Dialysis Staff Research Articles

Care of the Hospitalized Patients with Kidney Failure during COVID-19 Pandemic: Lessons Learned.

Care of the Hospitalized Patients with Kidney Failure during COVID-19 Pandemic: Lessons Learned.

War in Ukraine and dialysis treatment: human suffering and organizational challenges.

In January 2021, there were 9648 patients in Ukraine on kidney replacement therapy, including 8717 on extracorporeal therapies and 931 on peritoneal dialysis. On 24 February 2022, foreign troops entered the territory of Ukraine. Before the war, the Fresenius Medical Care dialysis network in Ukraine operated three medical centres. These medical centres provided haemodialysis therapy to 349 end-stage kidney disease patients. In addition, Fresenius Medical Care Ukraine delivered medical supplies to almost all regions of Ukraine. Even though Fresenius Medical Care's share of end-stage kidney disease patients on dialysis is small, a brief narrative account of the managerial challenges that Fresenius Medical Care Ukraine and the clinical directors of the Fresenius Medical Care centres had to face, as well as the suffering of the dialysis population, is a useful testimony of the burden imposed by war on these frail, high-risk patients dependent on a complex technology such as dialysis. The war in Ukraine is causing immense suffering for the dialysis population of this country and has called for heroic efforts from dialysis personnel. The experience of a small dialysis network treating a minority of dialysis patients in Ukraine is described. Guaranteeing dialysis treatment has been and remains an enormous challenge in Ukraine and we are confident that the generosity and the courage of Ukrainian dialysis staff and international aid will help to mitigate this tragic suffering.

Exercise guide to help on arteriovenous fistula maturation and maintenance.

The arteriovenous fistula is the main vascular access in hemodialysis. Arteriovenous fistula access is generally evaluated by a vascular surgeon after 2 weeks of its surgery, however, exercise programs may begin earlier for improving outcomes. Therefore, we propose this guide with simple, but potentially effective exercises, using low-cost materials that can be safely performed by the patients at home or in the dialysis center. It also provides to the dialysis staff team a starting point for implementing an upper-limb exercise program that may facilitate arteriovenous fistula maturation and maintenance. This exercise routine for arteriovenous fistula maturation can be performed three to four times a day, every day, from 2 to 4 weeks. After its maturation, it can be performed on every non-dialysis day for conventional treatment and every other day, before dialysis, for short daily treatment. Based on the available evidence, we have gathered some exercises, in a very easy and understandable language, that may potentially help arteriovenous fistula maturation and maintenance for hemodialysis patients.

IMPACT OF HEMODIALYSIS ON THE QUALITY OF LIFE AMONG ESRD PATIENTS

Aim: To determine QOL standards in patients with ESRD undergoing twice/week hemodialysis. Methods: This was a multicenter cross-sectional study conducted in patients of either sex, aged above 18 years diagnosed with ESRD who were undergoing hemodialysis for at least three months in three hemodialysis centers. For QOL assessment, patients underwent KDQOL questionnaire survey. KDQOL is a disease-specic QOL questionnaire. Results: Total of 74 patients with ESRD (mean age: 54.7 years; men: 67.6%) undergoing hemodialysis enrolled. Overall, 53 (71.6%) patients had improvement in their life in comparison to last year. Majority of patients reported no bodily pain (66.2%). Majority of patients (68.9%) did not feel frustrated due to kidney disease. Total of 75.7% of patients did not feel like a burden on their family. More than half of the patients reported they did not bother about dry skin (55.4%), sleep disturbance (66.2%), and problem with access site (75.7%). Most of the patients reported that dialysis staff encouraged them to be as independent as possible (93.7%) and support them in coping their kidney disease (93.3%). Conclusion: The present study was done to throw a light on the status of QOL of Indian patients undergoing hemodialysis and might inspire the healthcare providers to endeavor for quality in delivery of dialysis in the future.

