Care Of End-stage Renal Disease Patients Research Articles

Improving Patient-Centered Care for End-Stage Renal Disease Patients at a Community Palliative Setting.

End-stage renal disease (ESRD) is a complex medical condition growing fastest in Americans 65 years and older. Despite its chronic nature, fewer than 10% of these patients have had advanced care planning. A chart audit (n = 20) of the palliative patients at a community palliative program revealed that no patient had a conversation about prognostication, 10% (n = 2) about the burden of kidney disease, 30% (n = 6) had coordination of care with the nephrologist, and 35% (n = 7) had engaged in end-of-life planning. This project aimed to increase patient-centered care for ESRD patients to 80% in 90 days. The project utilized the Plan-Do-Study-Act quality improvement model in four 2-week rapid cycles with 2 focus improvement areas. The 2 core interventions were patient screening for preferences and values and providing the right care for palliative management utilizing a checklist. At the end of the project, patient-centered right care for ESRD increased from a baseline of 24% to 94%. Patient engagement scores increased from a baseline of 3.2 to 4.9 on a 5-point Likert scale, with 5 being the highest supporting a shared decision model of care in improving patient-centered right care.

#1678 The relationship between national dialysis catheter rates and kidney transplantations

Abstract Background and Aims Vascular access for chronic hemodialysis is either achieved by an arteriovenous fistula or graft (AVF/G) or central venous catheter (CVC) and AVF/Gs have been repeatedly reported to be superior to CVCs and guidelines usually recommend it as the preferred vascular access. AVF/Gs are associated with better quality of dialysis, less complications, and a lower mortality than CVCs. This has led to initiatives such as Fistula First that aimed at maximizing AVF/Gs rates and national healthcare systems now frequently evaluate their efficiency of care for end-stage renal disease (ESRD) patients based on this metric. However, transplant activity might be a significant confounding factor since high transplant rates and therefore limited transition phases might contribute to a higher acceptance of CVCs in patients awaiting kidney transplantation. I aimed at investigating the relationship between CVC rates and transplant activity in different countries by analyzing data from national dialysis and transplant registries. Method Data was obtained from national transplant and dialysis registries including Argentina (2012-2021), Australia (2004-2022), Austria (2005-2022), New Zealand (2005-2022), Sweden (2011-2022), Turkey (2004-2022), and the USA (2012-2021). Population estimates were obtained from the World Bank. The conducted analyses included unadjusted correlation analysis as well as multivariate regression analysis. Results The study sample included data from 7 different countries spanning from North and South America, over Europe and Asia to Oceania covering data from 107 annual reports. CVC rates and transplant activity per million showed a weak positive correlation (0.283, 95% CI: 0.093–0.454) within the same year (Fig. 1). When correlating catheter rates with transplant activity of the previous year, the association increased slightly (0.357, 95% CI: 0.173–0.517). The change of incidence of ESRD or hemodialysis patients (depending on data availability) showed a moderate correlation with the change of catheter rates (0.507, 95% CI: 0.272-0.685). A regression model including the incidence of ESRD improved model fit compared to a model that uses only transplant activity to estimate catheter rates. Conclusion Even though most healthcare systems, clinicians, and epidemiologists recommend low CVC rates, a thorough evaluation of the care of ESRD patients requires the adjustment of several contributing factors, primarily kidney transplantation activity. Higher kidney transplantation rates are associated with higher CVC rates which might be due to reduced waiting times until transplantation. An increase in kidney transplantations might especially increase CVC-based dialysis in the subsequent year. There is some evidence that the incidence of ESRD in general or hemodialysis in specific additionally affects CVC rates. Increasing incidence of ESRD is associated with increasing catheter rates, indicating that healthcare systems might struggle to adapt to short-term changes regarding access demands.

Risk of COVID-19 and Cost Burden in End-Stage Renal Disease Patients and Policy Implications for Managing Nephrology Services during the COVID-19 Pandemic.

