best chronic kidney disease management during the time of decline of renal allograft function. The gold standard for patients with Stage V chronic kidney disease is to have pre-emptive living donor transplants, where possible and the same is true for healthy renal transplant recipients with declining renal allograft function. The consideration for children and young people as they embark on their end-stage kidney disease journey is the risk-benefit profile of giving the best immunologically matched and good quality renal allografts as they may require multiple renal transplantation operations during their lifetime.
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Affiliation(s)
- Richard J. Baker
- Renal Unit, Lincoln Wing, St. James’s University Hospital, Beckett Street, Leeds, LS9 7TF UK
| | - Stephen D. Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK ,University College London Great Ormond Street Institute of Child Health, London, UK
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11
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Scott J, Owen-Smith A, Tonkin-Crine S, Rayner H, Roderick P, Okamoto I, Leydon G, Caskey F, Methven S. Decision-making for people with dementia and advanced kidney disease: a secondary qualitative analysis of interviews from the Conservative Kidney Management Assessment of Practice Patterns Study. BMJ Open 2018; 8:e022385. [PMID: 30420346 PMCID: PMC6252646 DOI: 10.1136/bmjopen-2018-022385] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To explore dialysis decision-making for adults who lack capacity due to cognitive impairment, a common and under-recognised condition in those with advanced chronic kidney disease (CKD). DESIGN Secondary analysis of qualitative data collected during the Conservative Kidney Management Assessment of Practice Patterns Study programme of research was performed. Sixty semistructured interviews were conducted with multiprofessional team members from UK renal centres. Staff were asked about local facilities, the value of conservative kidney management (CKM), when and with whom CKM was discussed and how CKM could be improved. Thematic analysis was employed to identify, characterise and report on themes that emerged from the data, focused on the specific issues experienced by people with dementia. SETTING A purposive sample of nine UK renal centres differing in the scale of their CKM programmes. PARTICIPANTS Clinical directors of renal centres identified staff involved in CKM. Staff were asked to participate if they had experience of low clearance clinics or of caring for patients with advanced CKD (estimated glomerular filtration rate <20mL/min/1.732 or >65 years with end-stage kidney disease). RESULTS Two overarching themes were identified: factors taken into consideration during decision-making, and the process of decision-making itself. Comorbidity, social support, quality of life and the feasibility of dialysis were reported as factors pertinent to clinicians' decisions regarding suitability. The majority of renal centres practised multidisciplinary 'best interests' decision-making for those without capacity. Attitudes to advance care planning were divided. CONCLUSIONS In view of the prevalence of cognitive impairment among those with advanced CKD, we suggest consideration of routine assessment of cognition and capacity. In the UK, dialysis is initiated and continued for individuals with dementia and services should be adapted to meet the needs of this population.
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Affiliation(s)
- Jemima Scott
- Richard Bright Renal Unit, Southmead Hospital, Bristol, UK
- Department of Social & Community Medicine, University of Bristol, Bristol, UK
| | - Amanda Owen-Smith
- Department of Social & Community Medicine, University of Bristol, Bristol, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Bristol, UK
| | - Hugh Rayner
- Department of Renal Medicine, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Paul Roderick
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Ikumi Okamoto
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Geraldine Leydon
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Fergus Caskey
- Richard Bright Renal Unit, Southmead Hospital, Bristol, UK
- Department of Social & Community Medicine, University of Bristol, Bristol, UK
- UK Renal Registry, Bristol, UK
| | - Shona Methven
- UK Renal Registry, Bristol, UK
- Department of Renal Medicine, Aberdeen Royal Infirmary, Aberdeen, UK
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12
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Baker RJ, Marks SD. Management of chronic renal allograft dysfunction and when to re-transplant. PEDIATRIC NEPHROLOGY (BERLIN, GERMANY) 2018. [PMID: 30039433 DOI: 10.1007/s00467-018-4000-9x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Despite the advances in renal transplantation over the last decades, chronic allograft dysfunction remains the largest concern for patients, their families, clinicians and other members of the multi-disciplinary team. Although we have made progress in improving patient and renal allograft survival within the first year after transplantation, the rate of transplant failure with requirement for commencement of dialysis or re-transplantation has essentially remained unchanged. It is important that paediatric and adult nephrologists and transplant surgeons, not only manage their patients and their renal transplants but provide the best chronic kidney disease management during the time of decline of renal allograft function. The gold standard for patients with Stage V chronic kidney disease is to have pre-emptive living donor transplants, where possible and the same is true for healthy renal transplant recipients with declining renal allograft function. The consideration for children and young people as they embark on their end-stage kidney disease journey is the risk-benefit profile of giving the best immunologically matched and good quality renal allografts as they may require multiple renal transplantation operations during their lifetime.