Intradialytic hypotension frequency is reduced by levocarnitine supplementation

Introduction: Intradialytic hypotension (IDH) is a frequent complication of hemodialysis. IDH causes intradialytic discomfort and subclinical ischemia, resulting in a higher rate of morbidity and mortality. Levocarnitine (LC) administration has been suggested for the treatment of IDH, but conflicting reports about its efficacy have been published. We describe the effect of LC supplementation in patients experiencing recurrent IDH episodes, in spite of common strategies used to prevent it. Methods: Sixteen hemodialysis patients were studied. IDH was defined as a drop in systolic blood pressure ≥20 mmHg, with or without symptoms, prompting an intervention by the dialysis staff, such as reducing/stopping ultrafiltration rate and/or fluid administration. Blood pressure was recorded for 192 hemodialysis sessions, before LC supplementation. Thereafter LC (30 mg/kg dry weight) was administered at the beginning of each hemodialysis, registering blood pressure for 384 hemodialysis treatments. The difference between the predialysis systolic blood pressure and the minimum systolic blood pressure of each hemodialysis was evaluated (∆SBP), before and after LC supplementation. Cardiac ejection fraction was also measured. Results: Predialysis and postdialysis systolic, diastolic, and mean arterial pressures did not differ before and after LC supplementation. Before LC supplementation, 36 episodes of IDH occurred (19%), while after LC supplementation, the IDH episodes were 29 during 384 hemodialysis sessions (8%; χ2 = 16.03; p = 0.0001). ∆SBP was lower after LC supplementation, even though the difference was not significant (p = 0.22). Conclusion: IDH frequency was significantly reduced by predialysis LC supplementation, which can be helpful for patients’ well-being and reduction in IDH-associated risks.

Organizational support, training and equipment are key determinants of burnout among dialysis healthcare professionals during the COVID-19 pandemic

IntroductionBurnout was already found to be an important factor in the professional landscape of nephrology prior to the COVID-19 outbreak and is expected to worsen during the pandemic.ObjectivesThe aim of our study was to assess pandemic experiences, perceptions, and burnout among Polish dialysis unit professionals in the COVID-19 period.Participants and methodsA survey, which consisted of a Pandemic Experiences and Perceptions Survey (PEPS) and a Maslach Burnout Inventory was distributed online to Polish dialysis units. The study group comprised 379 participants (215 nurses, 148 physicians, and 16 respondents of other professions).ResultsThe pandemic largely affected or completely dominated the work of dialysis units according to 53.4% and 25.5% of nurses responding to the PEPS, respectively. Among physicians, the prevalence was 55.5% and 15.4% of participants, respectively. Serious or life-threatening risk was perceived by 72.1% and 11.9% of dialysis healthcare professionals, respectively. Furthermore, 74.6% of the study participants stated that their work in a dialysis setting amidst the pandemic was felt to be associated with serious risk for their relatives. Adequate personal protective equipment and information from management decreased burnout among dialysis staff. Burnout was lower in all dimensions among those participants who felt more in control of their exposure to infection, provided by proper training, equipment, and support (p = 0.0004 for emotional exhaustion, p = 0.0007 for depersonalization, and p < 0.0001 for feelings of personal accomplishment).ConclusionsThe COVID-19 pandemic has largely affected the work in dialysis units. Providing proper training, equipment, and support may decrease burnout among dialysis staff.Graphical abstract

National response to the COVID-19 Omicron variant crisis in the ambulatory hemodialysis service in the State of Qatar.

The coronavirus disease (COVID-19) pandemic has had a significant worldwide impact since its emergence in 2019. End-stage kidney disease patients have been among the most vulnerable population affected and have a higher risk of acquiring infection and developing more severe disease. We have encountered three major COVID-19 waves in Qatar and they have required different strategies to overcome. The most recent wave was due to the Omicron variant characterized by higher transmissibility. The monthly incidence of COVID-19 infection during the Omicron wave in patients with end-stage renal disease peaked at 256 patients compared to 35 and 39 patients during the first and second waves, respectively. In addition, more than one-third of our dialysis staff became infected during this wave. Unlike the previous two waves, COVID-19 due to the Omicron variant was less severe with only 5% of hemodialysis patients requiring admission to the intensive care unit compared to 25% during the previous waves. The Omicron variant wave resulted in a crisis in our country due to the high number of non-hospitalized COVID-19 hemodialysis patients and the severe staff shortage. Several measures were taken to overcome the crisis, such as designating one facility to dialyze all COVID-19 ambulatory patients, reducing dialysis sessions to 3 hours, and introducing a fourth dialysis shift.This article describes the challenges we faced in the ambulatory hemodialysis service during the Omicron wave and the measures taken in the COVID-19 and non-COVID-19 designated facilities to combat the crisis.