The aim of this study was to evaluate the risk of COVID-19 in end-stage renal disease (ESRD) patients, the cost burden of the COVID-19 pandemic on the management of ESRD and the cost of catheter infections. In this multicentre, retrospective study, data were obtained from the records of four dialysis centres providing care for ESRD patients in Northern Cyprus. Of the 358 ESRD patients that were receiving haemodialysis (HD) 13 were diagnosed with COVID-19. The average cost of HD treatment per patient was $4822.65 in 2019 and $3759.45 in 2020 (p ≤ 0.001). The average control cost of HD treatment per patient was $618.80 in 2019 and $474.03 in 2020 (p ≤ 0.001). The outpatient treatment costs of catheter infections were not significantly different in 2019 (before) compared to 2020 (after) the pandemic ($54.61 in 2019 compared to $54.74 in 2020, p = 0.793). However, the inpatient treatment costs were significantly greater before the pandemic compared to after the pandemic ($315.33 in 2019 compared to $121.03 in 2020, p = 0.015). The costs for monitoring COVID-19 transmission in patients having ESRD management were significantly higher in HD compared to in peritoneal dialysis (PD) and transplants. Since there is a high risk of transmission of infections in the hospital environment during a pandemic, it is important to implement alternative ESRD management methods, such as enhancing transplants in populations, switching to PD, and implementing home dialysis programmes to reduce the risk of infection and associated complications, as well as the health costs associated with infection monitoring.

Role of Clinical Pharmacist in the Management of Anemia in Dialysis Patients

Background: Anemia management is complicated in patients with End Stage Renal Disease (ESRD) on hemodialysis. Clinical pharmacists have been involved in the care of ESRD patients in various settings. Aims of the study: The aim of this study was to explore the therapeutic and pharmacoeconomic outcome of a clinical pharmacist- implemented anemia management in dialysis patients through a randomized, controlled, open label design clinical study. Methods: The study was carried out over a period of three months at renal /hemodialysis unit of King Hussein Medical Center at the Royal Medical Services. A total 203 patients of both genders on hemodialysis were randomized into an intervention or control arm, 102 patients were allocated to the intervention arm and 101 patients to the control arm. In the intervention arm, patients received physician-pharmacist collaborative care. In the control arm, patients received usual care. Results: In this study, clinical pharmacist interventions had a positive impact on achieving target goal of Hb concentrations among HD patients. The percent of patients who achieved target Hb and Hct at the end of the study was 87.2% in the intervention arm versus 36.6% in the control arm, p = 0.02). Patients in the intervention arm used less epoetin α, leading to a savings of 5723.4 JD. The average amount of epoetin α vials used in the intervention arm was significantly lower than that in the control arm (p = 0.002). Conclusion: Clinical pharmacists can positively contribute to the care of ESRD patients and reduce the gaps in current patient care.

A world-wide survey on kidney transplantation practices in breast cancer survivors: The need for new management guidelines

Kidney transplantation reduces mortality in patients with end stage renal disease (ESRD). Decisions about performing kidney transplantation in the setting of a prior cancer are challenging, as cancer recurrence in the setting of immunosuppression can result in poor outcomes. For cancer of the breast, rapid advances in molecular characterization have allowed improved prognostication, which is not reflected in current guidelines. We developed a 19-question survey to determine transplant surgeons' knowledge, practice, and attitudes regarding guidelines for kidney transplantation in women with breast cancer. Of the 129 respondents from 32 states and 14 countries, 74.8% felt that current guidelines are inadequate. Surgeons outside the United States (US) were more likely to consider transplantation in a breast cancer patient without a waiting period (p=.017). Within the US, 29.2% of surgeons in the Western region would consider transplantation without a waiting period, versus 3.6% of surgeons in the East (p=.004). Encouragingly, 90.4% of providers surveyed would consider eliminating wait-times for women with a low risk of cancer recurrence based on the accurate prediction of molecular assays. These findings support the need for new guidelines incorporating individualized recurrence risk to improve care of ESRD patients with breast cancer.

