Hemodialysis Practice Research Articles

Home Hemodialysis (HHD) Practice and Curriculum Recommendations among Graduates of a Training Program without a HHD Clinic Experience

Home Hemodialysis (HHD) Practice and Curriculum Recommendations among Graduates of a Training Program without a HHD Clinic Experience

Explaining International Trends in Mortality on Hemodialysis Through Changes in Hemodialysis Practices in the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Rationale & ObjectiveCase-mix adjusted hemodialysis mortality has decreased since 1998. Many factors that influence mortality may have contributed to this trend and these associations may differ by continental region. We studied changes in hemodialysis facility practices over time and their potential role in mediating changes in patient survival. Study DesignObservational prospective cohort study. Setting & ParticipantsAdult hemodialysis patients treated in hemodialysis 500 facilities participating in the Dialysis Outcomes Practice Patterns Study (DOPPS) between 1999 and 2015 in the US, Japan, and 4 four European countries: Germany, Italy, Spain, and UK. PredictorsFour practice measures at each facility: the percentages of patients with Kt/V>1.2, interdialytic weight gain [IDWG]<5.7%, phosphorus<6 mg/dL, and using AV fistulae. OutcomesPatient survival. Analytical ApproachMediation analyses, adjusted for case mix, were conducted using 3-year study phase as the exposure and facility practice measures as potential mediators. ResultsIn Europe, we observed a 13% improvement in overall case-mix adjusted survival per decade. Trends in facility practice measures, especially Kt/V and phosphorus, explained 10% improvement in case-mix survival per decade, representing 77% (10% explained of 13% improvement) of the observed improvement. In Japan, 73% of the observed 12%/decade improvement in case-mix adjusted survival could be attributed to facility practices, especially Kt/V and IDWG. In the US, 56% of the observed 47%/decade improvement in case-mix adjusted survival could be attributed to facility practices, especially AV fistula use and phosphorus control. LimitationsUnmeasured changes in the characteristics of the patient population over this period may confound the observed associations. ConclusionThe improvements in adjusted hemodialysis patient survival in Europe, Japan, and the US from 1999 to 2015 can be largely explained by improvements in specific facility practices. Future changes in patient survival may be responsive to further evolution in the implementation of common clinical practices.

Gender Disparity in Hemodialysis Practices and Mortality: A Nationwide Cross-Sectional Observational Study

Background Disparities between genders are well documented in incidence, progression, and outcomes of chronic kidney disease (CKD). This study aimed to describe demographic characteristics, clinical and socio-economic factors among males and females on maintenance hemodialysis and to determine any association with mortality among males and females. Materials and Methods A nationwide cross-sectional study was conducted in a hemodialysis network in India. All adult (&gt;18 years) patients who died while receiving maintenance hemodialysis and an equal number of surviving control patients on maintenance hemodialysis (MHD) between January 1, 2021 to March 31, 2021 were included in the study. The demographic, socioeconomic, and hemodialysis factors were compared between both the genders. Results A total of 1177 patients who died during the study period were included. The majority were males (824, 70.01%). Males were more educated than females (P &lt; 0.001). The proportion of female patients dialysed with temporary catheters where more than males, who had definite vascular access such as AV fistula or AV graft (P &lt; 0.001). More female patients required out-of-pocket expenditure (P = 0.005). Multivariate logistic regression demonstrated that lower educational status, hypoalbuminemia, previous history of hospitalization, and dialysis in centres run by Public Private Partnership (PPP) were associated with mortality in males. Lower educational status, heart failure and previous history of hospitalization were the factors associated with mortality in females. Conclusion Males predominated on hemodialysis. Females were less educated and were less likely to be covered under public or private health insurance compared to males.