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Affiliation(s)
- Richard J Baker
- Renal Unit, Lincoln Wing, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK.
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,University College London Great Ormond Street Institute of Child Health, London, UK
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13
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Evans RDR, Bekele S, Campbell SM, Clark SG, Harris L, Thomas A, Jones GL, Thuraisingham R. Assessment of a Dedicated Transplant Low Clearance Clinic and Patient Outcomes on Dialysis After Renal Allograft Loss at 2 UK Transplant Centers. Transplant Direct 2018; 4:e352. [PMID: 30123825 PMCID: PMC6089513 DOI: 10.1097/txd.0000000000000788] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 03/09/2018] [Indexed: 12/12/2022] Open
Abstract
Background Low clearance transplant clinics (LCTCs) are recommended for the management of recipients with a failing kidney transplant (RFKT) but data to support their use is limited. We conducted a retrospective study to assess management of RFKT at 2 transplant centers, 1 with a LCTC (center A) and 1 without (center B). Methods Patients who transitioned to an alternative form of renal replacement therapy (RRT) between January 1, 2012, and November 30, 2016, were included. Patients with graft failure within a year of transplantation or due to an unpredictable acute event were excluded. Clinical data were collected after review of medical records. Results One hundred seventy-nine patients (age, 48.6 ± 13.4 years, 99 [55.3%] male, and mean transplant duration 10.3 ± 7.8 years) were included. RRT counseling occurred in 79 (91%) and 68 (74%) patients at centers A and B (P = 0.003), at median 135 (61-319) and 133 (69-260) days before dialysis after graft loss (P = 0.92). Sixty-one (34.1%) patients were waitlisted for retransplantation; 18 (32.7%) nonwaitlisted patients were still undergoing workup at center A compared with 37 (58.7%) at center B (P = 0.028). Preemptive retransplantation occurred in 4 (4.6%) and 5 (5.4%) patients at centers A and B (P = 0.35). At 1 year after initiation of dialysis after graft loss, 11 (15.3%) and 11 (17.2%) patients were retransplanted (P = 0.12), and mortality was 6.6% overall. Conclusions A dedicated LCTC improved RRT counseling and transplant work-up but did not lead to improved rates of retransplantation. Earlier consideration of retransplantation in LCTCs is required to improve RFKT outcomes.
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Affiliation(s)
- Rhys D R Evans
- Center for Nephrology, University College London (UCL), London, United Kingdom
| | | | | | | | - Lauren Harris
- Royal Free Hospital NHS Trust, London, United Kingdom
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14
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Rutherford E, Mark PB. What happens to the heart in chronic kidney disease? J R Coll Physicians Edinb 2018; 47:76-82. [PMID: 28569289 DOI: 10.4997/jrcpe.2017.117] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Cardiovascular disease is common in patients with chronic kidney disease. The increased risk of cardiovascular disease seen in this population is attributable to both traditional and novel vascular risk factors. Risk of sudden cardiac or arrhythmogenic death is greatly exaggerated in chronic kidney disease, particularly in patients with end stage renal disease where the risk is roughly 20 times that of the general population. The reasons for this increased risk are not entirely understood and while atherosclerosis is accelerated in the presence of chronic kidney disease, premature myocardial infarction does not solely account for the excess risk. Recent work demonstrates that the structure and function of the heart starts to alter early in chronic kidney disease, independent of other risk factors. The implications of cardiac remodelling and hypertrophy may predispose chronic kidney disease patients to heart failure, arrhythmia and myocardial ischaemia. Further research is needed to minimise cardiovascular risk associated with structural and functional heart disease associated with chronic kidney disease.