Variation in Waitlisting Rates at the Dialysis Facility Level in the Context of Goals for Improving Kidney Health in the United States

Variation in Waitlisting Rates at the Dialysis Facility Level in the Context of Goals for Improving Kidney Health in the United States

Symptoms and Management Strategies for Older Chinese Adults with End Stage Renal Disease (ESRD) and Other Chronic Conditions (GP792)

• Name common, bothersome symptoms symptoms in adult Chinese-American ESRD patients.• Identify strategies reported by adult Chinese-American ESRD patients to ameliorate the identified symptoms. Over $50 billion is spent on elderly patients with chronic kidney disease in the United States; with 1.5 times higher incidence of end stage renal disease (ESRD) in Asian Americans compared to Caucasians, there is a dire need to improve self-care and symptom management studies for this population. ESRD patients typically have a very short life expectancy and do not qualify for hospice benefits while they remain on dialysis or transplant lists. There are calls to strengthen palliative care for ESRD patients to help decrease distressing symptoms. Chinese-American patients have low use of both hospice and palliative care and may withdraw from hospice even when enrolled, resulting in few Chinese-American patients receiving the benefits of palliative care. To identify common, bothersome symptoms and strategies used to ameliorate these symptoms in adult Chinese-American ESRD patients. Using purposive sampling, elderly Chinese-Americans were surveyed for commonly occurring symptoms using standardized instruments and open-ended questions to identify strategies used to ameliorate those symptoms. Thirty Chinese-American participants were recruited with an average age of 80 (SD =13.08). They scored higher-than-average for constipation and lower than average for quality of life (QoL) measures. There were statistically significant higher levels of nausea and vomiting in those with ESRD and diabetes (p = 0.042), pruritus in those who also had heart disease and ESRD (p = 0.002), and fatigue for those with ESRD and arthritis compared to those without (p = 0.048). Strategies were reported for 8 common symptoms: fatigue, pain, sleep disturbance, dyspnea, anxiety, nausea and vomiting, constipation and pruritus. On average, participants reported fewer symptoms compared to the general population but scored lower for QoL. Further exploration is needed to understand this phenomenon and to validate the reported amelioration strategies.

Patient-nephrologist prognostic awareness and discordance in end stage renal disease on renal replacement therapy.

The 1-year mortality rate of patients with end-stage renal disease (ESRD) on renal replacement therapy (RRT) is 20-25% comparable to many cancers. Studies have shown that cancer patients commonly overestimate their likelihood of survival relative to their physicians. It is unclear if this translates into other terminal illnesses. Adult and elderly patients with ESRD on RRT without cognitive defect were interviewed to evaluate their prognostic estimates at 1 and 5years. Past medical history and demographic data was abstracted from their medical charts. Each patient's proper nephrologist was then interviewed regarding his proper prognostic estimate for this patient. Both the patient and the nephrologist's estimates were compared and a difference of greater than 20% was defined as the threshold for prognostic concordance. 77% of patients were found to be in prognostic discordance with their nephrologists. This group was older, had more comorbidities, a lower albumin level and a poorer prognosis. The majority of patients were in disagreement with their nephrologists regarding whether a discussion about prognosis had taken place. The choice of end of life care for 55% of patients was focused on relieving pain and discomfort. Communication of prognosis and discussions related to life expectancy and end of life care are lacking in the routine care of ESRD patients. ESRD patients therefore tend to overestimate their prognosis which might lead to overutilization of invasive procedures with increased acute healthcare costs as well as a delay in instigation of palliative or hospice measures.

Supporting quality care for ESRD patients: the social worker can help address barriers to advance care planning

BackgroundAdvance Care Planning (ACP) is essential for preparation for end-of-life. It is a means through which patients clarify their treatment wishes. ACP is a patient-centered, dynamic process involving patients, their families, and caregivers. It is designed to 1) clarify goals of care, 2) increase patient agency over their care and treatments, and 3) help prepare for death. ACP is an active process; the end-stage renal disease (ESRD) illness trajectory creates health circumstances that necessitate that caregivers assess and nurture patient readiness for ACP discussions. Effective ACP enhances patient engagement and quality of life resulting in better quality of care.Main bodyDespite these benefits, ACP is not consistently completed. Clinical, technical, and social barriers result in key challenges to quality care. First, ACP requires caregivers to have end-of-life conversations that they lack the training to perform and often find difficult. Second, electronic health record (EHR) tools do not enable the efficient exchange of requisite psychosocial information such as treatment burden, patient preferences, health beliefs, priorities, and understanding of prognosis. This results in a lack of information available to enable patients and their families to understand the impact of illness and treatment options. Third, culture plays a vital role in end-of-life conversations. Social barriers include circumstances when a patient’s cultural beliefs or value system conflicts with the caregiver’s beliefs. Caregivers describe this disconnect as a key barrier to ACP. Consistent ACP is integral to quality patient-centered care and social workers’ training and clinical roles uniquely position them to support ACP.ConclusionIn this debate, we detail the known barriers to completing ACP for ESRD patients, and we describe its benefits. We detail how social workers, in particular, can support health outcomes by promoting the health information exchange that occurs during these sensitive conversations with patients, their family, and care team members. We aim to inform clinical social workers of this opportunity to enhance quality care by engaging in ACP. We describe research to help further elucidate barriers, and how researchers and caregivers can design and deliver interventions that support ACP to address this persistent challenge to quality end-of-life care.