Effect of hemodialysis practice guideline on dialysis indicators and hemodynamic complications among patients undergoing hemodialysis

To assess the effect of haemodialysis practice guidelines on dialysis indicators and haemodynamic complications, the comparative study was conducted at the dialysis unit of Sheikh Zayed Hospital, Lahore, Pakistan, and comprised patients undergoing haemodialysis who were divided into intervention group A in which updated haemodialysis practice guidelines were used, and control group B in which routine base dialysis was given. Data was collected using a self-structured tool. Data was analysed using McNemar test and Mann-Whitney U-test with p&lt;0.05. Compared to baseline, there was a significant improvement in post-intervention ratio of effective removal of clearance (K) resulting from the treatment characterised by time (t) in the patient with a specific volume of distribution (V), or Kt/V, median &amp; IQR 0.83(0.355) vs 1.21(0.11) and percentage of urea reduction ratio with median &amp; IQR 49(12) vs. 66.5(18.65) (p&lt;0.05). ---Continue

#2454 Meeting guideline goals at hemodialysis patients impact their survival?

Abstract Background and Aims The Institute of Medicine (IOM) defines clinical practice guidelines as "statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options". First publication of Clinical Guidelines by the National Kidney Foundation (NKF), addressing good clinical practice in hemodialysis, was published in 1998. The aim of the present study was to investigate the influence of adherence to current guidelines of Mineral and Bone Disorders, Anemia and Adequacy of Dialysis, on their survival in patients undergoing hemodialysis. Method This is a single center retrospective study of 113 chronic hemodialysis patients (79 males and 34 females), with median age 70 years (56, 78), median duration on hemodialysis 52 months (21, 95). Based on whether or not they met the KDIGO guidelines’ targets for anemia, bone disease, dialysis adequacy, and the targets of all three guidelines during the last three years, patients were divided in two groups: group A with the patients who met the goals of the guidelines and group B with the patients who did not meet the goals. Clinical and biochemical parameters were compared among the groups of patients as well as hemodialysis adequacy (Kt/V). The survival analysis of the patients was calculated by Kaplan-Meier, while the possible effect of any parameter on survival was also evaluated with Cox-Regression. Results There was significant difference between the two groups in age, phosphorous (P), PTH, Kt/V, URR and Alb. There was no significant difference between the two groups in sex, duration of HD, Hemoglobin (Hg), Calcium (Ca++), Hypertension and Diabetes (Table). In Cox analyses, patient survival was associated with delivered dialysis dose (single pool Kt/V, p=0.044). There was no significant difference between the two groups when we compare the adherence to guidelines for MBD (p=0.507) and anemia (p=0.394). There was no statistical difference when we compare the achievement of targets of all three guidelines (p=0.796). We identified as an independent risk factor for patient survival the serum albumin (p&amp;lt;0.001). Patient survival was better with higher dialysis dose and adequate serum albumin level. Conclusion Clinical guidelines are useful tools for good clinical practice for hemodialysis patients. Adherence to clinical guidelines regarding dialysis adequacy is an independent risk factor for better survival of patients undergoing hemodialysis.

Latest Trends in Hemodiafiltration.

This review provides a detailed analysis of hemodiafiltration (HDF), its progress from an emerging technique to a potential conventional treatment for chronic hemodialysis patients, and its current status. The article covers the advances, methods, and clinical benefits of HDF, specifically focusing on its impact on cardiovascular health, survival rates, and overall well-being. The review also addresses questions about the safety of HDF and provides evidence to dispel concerns related to the elimination of beneficial substances and infection risks. Additionally, the article explores the potential implications of expanded hemodialysis (HDx) as an alternative to HDF, its classification, safety profile, and an ongoing trial assessing its non-inferiority to HDF. Supported by evidence from randomized controlled trials and observational studies, the review emphasizes the superiority of HDF as a hemodialysis modality and advocates for its positioning as the gold standard in treatment. However, it acknowledges the need for extensive research to define the role of HDx in comprehensive treatment approaches in individuals undergoing dialysis. The synthesis of current knowledge underscores the importance of ongoing exploration and research to refine hemodialysis practices for optimal patient outcomes.