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Affiliation(s)
- E Rutherford
- P Mark, BHF Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK,
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15
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Winterbottom A, Bekker H, Mooney A. Dialysis modality selection: physician guided or patient led? Clin Kidney J 2016; 9:823-825. [PMID: 27994862 PMCID: PMC5162419 DOI: 10.1093/ckj/sfw109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/27/2016] [Indexed: 11/14/2022] Open
Abstract
The process of choosing dialysis modality for patients is complex and requires input from the expert renal team. Although it is commonplace for nephrologists to recommend dialysis modalities to patients, this might not always lead to the patient receiving treatment which they regard as most suitable. Nephrologists should consider whether it is appropriate for pre-dialysis education to be directive, or whether the choice between treatment options should be led by the patient.
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Affiliation(s)
| | - Hilary Bekker
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Andrew Mooney
- Renal Unit, St James's University Hospital, Leeds, UK
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16
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Affiliation(s)
- Elizabeth Oei
- Singapore General Hospital - Department of Renal Medicine, Singapore, Singapore
| | - Stanley Fan
- Barts Health NHS Trust - Department of Renal Medicine and Transplantation London, United Kingdom
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Increased Number and Distribution of Cerebral Microbleeds Is a Risk Factor for Cognitive Dysfunction in Hemodialysis Patients: A Longitudinal Study. Medicine (Baltimore) 2016; 95:e2974. [PMID: 27015171 PMCID: PMC4998366 DOI: 10.1097/md.0000000000002974] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The aim of this study was to explore the risk factors associated with longitudinal changes in hemodialysis patients including the correlation between number and distribution of cerebral microbleeds (CMBs). Sixty-one hemodialysis patients were enrolled in this prospective study. Twenty-eight patients had follow-up examinations with a mean interval of 24.79 ± 5.17 months. The number of CMBs was manually counted on susceptibility-weighted imaging. Subjects were divided into 2 groups with and without CMBs. In the CMB group, 8 of 33 patients did not have a mini-mental state examination (MMSE) because of blurred vision. Multiple logistic regression was used to investigate the risk factors for CMBs. Partial correlation was used to explore the correlation between the increased number of CMBs and the change of MMSE scores. CMBs were seen in 33 (54%) hemodialysis patients. Both age and pre/postdialysis systolic blood pressure (SBP) positively correlated with CMBs. Serum iron (SI), and high-density lipoprotein cholesterol (HDL-c) negatively correlated with CMBs (all P < 0.05). Among 25 patients with CMBs and MMSE, 9 patients had scores <27, which was considered as subnormal and most CMBs in these patients were located in the brainstem and basal ganglia. Considering age and follow-up time as the co-confounding factors, the number of new CMBs over the 2 imaging time points negatively correlated with the change of MMSE scores (r = −0.673, P = 0.023). The presence of new CMBs was a risk factor for cognitive dysfunction and the location of CMBs may be correlated with cognitive impairment. Both SI and HDL-c were protective factors for the CMBs. The risk factors for CMBs included age, pre- and postdialysis SBP.