A practical guide to the supportive and palliative care of patients with chronic kidney disease

We are sure that all of us involved in the field of renal medicine in South Africa would agree that the guidelines, published on page 86 of this issue, around the supportive care of renal patients, especially those who cannot access renal replacement therapy – produced in collaboration between the South African Renal Society and the Association of Palliative Care Practitioners of South Africa – will prove valuable in assisting us in making difficult decisions and in providing constructive advice on the management of our patients with advanced chronic kidney disease (CKD).South Africa’s GDP per capita, of around US$3600, places it within the upper-middle-income economic group. Unfortunately, our economy must cope with limited resources with the burden of both non-communicable and communicable diseases. We have one of the highest prevalences of HIV infection in the world, with high frequencies for the APOL1 G1 and G2 risk alleles for HIV-associated (and other) nephropathies [1]. The World Health Organization’s Global Health Observatory (https://www.who.int/data/gho) reports the crude prevalence of hypertension in South Africa at 24%, diabetes at 9.8%, overweight at 51.9% and physical inactivity at 37.2%.The South African Renal Registry [2] reports that 84% of South Africans rely on state-funded medical facilities. A metaanalysis by Kaze et al. [3] quotes the prevalence of CKD stages 3 to 5 to be around 4.8% of the population in sub-Saharan African countries, and in South Africa this amounts to some 2.7 million people with significant kidney disease. Considering our risk profile for renal disease, this is unlikely to be an overestimate. According to the renal registry, only around 11 000 individuals in South Africa are on dialysis or have functioning kidney transplants, with 3100 served by the public sector. Unfortunately, our transplantation rate is low – 4.8 pmp in the public sector and 15.2 pmp in the private sector between 1991 and 2015 [4]. Transplant centres in the UK reported adult deceased donor renal transplant rates between 24 and 66 per million population in 2018/19 [5].We have large numbers of individuals with end-stage renal disease (ESRD), who are on a palliative care path, not by choice, and this is distressing. These guidelines should not be a substitute for ongoing efforts by our government to “move as expeditiously as possible towards the full realisation of the right to healthcare services”, as enshrined in Section 27 of our constitution.We congratulate our nephrology and palliative care community, and thank our visiting Australian colleagues, for well thought out and practical guidelines, which cover all aspects of supportive care for ESRD patients, including effective and caring communication, symptom management, preserving renal function, end-of-life care, care of paediatric patients, and models for setting up a renal palliative care service. The South African Essential Drugs List was used where possible to ensure that the medications are universally available in South Africa. Graham Paget and Vakhtang RekhviashvilliSouth African Renal Society [see PDF file for references]

Adherence to Hemodialysis and Associated Factors among End Stage Renal Disease Patients at Selected Nephrology Units in Rwanda: A Descriptive Cross-Sectional Study.