Spread of Covid-19 in hemodialysis centres; the effects of ventilation and communal transport.

AimsHemodialysis (HD) patients are at increased risk of respiratory infections, due to increased use of communal travel, waiting areas, close proximity to others when dialysing, and contact with healthcare personnel. We wished to determine the major factors associated with transmission of COVID‐19 within dialysis centres.MethodsWe compared the differences in the number of COVID‐19 infections in patients and staff in 5 dialysis centres during the 1st COVID‐19 pandemic between March and June 2020, and analyzed differences between centres. Isolation policies and infection control practices were identical between centres.Results224 (30.3%) patients tested positive for COVID‐19, by reverse transcriptase polymerase chain reaction, ranging from 4.8% (centre 1 size 55 patients) to 41.5% (centre 5–248 patients) p = 0.007. Communal transport had a significant effect; with 160 of 452 (35.4%) patients using communal testing positive compared to 22.2% of those not using communal transport (X214.5, p < 0.001). Staff sickness varied; 35 of 36 (97.3% centre 5) dialysis staff contracting COVID‐19, compared to 60% from centre 4 (189 patients 30 staff) (p < 0.001). Whereas centre 5 had no natural ventilation, and fan assisted ventilation did not meet standards for air changes and air circulation, centre 4 met ventilation standards.ConclusionsAlthough there are many potential risk factors accounting for the increased risk of COVID‐19 infection in hemodialysis patients, we found that differences in communal transport for patients and ventilation between centres was a major contributor accounting for the differences in patients testing positive for COVID‐19 and staff sickness rates. This has important practical applications for designing kidney dialysis centres.

Assessing Illness Acceptance and Quality of Life among the End Stage Renal Disease (ESRD) Patients Undergoing Hemodialysis

Haemodialysis is the best treatment for the long-term survival of end-stage renal disease patients that requires the acceptance of illness, which can maintain patients' Quality of life. Three hundred thirty-seven hemodialysis patients were involved in this study, which reported the acceptance of illness was moderate and was lowest among the males. The Quality of life was good and supported by the emotional well-being, dialysis staff encouragement, social support, and the acceptance of illness. Multidisciplinary intervention should be targeted to address the physical status and disease-specific core aiming to reduce further health complications and improve Quality of life. Keywords: acceptance to illness; quality of life; hemodialysis, end-stage renal disease patients eISSN: 2398-4287 © 2022. The Authors. Published for AMER ABRA cE-Bs by e-International Publishing House, Ltd., UK. This is an open access article under the CC BYNC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer–review under responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers), ABRA (Association of Behavioural Researchers on Asians/Africans/Arabians) and cE-Bs (Centre for Environment-Behaviour Studies), Faculty of Architecture, Planning &amp; Surveying, Universiti Teknologi MARA, Malaysia. DOI: https://doi.org/10.21834/ebpj.v7i20.3458

Nursing Experience of Applying Swanson's Caring Theory in the Care for a Patient Who was Non-compliant with Hemodialysis