The effect of cold packs, lidocaine spray, and flashlights on cannulation pain in patients undergoing hemodialysis: a randomized controlled trial

BackgroundPain is a frequent and critical problem in daily hemodialysis practice. The pain experienced during arteriovenous fistula cannulation varies from 12% to even 80% in hemodialysis patients depending on the pain assessment tools used. Pain can lead to sleep problems, decreased compliance with hemodialysis therapy, frequent hospital hospitalizations, a decline in quality of life, and high death rates. Despite utilizing several methods as pain relief, it is still unknown in the literature and practice which method is the most effective. The purpose of the study was to compare the effect of lidocaine spray, cold packs, and flashlights on the pain induced by arteriovenous cannulation in hemodialysis patients. This was a prospective randomized open-label controlled trial. Hundred and eight adult patients on regular hemodialysis were recruited and simply randomized into one of four groups (lidocaine spray, cold packs, flashlights, and control) before cannulation.ResultsThe mean pain severity using visual analog scale was 4.3 (3.3–5.7) in lidocaine group, 4 (3–5.7) in cold packs group, 4.3 (3.3–5.3) in flashlight group, and 4.7 (3–6) in control group. There was a borderline significant difference between groups using Kruskal–Wallis test (p = 0.054). The post hoc Tukey test showed that only cold packs differ from control group with borderline significance (p = 0.051).ConclusionThe results showed that cold packs were safe and effective than lidocaine spray or flashlights in reducing cannulation pain. It is suggested to implement this method before cannulation in hemodialysis patients to reduce pain and improve quality of life. Future studies are needed to compare different application times of cold packs and its impact on pain scores to recommend the optimum time needed to achieve maximum analgesic effect.Trail registration: Clinical trials.gov NCT05822063, REC #194.Graphical abstract

Nurses' perceptions of point-of-care ultrasound for haemodialysis access assessment and guided cannulation: A qualitative study.

To explore nurses' perceptions of using point-of-care ultrasound for assessment and guided cannulation in the haemodialysis setting. Cannulation of arteriovenous fistulae is necessary to perform haemodialysis. Damage to the arteriovenous fistula is a frequent complication, resulting in poor patient outcomes and increased healthcare costs. Point-of-care ultrasound-guided cannulation can reduce the risk of such damage and mitigate further vessel deterioration. Understanding nurses' perceptions of using this adjunct tool will inform its future implementation into haemodialysis practice. Descriptive qualitative study. Registered nurses were recruited from one 16-chair regional Australian haemodialysis clinic. Eligible nurses were drawn from a larger study investigating the feasibility of implementing point-of-care ultrasound in haemodialysis. Participants attended a semistructured one-on-one interview where they were asked about their experiences with, and perceptions of, point-of-care ultrasound use in haemodialysis cannulation. Audio-recorded data were transcribed and inductively analysed. Seven of nine nurses who completed the larger study participated in a semistructured interview. All participants were female with a median age of 54 years (and had postgraduate renal qualifications. Themes identified were as follows: (1) barriers to use of ultrasound; (2) deficit and benefit recognition; (3) cognitive and psychomotor development; and (4) practice makes perfect. Information identified within these themes were that nurses perceived that their experience with point-of-care ultrasound was beneficial but recommended against its use for every cannulation. The more practice nurses had with point-of-care ultrasound, the more their confidence, dexterity and time management improved. Nurses perceived that using point-of-care ultrasound was a positive adjunct to their cannulation practice and provided beneficial outcomes for patients. Haemodialysis clinics seeking to implement point-of-care ultrasound to help improve cannulation outcomes may draw on these findings when embarking on this practice change. This study is reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ). Patients were not directly involved in this part of the study; however, they were involved in the implementation study. The larger study was registered with Australian New Zealand Clinical Trials Registry: ACTRN12617001569392 (21/11/2017) https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373963&isReview=true.