Introduction Worldwide, End Stage Renal Disease (ESRD) has become a public health concern increasing the number of patients maintained on hemodialysis prior to renal transplantation. Nonadherence to hemodialysis continues to impact on the care of ESRD patients, causing high increase in morbidity and mortality. Purpose of the Study The purpose of this study was to determine the level of adherence to hemodialysis and the associated factors among End Stage Renal Disease (ESRD) patients in selected nephrology units in Rwanda. Methods This was a descriptive cross-sectional design involving 41 participants. Participants were recruited using a purposive sampling technique. Demographic and adherence to hemodialysis data were collected with the use of structured interview schedules. Descriptive statistics were used to describe the demographic variables and the level of adherence to hemodialysis. Inferential statistics of chi-square was used to establish factors associated with adherence to hemodialysis. Results Twenty-one (51%) of ESRD participants adhered highly (scores < 80%) to HD. Seventeen (42%) adhered moderately (70–79%) to HD while three (7%) had low level of adherence to HD (below 70%). The factors associated with adherence to hemodialysis were age (mean = 27; 95% CI 26.76–29, 17; p = 038) and religion (95% CI 26.29–60.12, p = 003). Frequencies of education of health care workers about the importance of not missing dialysis (95% CI 26.71–42.56, p = .000), perceived relative importance of hemodialysis (95% CI 20.44–27.76, p = .020), and experiencing difficulties during the procedure (95% CI 20.80–28.36, p = .004) were significantly associated with adherence to hemodialysis. Conclusion. Adherence to hemodialysis is still a public health concern in Rwanda. Health care providers and particularly nurses should continue to advocate for adherence to HD for better health outcomes. Further research is needed to identify the barriers to HD in Rwanda.

What the non-nephrologist needs to know about dialysis.

The End-Stage Renal Disease (ESRD) program now serves approximately 675,000 individuals in the United States at a cost of $26.1 billion to the Medicare system. Given the size of this population, healthcare providers from all disciplines will deliver care to patients on dialysis. Mortality remains high among patients on chronic dialysis, with 42.3% surviving 5years. As this is a vulnerable population, it is important in the care of ESRD patients that non-nephrologists have a working knowledge of issues germane to dialysis. This review examines the physiology, mechanics, complications, and care delivery concerns of kidney dialysis modalities relevant to the non-nephrologist. The majority of patients receive in-center hemodialysis thrice weekly, with a small proportion on home-based therapies such as peritoneal dialysis or home hemodialysis. Inpatients may undergo hemodialysis or peritoneal dialysis, and in critically ill patients, continuous renal replacement therapies are utilized. Practical aspects of each of these modalities are discussed.

Nursing Intervention on the Compliance of Hemodialysis Patients with End-Stage Renal Disease: A Meta-Analysis

Background: Dialysis is imperative for patients with end-stage renal disease (ESRD); however, compliance ensures its efficacy. Nursing intervention has been considered to improve compliance. This meta-analysis is aimed at exploring the effects of nursing intervention on dialysis compliance. Methods: A search was performed in the PubMed, Cochrane, and Embase databases for relevant original research articles. Studies were included or excluded based on the simultaneous consideration of quality as ranked by Jadad score and the compliance with predefined selection criteria. Results: A total of 817 participants were included. The results showed that nursing intervention led to significantly higher compliance with dialysis than in standard care. A pilot analysis evidenced that different intervention strategies, including educational, cognitive, and behavioral approaches, had limited effects on dialysis compliance. Conclusion: Nursing intervention is beneficial for raising dialysis compliance, providing evidence of the need to strengthen nursing care for ESRD patients administered with dialysis in daily clinical practice.

Contemporary outcomes of surgical revascularization of the lower extremity in patients on dialysis