&lt;p&gt;本文旨在敘述一位不遵從血液透析治療療程病人之護理經驗。照護期間自2019年2月1日至6月3日，發現個案因飲食及水份自我控制差，導致透析過程中身體不適及影響透析品質，且由於個案無法接受增加透析次數，亦對未來感到無力、無助感，故以Gordon’s十一項功能性健康型態評估作為指引，歸納出主要健康問題為：體液容積過量、不遵從及無力感。筆者運用Swanson關懷理論中五個核心過程：「了解、在旁陪伴、為他做某些事、使他能夠、維持信念」，主動關懷個案需求，透過護理活動介入，協助個案獲得良好支持系統，以減輕個案內心之無力、無助感；加強對疾病深入認識了解，使其能以正向態度坦然並積極遵從血液透析治療，重建自我價值，提升對於未來的正向信念。建議對於處於疾病調適期的個案，醫護人員應該用正向角度看待個案，強調遵從的正向效果，誘發個案自我效能以重建信心。期望藉由此照護經驗，能提供護理人員對於血液透析病人照護之參考及運用。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;This article aims to share our nursing experience of caring a noncompliant patient receiving maintenance hemodialysis. The patient had large interdialytic weight gain secondary to poor adherence to sodium and fluid restriction during February 1, 2019 to June 3, 2019. The frequent poor self-control of dietary water and inadequate dialysis made him extremely tired, uneasy, edematous, and despond. He was then in a depressive mood, feeling powerless and hopeless for the future.&lt;/p&gt; &lt;p&gt;Gordon’s11 functional assessment tool was applied; we evaluated and categorized the patient&amp;rsquo;s health problems as fluid overload, noncompliance, and powerlessness. Based on Swanson’s Theory of Caring, the five key principles of care were knowing, being with, doing for, enabling, and maintaining belief. Through the patient-centered nursing process, we looked after his needs, utilized resources to get him a good support system, tried to regain his confidence in the fight against the illnesses, and alleviated his helplessness and powerlessness. By collaborating with the dialysis staff and handling the difficulties in a positive manner, the patient rebuilt his self-worth and optimistic attitude toward life.&lt;/p&gt; &lt;p&gt;It is recommended that for patients with an adjustment disorder, the medical staff should treat them properly in a positive perspective, utilize available resources to develop a supportive system, reassure the importance of dietary and fluid compliance, and increase the patients&amp;rsquo; self-confidence. We think that the nursing experience is a good example for professionals taking care of patients on hemodialysis.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Challenges Faced by Dialysis Unit Staff During COVID-19 Times: A Qualitative Study

Background: The Coronavirus has caused an epidemic affecting the whole world for the last two years and has been spreading steadily. The hemodialysis patients are at high risk because of their lowered immunity status. The dialysis staff is also at higher risk of contracting COVID-19 as these patients come for twice/thrice weekly treatment sessions. Objectives: This study was done to study the hardships and problems afflicting the dialysis staff during the infections caused by COVID-19 in a rural hemodialysis unit. Methods: This study setting was the hemodialysis unit located in a rural hospital in Pondicherry, India. Free listing and pile sorting were done to study the structure and salient problems as felt in the cognitive domain by the dialysis team. Smith's S value was calculated for a free listing. Multidimensional scaling and cluster analysis were conducted to do pile sorting of data. Data were analyzed using Anthropac 4.983/X. Group interviews were carried out to get in-depth information and validate the findings obtained from the free list and pile sorting exercise. Results: Twelve salient items were obtained from the free list. Three broad domains emerged: the absence of personal safety, shortage of personal safety equipment, and presence of logistical and operational problems. Surprisingly, RT-PCR testing was not perceived to be of importance for them. Conclusions: Accepting the true feelings, fears, and needs of the dialysis staff, helping to tackle the impediments to personal safety, and the lack of personal safety equipment in a dialysis unit during COVID-19 outbreak are vital in ensuring personal safety and improving working dynamics.