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Findlay MD, Donaldson K, Doyle A, Fox JG, Khan I, McDonald J, Metcalfe W, Peel RK, Shilliday I, Spalding E, Stewart GA, Traynor JP, Mackinnon B. Factors influencing withdrawal from dialysis: a national registry study. Nephrol Dial Transplant 2016; 31:2041-2048. [PMID: 27190373 DOI: 10.1093/ndt/gfw074] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/16/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Dialysis withdrawal is the third most common cause of death in patients receiving dialysis for established renal failure (ERF) in Scotland. We describe incidence, risk factors and themes influencing decision-making in a national renal registry. METHODS Details of deaths in those receiving renal replacement therapy (RRT) for ERF in Scotland are reported to the Scottish Renal Registry via a unique mortality report. We extracted patient demographics and comorbidity, cause and location of death, duration of RRT and pertinent free text comments from 1 January 2008 to 31 December 2014. Withdrawal incidence was calculated and logistic regression used to identify significantly influential variables. Themes emerging from clinician comments were tabulated for descriptive purposes. RESULTS There were 2596 deaths; median age at death was 68 [interquartile range (IQR) 58, 76] years, 41.5% were female. Median duration on RRT was 1110 (IQR 417, 2151) days. Dialysis withdrawal was the primary cause of death in 497 (19.1%) patients and withdrawal contributed to death in a further 442 cases (17.0%). The incidence was 41 episodes per 1000 patient-years. Regression analysis revealed increasing age, female sex and prior cerebrovascular disease were associated with dialysis withdrawal as a primary cause of death. Conversely, interstitial renal disease, angiographically proven ischaemic heart disease, valvular heart disease and malignancy were negatively associated. Analysis of free text comments revealed common themes, portraying an image of physical and psychological decline accelerated by acute illnesses. CONCLUSIONS Death following dialysis withdrawal is common. Factors important to physical independence-prior cerebrovascular disease and increasing age-are associated with withdrawal. When combined with clinician comments this study provides an insight into the clinical decline affecting patients and the complexity of this decision. Early recognition of those likely to withdraw may improve end of life care.
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Affiliation(s)
- Mark D Findlay
- The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, UK
| | | | | | - Jonathan G Fox
- The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, UK
| | | | - Jackie McDonald
- ISD Healthcare Information Group, NHS Scotland National Services Division, Edinburgh, UK
| | - Wendy Metcalfe
- Department of Renal Medicine, Edinburgh Royal Infirmary, Edinburgh, UK
| | | | | | - Elaine Spalding
- The John Stevenson Lynch Renal Unit, Crosshouse Hospital, Kilmarnock, UK
| | | | - Jamie P Traynor
- The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, UK
| | - Bruce Mackinnon
- The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, UK
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Amro OW, Ramasamy M, Strom JA, Weiner DE, Jaber BL. Nephrologist-Facilitated Advance Care Planning for Hemodialysis Patients: A Quality Improvement Project. Am J Kidney Dis 2016; 68:103-9. [PMID: 26806003 DOI: 10.1053/j.ajkd.2015.11.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/30/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND The Renal Physicians Association's clinical practice guideline recommends that physicians address advance care planning with dialysis patients. However, data are lacking about how best to implement this recommendation. STUDY DESIGN Quality improvement project. SETTINGS & PARTICIPANTS Nephrologists caring for patients treated with maintenance hemodialysis at 2 dialysis facilities identified patients who might benefit most from advance care planning using the "surprise" question ("Would I be surprised if this patient died in the next year?"). QUALITY IMPROVEMENT PLAN Patients identified with a "no" response to the surprise question were invited to participate in nephrologist-facilitated advance care planning, including completion of a Medical Orders for Life-Sustaining Treatment (MOLST) form. OUTCOMES Change in MOLST completion rate and identification of preferences for limits on life-sustaining treatment. MEASUREMENTS Pre- and postintervention code status, MOLST completion rate, and vital status at 1 year. RESULTS Nephrologists answered "no" to the surprise question for 50 of 201 (25%) hemodialysis patients. Of these, 41 (82%) patients had a full-code status and 9 (18%) had a do-not-resuscitate (DNR) status. Encounters lasted 15 to 60 minutes. Following the encounter, 21 (42%) patients expressed preference for a DNR status and 29 (58%) maintained full-code status (P=0.001). The MOLST completion rate increased from 10% to 90%. One-year survival for patients whose nephrologists answered "no" to the surprise question was 58% compared to 92% for those with a "yes" answer (P<0.001). LIMITATIONS Sample size and possible nonrepresentative dialysis population. CONCLUSIONS Nephrologist-facilitated advance care planning targeting hemodialysis patients with limited life expectancy led to significant changes in documented patient preferences for cardiopulmonary resuscitation and limits on life-sustaining treatment. These changes demonstrate the benefit of advance care planning with dialysis patients and likely reflect better understanding of end-of-life treatment options.