ObjectivePeripheral arterial disease is a common comorbidity found in up to 38% of patients with end-stage renal disease (ESRD). With an increase in the survival rate of patients with ESRD by >25%, there is a lack of contemporary data on the safety of open surgical revascularization of the lower extremity (OSRLE) in this population of patients. We sought to identify the perioperative morbidity and mortality and independent risk factors of mortality in dialysis patients undergoing OSRLE. MethodsWe reviewed data from 34,941 patients who underwent OSRLE from January 2011 to December 2014 at all hospitals in North America participating in the National Surgical Quality Improvement Program (NSQIP). Trauma, emergencies, aneurysms, and endovascular cases were excluded. We compared the 30-day outcomes of 1623 patients on dialysis with those of 33,318 patients not on dialysis. ResultsPatients on dialysis were younger (66.0 vs 66.7; P < .01), were more likely to be treated for critical limb ischemia (49.7% vs 33.1%; P < .01), and had more comorbidities compared with patients not on dialysis. Dialysis patients had higher mortality (7.8% vs 2.1%; P < .01) and postoperative complication rates after OSRLE, including myocardial infarction (3.5% vs 1.4%; P < .01), return to the operating room (6.1% vs 2.8%; P < .01), and unplanned readmission (5.2% vs 2.9%; P < .01). Although 30-day patency was not different (0.4% vs 0.4%; P = .56) between the two study groups, major amputation rate was threefold higher in dialysis patients (1.7% vs 0.57%; P < .01). In addition, we identified multiple risk factors that predispose dialysis patients to worse outcome after OSRLE, including older age, African American race, and congestive heart failure. In a subgroup analysis by procedure, dialysis patients who underwent aortobifemoral bypass carried the highest mortality risk (25% vs 3.6%; P < .01). Dialysis patients had higher rates of unplanned reoperation (7.9% vs 3.9%; P < .01) and unplanned readmission (6.2% vs 3.7%; P < .01) and increased length of stay (67.5% vs 47.3%; P < .01) after femoral-distal bypass. ConclusionsWith improvements in the medical care of ESRD patients resulting in a large increase in survival rates, little is known about how dialysis patients fare after OSRLE in the contemporary period. Our study shows that despite advances in the medical management of dialysis patients, improvements in outcomes after revascularization have not yet been realized. We found that specific clinical and procedural factors increase the risk for inferior results. Careful selection of dialysis patients suitable for OSRLE according to these risk factors may improve the management of this still high-risk vascular population.

Global challenges posed by the growth of end-stage renal disease

Profound challenges confront societies worldwide due to the growth of end-stage renal disease (ESRD). Meeting these challenges requires a sober assessment of how overall global health trends affect ESRD, coupled with an understanding of how progress in the care of ESRD patients is most appropriately measured and monitored. For many affluent countries, incident ESRD rates have stabilized since about the middle of the last decade. For example, the number of new cases in the USA has remained stable at approximately 110,000 per year during this period, while in Japan, growth in annual incident counts appears to have stabilized as of 2012. However, incidence rates rose for many developing countries. An immense “renal replacement therapy (RRT) gap,” the difference between the number of people receiving RRT and the number needing it, was recently described, highlighting the magnitude of the difficulties these countries face as they continue to develop. To guide efforts to improve care, broad goals should be established by the worldwide renal health care community. For countries without universal dialysis access, expansion of RRT accessibility should be the first target in order to reduce the RRT gap; for countries that have moved beyond this stage, the goals should include reductions in ESRD incidence rates; all-cause, cardiovascular, and infection-related death rates; and cardiovascular- and infection-related hospitalizations. To inform judgements about progress in this area, measures beyond the traditional standardized mortality ratio are needed. Carefully determining trends over time within a given country, such as is done by the World Health Organization, might prove to be a more useful way to determine progress in combating ESRD and its complications.

Sodium Glucose Transport 2 (SGLT2) Inhibition Decreases Glomerular Hyperfiltration

Chronic kidney disease (CKD) is a growing major worldwide health problem 1. In the USA, about 14% of the population has CKD defined as an estimated glomerular filtration (eGFR) of 30 mg/g 1. Decreasing eGFR and/or increasing urine albumin level is associated with development of many comorbid conditions including highly significant increases in cardiovascular disease 2 and a significant increase in mortality rates as compared to age-matched controls without CKD3. A recent analysis led to the conclusion that possibly all of the excess mortality in people with type 2 diabetes as compared to the non-diabetic population is due to the development of CKD4. Perhaps the impact of CKD is best illustrated by the epidemic rise in the end stage renal disease (ESRD) population. In 1978, there were 41,421 people with ESRD (these numbers include all people on hemodialysis, on peritoneal dialysis, and who have received a transplant). In 2011, 612,966 people in the USA have ESRD, (an almost 15 fold increase in prevalence in 35 years) 1. Considering that death rates for people on dialysis are about 20% per year 1 and that there is a much better chance a CKD patient will die from cardiovascular disease than reach dialysis 5, there must be a very large number of people with CKD to produce the continued increase in prevalence in the ESRD population. There is also an enormous societal financial burden in that the cost of care for ESRD patients was near 30 billion dollars (about 6% of the Medicare budget for about 0.2% of the population). And as this dollar amount does not take into account care the CKD (pre-ESRD) population, the financial costs are actually much higher for the care of all people with kidney disease. In addition, this is an epidemic of global proportions. Indeed India and China have the most people with diabetes mellitus and will eventually have very high numbers of CKD patients.