MO607: Intradialytic Exercise: A Large-Scale Nationwide Implementation Study

Abstract BACKGROUND AND AIMS Intradialytic exercise (IDE) is recommended for HD patients. However, this recommendation is mostly based on research conducted under optimal instead of real-world conditions, limiting generalizability and its implementation into routine clinical care. This study aims to analyze implementation outcomes of IDE in real-world conditions at a large-scale, nationwide level. METHOD After a pilot experience in a single unit, all NephroCare Portugal dialysis clinics were invited to initiate an IDE program. A national coordinator was nominated, and a nurse and a doctor were selected in each unit as local coordinators. A simple exercise protocol was designed to be easily applied by current dialysis staff (though some units benefited from exercise science student internships). The IDE protocol includes a bout of aerobic exercise (cycle ergometer) and lower limb resistance exercises (ankle weights). The RE-AIM (reach, effectiveness, adoption, implementation and maintenance) framework was used to study clinical implementation over the first year. For each RE-AIM dimension, specific implementation outcomes were adapted to IDE. Effectiveness measures included safety (incidence of intradialytic adverse events over 1 year) and physical function at baseline and at 1 year (sit to stand 30, 8-foot up &amp; go, handgrip strength, sit to stand 5 and single leg stance). For safety measures, IDE group was compared to a group of patients that refused IDE. Physical function measures were only applied to IDE patients, and so comparisons were made between low- and high-frequency exercise groups. RESULTS Adoption: 21 dialysis units (58.3%). Reach: 1270 eligible patients (55.8%). Main reasons for noneligibility were physical/cognitive incapacity (50.8%) and cardiovascular risk (34.9%). Eligible patients were younger (P &amp;lt; 0.001) and had a better health status (lower comorbidity index: P &amp;lt; 0.001; lower prevalence of diabetes: P &amp;lt; 0.001; lower fat tissue index: P &amp;lt; 0.001; and a higher lean tissue index: P &amp;lt; 0.001). 811 (63.9%) committed to the intervention. Compared with non-IDE patients, IDE patients were younger (&amp;lt;0.001), had a lower dialysis vintage (&amp;lt;0.001), a lower comorbidity index (P &amp;lt; 0.001) and a higher lean tissue index (P = 0.035). Implementation: adherence to exercise sessions was 75.0% ± 19.7%. In 77% of the 50 356 HD treatments, exercise was performed as prescribed. Non-performed exercise sessions (n = 9768) are mostly justified by patient refusal (61.5%) and pain (8.4%). Patients performed 2.2 ± 0.6 exercise sessions/week achieving 86.3 ± 29.0 min/week. Maintenance (setting level): none of the clinics interrupted IDE. Maintenance (patient level): attrition rate was 57.2% mainly due to voluntary withdrawal (52.4%). Comparing to voluntary withdrawals, completers were mainly males (P &amp;lt; 0.001) and had a lower dialysis vintage (P = 0.007), and higher lean tissue index (P = 0.023). Effectiveness: IDE (n = 347) and non-IDE patients (n = 394) were compared. Total incidence of adverse events was lower in IDE, but no significant differences were found (P = 0.808). The individual analysis of each adverse event demonstrated no significant differences for cramps, hypotension, needle dislodgement and other adverse events. Overall physical function improved in IDE (P &amp;lt; 0.001), despite a slight reduction in handgrip strength (P = 0.001). A within-group (low- versus high-frequency exercise) effect was observed, highlighting a deterioration in handgrip strength in the low-frequency group (P = 0.002), whereas no change was observed in the high-frequency group (P = 0.097). CONCLUSION Large-scale implementation of IDE is a realistic and safe way to promote physical activity in HD patients with benefits on physical function. Yet, to optimize its generalizability, strategies to increase patients´ acceptability and long-term adherence are needed.

Comparison of Vaccine Effectiveness Against the Omicron (B.1.1.529) Variant in Hemodialysis Patients

Comparison of Vaccine Effectiveness Against the Omicron (B.1.1.529) Variant in Hemodialysis Patients

The Influence of an Unexpected Switch of Hemodialysis Facilities on the Quality of Life (QOL) in Hemodialysis Patients.

BackgroundWe experienced a sudden breakdown of hemodialysis system during a clinical study of dermal itch and serum BNP concentrations.Patients and MethodsForty-eight hemodialysis patients were enrolled in the itch-related study. It was intended to improve itch by lowering BNP with supportive communication between the patients and the dialysis staff. We planned to collect data, including visual analogue scale (VAS), dermatology life quality index (DLQI), blood samples and QOL score (KDQOL-SF), four times over a four week interval. The first data was obtained just prior to switching facilities due to a breakdown. The patients underwent hemodialysis in other facilities for two weeks and underwent determination of their clinical data, including QOL scores, three times.ResultsWhile mean blood pressure showed no significant differences, serum albumin, iron and phosphate levels were worsened significantly between pre- and post-relocation. Serum BNP and DLQI showed no significant changes. VAS was significantly worsened. The mean values of the cognitive function in the KDQOL-SF and sleep and the role-physical, role-emotional, social function, dialysis staff’s encouragement in SF-36 analysis were identified as statistically significant items by MANOVA. Both SF-12 physical and mental composites were also statistically significant. Although SF-12 physical composites were significant among the patients under 66 yrs of age (median), eight factors were significant among those over 66 yrs. Independent analyses revealed every item that was detected worsened significantly after the switch of facilities.ConclusionUnexpected switching of hemodialysis facilities severely impacts the QOL for a long duration as well as the patients’ symptom and laboratory data.