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Affiliation(s)
- Osama W Amro
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Malar Ramasamy
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - James A Strom
- Department of Medicine, Tufts University School of Medicine, Boston, MA; Division of Nephrology, Department of Medicine, St Elizabeth Medical Center, Boston, MA
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Bertrand L Jaber
- Department of Medicine, Tufts University School of Medicine, Boston, MA; Division of Nephrology, Department of Medicine, St Elizabeth Medical Center, Boston, MA.
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Prieto-Velasco M, Isnard Bagnis C, Dean J, Goovaerts T, Melander S, Mooney A, Nilsson EL, Rutherford P, Trujillo C, Zambon R, Crepaldi C. Predialysis education in practice: a questionnaire survey of centres with established programmes. BMC Res Notes 2014; 7:730. [PMID: 25326141 PMCID: PMC4210595 DOI: 10.1186/1756-0500-7-730] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 10/09/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is growing evidence that renal replacement therapy option education (RRTOE) can result in enhanced quality of life, improved clinical outcomes, and reduced health care costs. However, there is still no detailed guidance on the optimal way to run such programmes. To help address this knowledge gap, an expert meeting was held in March 2013 to formulate a position statement on optimal ways to run RRTOE. Experts were selected from units that had extensive experience in RRTOE or were performing research in this field. Before the meeting, experts completed a pilot questionnaire on RRTOE in their own units. They also prepared feedback on how to modify this questionnaire for a large-scale study. METHODS A pilot, web-based questionnaire was used to obtain information on: the renal unit and patients, the education team, RRTOE processes and content, how quality is assessed, and funding. RESULTS Four nurses, 5 nephrologists and 1 clinical psychologist (9 renal units; 6 EU countries) participated. Nurses were almost always responsible for organising RRTOE. Nephrologists spent 7.5% (median) of their time on RRTOE. Education for the patient and family began several months before dialysis or according to disease progression. Key topics such as the 'impact of the disease' were covered by every unit, but only a few units described all dialysis modalities. Visits to the unit were almost always arranged. Materials came in a wide variety of forms and from a wide range of sources. Group education sessions were used in 3/9 centres. Expectations on the timing of patients' decisions on modality and permanent access differed substantially between centres. Common quality assurance measures were: patient satisfaction, course attendance, updated materials. Only 1 unit had a dedicated budget. CONCLUSIONS There were substantial variations in how RRTOE is run between the units. A modified version of this questionnaire will be used to assess RRTOE at a European level.
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Affiliation(s)
| | - Corinne Isnard Bagnis
- />Service de Néphrology, Groupe Hospitalier Pitié-Salpêtrière et Chaire de Recherche en Education Thérapeutique, Université Pierre et Marie Curie, Paris, France
| | - Jessica Dean
- />Department of Clinical Health Psychology, Salford Royal Hospital, Salford, M6 8HD UK
| | - Tony Goovaerts
- />Cliniques Universitaires St. Luc, Service de Néphrologie, Brussels, Belgium
| | - Stefan Melander
- />Department of Nephrology, University Hospital of Linköping, Linköping, Sweden
| | - Andrew Mooney
- />Renal Unit, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF UK
| | - Eva-Lena Nilsson
- />Department of Nephrology and Transplantation, Skånes University Hospital, Malmö, Sweden
| | | | - Carmen Trujillo
- />Unidad clínica de Gestión de Nefrología, Hospital Regional Carlos Haya, Malaga, Spain
| | - Roberto Zambon
- />Unità Operativa di Nefrologia, Dialisi e Trapianto, Ospedale San Bortolo, ULSS106 Vicenza, Italy
| | - Carlo Crepaldi
- />Unità Operativa di Nefrologia, Dialisi e Trapianto, Ospedale San Bortolo, ULSS106 Vicenza, Italy
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21
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Farrington K. Striking a Balance. Semin Dial 2012; 25:525-7. [DOI: 10.1111/j.1525-139x.2012.01119.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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