Dedication of a nurse to educating suboptimal haemodialysis starts improved transition to independent modalities of renal replacement therapy

Abstract

Haemodialysis (HD) initiation is unplanned in up to 50% of patients, mainly due to late diagnosis and/or late nephrology referral. In these patients, time does not permit the multidisciplinary predialysis care that is associated with increased independent renal replacement therapy (RRT) modality choice and better access to kidney transplantation. We established a Renal Triage Nurse (RTN) position to educate suboptimal HD starts and to facilitate transition to independent modalities of RRT. Adult patients starting HD from 1 January 2005 to 31 December 2008 with < 180 days nephrology follow-up and surviving at least 180 days were included (suboptimal HD starts). The RTN educated suboptimal HD starts beginning in December 2006. Patients initiating RRT via the multidisciplinary predialysis clinic (MPC) were included for comparison. Multivariable logistic regression was used to determine the association between being seen by the RTN and achieving independent modalities of RRT. There were 176 patients: 78 suboptimal HD starts (38 of these were educated by the RTN) and 98 patients initiated RRT after a minimum 180-day follow-up at the MPC. Of the RTN patients, 27.8% switched to independent RRT modalities (peritoneal dialysis n = 7, home haemodialysis n = 1, transplant n = 2). RTN patients were more likely to live alone (33.3% versus 10.8%, P = 0.02) and to have cerebrovascular disease (25.0% versus 7.1%, P = 0.03); however, adjusting for these variables, suboptimal HD starts seen by the RTN were more likely to transition to independent RRT (OR 3.75, 95% CI 1.08-13.05) than those not seen. The proportion starting on an independent modality via the MPC was 39.8%. The RTN achieved a rate of independent RRT not statistically different to that observed in patients starting RRT via the MPC (OR 0.74, 95% CI 0.19-2.94 in multivariable analysis). Addition of the RTN to the HD care team facilitated transition to independent modalities of RRT in suboptimal HD starts. This standardized approach to the care of such patients should be considered in HD units where suboptimal HD starts are common.