Dialysis Staff–Reported Impact of COVID-19 on Early Kidney Transplant Steps

COVID-19 has influenced multiple aspects of kidney transplantation, the preferred treatment for most patients with end-stage kidney disease (ESKD). Patients with ESKD and transplant recipients are vulnerable to severe COVID-19 illness given the high prevalence of comorbidities and immunosuppression in these populations.1 Vast disruptions to kidney transplant operations were reported early in the pandemic, with 72% of US transplant centers reporting temporary suspension of living donor kidney transplant activity and 84% of centers reporting some or major restrictions to deceased donor kidney transplants in a national survey in March 2020.

COVID-19 Infection among Dialysis Patients and Staff.

COVID-19 Infection among Dialysis Patients and Staff.

The Fluid Management Experience in Patients with Chronic Kidney Disease Undergoing Hemodialysis in Indonesia: A Qualitative Study

Background: Fluid management can reduce mortality, severe comorbidities, and debilitating symptoms in patients on hemodialysis. Therefore, a restricted fluid intake plan is crucial for patients with chronic kidney disease (CKD). Little evidence has been found to date on exploring the experience in fluid management of CKD patients in Indonesia.Purpose: This study aimed to explore the fluid management experience of adults with chronic kidney disease participating in hemodialysis treatment in Indonesia.Methods: A qualitative study with a phenomenological approach was conducted. Purposive sampling was used to recruit 14 adults patients with chronic kidney disease undergoing hemodialysis in a tertiary hospital in Padang between July and September 2020. Manual content analysis using the Colaizzi approach was used to identify themes.Results: Data analysis revealed four themes with 12 sub-themes. The four major themes include the challenge of thirst control, fluid/diet restriction management, inadequate information, and the support system.Conclusions: The result showed the severe suffering and sadness experienced by CKD patients who conform to fluid restrictions. It is important to provide clear information on the fluid prescription or the exact consumable amount per day. Structured education with a personal approach is recommended to ensure detailed information regarding "fluid prescribing". The support obtained from family, friends, and dialysis staff is a significant factor in promoting acceptance and adherence.

Using Focus Groups to Understand Dialysis Staff Perspectives on Delivering Transplant Education.

Kidney transplant education in dialysis facilities could be optimized with internet resources, like videos, but most qualitative research predates widespread availability of online video education about kidney transplantation. To improve understanding of dialysis staff transplant education practices, as well as the potential value of video, we conducted focus groups of dialysis center staff members in Buffalo, NY. Seventeen focus groups (97 participants: 53 nurses, 10 dialysis technicians, 6 social workers, 6 dieticians, 7 administrative personnel, 2 trainees, and 1 insurance coordinator) from 8 dialysis facilities in Buffalo, NY, were conducted, audio-recorded, transcribed, and analyzed. After thematic data analysis, a diverse patient and caregiver community advisory board was invited to comment, and their voices were integrated. Findings: Five key themes were identified that captured barriers to transplant education delivery and how online video could be a facilitator: (1) delivery of transplant education was reliant on one person, (2) other dialysis staff had time to answer transplant questions but felt uninformed, (3) patient lack of interest in existing supplementary transplant education, (4) patient disinterest in transplantation education was due to education timing, feeling overwhelmed, and transplant fear/ambivalence, and (5) video education could be flexible, low effort, and spark transplant interest. Study limitations are potential selection bias and inclusion of English-speaking participants only. Dialysis staff barriers of time, insufficient knowledge, and limited resources to provide education to patients and their care partners may be mitigated with online educational videos without increasing staff workload.

Challenges, Facilitators, and Recommendations for Implementation of Home Dialysis in the Veterans Health Administration: Patient, Caregiver, and Clinician Perceptions.