Kidney Disease in Disadvantaged Populations

Kidney Disease in Disadvantaged Populations

Palliative care and withholding and withdrawing dialysis

AbstractThe aging dialysis population, with its decreasing functional status, the high mortality of end‐stage renal disease (ESRD), and the rise of palliative medicine as a specialty have all served to promote the importance of end‐of‐life care for ESRD patients. Even though nephrologists have an increased understanding of the issues involved in ESRD end‐of‐life care, most individuals working in dialysis know of a case in which it felt as if “the dead were being dia‐lyzed.” An increased effort to focus on palliative care issues in ESRD, especially advance care planning, may serve to reduce the frequency of such cases.

The depression status of patients with end-stage renal disease in different renal replacement therapies

Depression is a common emotional problem among end-stage renal disease (ESRD) patients, but there is a paucity of research comparing the prevalence of depression between patients in different types of renal replacement therapies in Taiwan. The purpose of this study was to describe the prevalence of depression among ESRD patients in Taiwan who received different treatment regimens, and to determine the factors related to depression among these participants across various treatment regimens. A convenience sample of 342 participants was recruited from two medical centres. Participants were diagnosed with ESRD and received one of three renal replacement therapies, and screened for depression using the Taiwanese Depression Questionnaire (TDQ). The prevalence of depression (defined as TDQ score above 19) varied by treatment type: 36·3% (27/102) among peritoneal dialysis (PD) patients, 18·5% (17/92) among haemodialysis (HD) patients and 14·8% (21/142) among transplant patients. There were significant differences in the TDQ scores between the three treatment types (p < 0·001), indicating that participants' depression status varied by treatment type. Prevalence of depression among PD patients was higher than among HD and transplant patients. Logistic regression analysis revealed that treatment duration (p < 0·01) was a predictor of PD patients' depression, whereas self-reported health status was a predictor of depression among both HD patients (p < 0·01) and transplant patients (p < 0·05). Screening for and treatment of depression should be important parts of the standard care of ESRD patients. Pre- and post-therapy counselling by nurses and early recognition of emotional difficulties may also help these patients adapt to psychosocial stressors.

National survey of the current provision of specialist palliative care services for patients with end-stage renal disease

Patients with end-stage renal disease (ESRD) experience a significant symptom burden and have complex needs. However, involvement of specialist palliative care (SPC) services with these patients has previously been shown to be limited. This study assesses the current provision of and access to SPC services for ESRD patients in the UK and considers how the provision has evolved over recent years. A questionnaire was sent to the lead clinician for all UK adult hospital, hospice and community SPC services, identified from the Hospice and Palliative Care Directory 2008. Non-responders were mailed again after 5 weeks. Descriptive statistics and qualitative thematic analysis were performed. Three hundred and eighteen of 611 (52%) questionnaires were returned. Ninety-six per cent stated that SPC services have a role in caring for patients with ESRD. Two hundred and eighty-one of 318 (88%) accepted referrals, and 185 of 281 (66%) reported that 'none or few were referred'. Only 7% and 17% of respondents used specific ESRD referral and treatment guidelines, respectively; whereas 79% used the Liverpool Care Pathway for the Dying Patient. Seven per cent undertook joint renal and SPC multi-disciplinary team (MDT) meetings, and 3% held joint out-patient clinics. Forty percent of respondents proposed initiatives to improve palliative care for ESRD patients, with mutual education and collaborative working being key themes for improvement. The majority of SPC services accept ESRD patients, but limited numbers are referred. Respondents indicated that this barrier could be addressed by closer collaboration and better communication and education between renal and SPC services. Other initiatives to enable delivery of SPC to increased numbers of ESRD patients include the use of specific referral and clinical care guidelines and expansion of joint MDT meetings and out-patient clinics.