Home dialysis confers similar survival and greater quality of life than in-center hemodialysis for adults with ESKD but remains underutilized. We examined challenges and facilitators to implementation of home dialysis and identified stakeholder-centered strategies for improving it. We conducted a qualitative, cross-sectional, multisite evaluation that included five geographically dispersed Veterans Health Administration (VHA) home dialysis programs. Participants included patients with ESKD receiving home dialysis, their informal caregivers, and home dialysis staff. Semistructured telephone interviews were conducted and audio-recorded from 2017 through 2018, to assess perceived barriers and facilitators to patient home dialysis use in VHA. Transcribed interviews were analyzed thematically by each participant group. Participants included 22 patients receiving home dialysis (18 on peritoneal dialysis [PD] and four hemodialysis [HD]); 20 informal caregivers, and 19 home dialysis program staff. Ten themes emerged as challenges to implementing home dialysis, of which six (60%) spanned all groups: need for sterility, burden of home dialysis tasks, lack of suitable home environment, physical side effects of home dialysis, negative psychosocial effects of home dialysis, and loss of freedom. Four themes (40%), identified only by staff, were insufficient self-efficacy, diminished peer socialization, geographic barriers, and challenging health status. Twelve themes emerged as facilitators to implementing home dialysis, of which seven (58%) spanned all groups: convenience, freedom, avoidance of in-center HD, preservation of autonomy, adequate support, favorable disposition, and perceptions of improved health. Two themes (17%) common among patients and staff were adequate training and resources, and physical and cognitive skills for home dialysis. Recommendations to promote implementation of home dialysis common to all participant groups entailed incorporating mental health care services, offering peer-to-peer coaching, increasing home visits, providing health data feedback, and reducing patient burden. Stakeholder-centered challenges were rigorously identified. Facilitators and recommendations can inform efforts to support home dialysis implementation.

Application of the Clinical Frailty Score and body composition and upper arm strength in haemodialysis patients.

ABSTRACTBackground To improve outcomes, simple screening tests are required to detect patients at increased risk of mortality. As patients with muscle weakness and wasting are at increased risk of death, we wished to review the use of the Clinical Frailty Score (CFS).Patients and methods Dialysis staff graded haemodialysis (HD) patients attending for routine outpatient sessions using the CFS, a functional scoring scale, for patients who require help with their instrumental activities of daily living, classified as clinically frail with scores >4, which were compared with contemporaneous Stoke–Davies comorbidity scores, post-HD body composition measured by bioimpedance, hand grip strength (HGS) and standard laboratory investigations.Results The results from 2089 patients (60.2% male) were reviewed, with 890 (42.6%) classified as frail. Frail patients were older [mean ± standard deviation (SD) 71.5 ± 15.6 versus 59.1 ± 15.6 years) and female (50.7% versus 37.3%) and had greater comorbidity {median 2 [interquartile range (IQR) 1–3] versus 1 [0–2]}, body mass index (BMI) (26.0 ± 6.7 versus 25.5 ± 5.4 kg/m2), C-reactive protein (CRP) [8 (IQR 3–20) versus 5 (2–11) mg/L], lower serum albumin (37.6 ± 4.7 versus 40.1 ± 4.7 g/L), lean BMI (8.9 ± 1.7 versus 9.7 ± 1.6 kg/m2) and HGS [13.4 (IQR 9.6–18.8) versus 20.9 (14.5–29) kg] (all P < 0.001). Frailty was independently associated in a multivariable logistic model with age {odds ratio [OR] 2.33 [95% confidence limit (CL) 2.01–2.7]}, body fat mass [OR 1.02 (CL 1.01–1.03)], log CRP [OR 1.63 (CL 1.28–2.07)] (all P < 0.001) and comorbidity [OR 1.45 (CL 1.17–1.8); P = 0.001] and negatively associated with albumin [OR 0.95 (CL 0.92–0.98) and HGS [OR 0.91 (CL 0.9–0.93)] (both P < 0.001).Conclusion Frail patients are at increased risk of mortality and, as such, simple reliable screening tools are required to rapidly detect patients at risk. The CFS is a useful screening tool that can be readily performed by dialysis staff to identify frail patients. Frailty in HD patients was associated with increasing age, comorbidity, fat weight and inflammation and reduced muscle strength and muscle mass. There is an overlap between frailty and both sarcopenia and protein energy wasting, which requires additional assessments, potentially including body composition, strength, dietary assessments and laboratory investigations. In addition, as the CFS offers a scale, patient trajectories can potentially be serially monitored over time, thus allowing patient-specific interventions or holistic care plans.