Innovations en hémodialyse à domicile: Innovations in home hemodialysis

Dialysis is a restrictive treatment with a significant impact on the quality of life of patients. Home hemodialysis (HHD) allows to maintain quality of life while improving the conditions of purification, in particular with the daily or even nocturnal practice of hemodialysis. The arrival of systems with a cycler in the 2010s for home hemodialysis brings a new dynamism for this type of technique. The practice with dialysate low flow with the optimization of storage space, the simplification of the use of generators and the emmergence of telemonitoring tools increases the accessibility of this dialysis technique, so that we can hope in the coming years to be able to offer this dialysis modality to any patient with chronic renal failure requiring extra-renal purification. ©2022 Société francophone de néphrologie, dialyse et transplantation. Published by Elsevier Masson SAS. All rights reserved.

The Effect of the Hemodialysis Practice on the Dialysis Patients’ Sexual Functions

Objective: This study aims to analyze the effect of the hemodialysis practice on the patients’ sexual functions and sexual experiences. &#x0D; Materials and Methods: Designed as phenomenological research, the study was performed with 19 patients who had hemodialysis treatment from 20 January 2021 to 20 February 2021 and agreed to participate in the study. The research data were collected by using individual in-depth interviews, the researchers’ notes, and patients’ personal notes. The ‘Patient Information Form’ and the semi-structured ‘Interview Form’ were used as the data collection tools. &#x0D; Results: The research data were examined thematically by using the content analysis method. The participant patients’ mean age was found as 54.31±15.21 years. As per the content analysis, the sub-theme, ‘an indispensable part of life’, was identified under the theme of ‘the meaning of sexuality’ while seven sub-themes, ‘the loss of sexual drive and the sexual dissatisfaction/failure to have pleasure in sex’, ‘the fear of damaging the fistula or catheter during sexual intercourse’, ‘the fall in the frequency of sexual intercourse and the end of sex life’, ‘the erection problems due to additional diseases’, ‘the refusal to have sexual intercourse due to hemodialysis-based fatigue’, ‘the religious requirements to be met following the sexual intercourse’, and ‘the sexual avoidance during the COVID-19 pandemic’, were categorized under the theme of ‘the effects of hemodialysis on sex life’. &#x0D; Conclusion: In the study, it was found that the hemodialysis affected the participant patients’ sex lives negatively. Thus, it was concluded that the hemodialysis patients needed psychological support.

A Retrospective Study on Outcome of Hemodialysis in Elderly Diabetic Patients

Background and Aim: Hemodialysis is a valuable treatment for elderly individuals progressing to chronic kidney disease (CKD). Globally, hemodialysis demand is increasing for elderly individuals as a life-sustaining therapy which might lead to prolonged suffering in geriatric patients. Therefore, the current study aimed to evaluate the outcomes of hemodialysis in elderly diabetic patients. Methodology: This retrospective study was carried out on 64 type 2 diabetic patients admitted to the Dialysis Unit at Social Security Hospital, Multan Road Lahore from January 2021 to April 2022. Ethical approval was taken from the institution research and ethical committee. All the type 2 diabetic patients above 65 years age having CKD on dialysis were included. Patients having disease that require immunosuppressive treatment, history of malignancy, and those who died within three months of initial treatment were excluded. Patient’s survival data and comorbidities such as cognitive, vascular, and autonomy were studied. Other comorbid conditions such as cerebrovascular disease, peripheral vascular disease (PVD), and coronary artery disease (CAD) were reviewed. SPSS version 25 was used for data analysis. Results: Of the total 64 diabetes patients, there were 34 (53.1%) males and 30 (46.9%) females. The overall mean age was 68.9±3.1 years whereas dialysis mean duration was 28±22 months. Cognitive impairment, lost autonomy, and prior cerebrovascular accident had significant association with mortality rate reported as 7.8% per year. The incidence of fistula or graft, depression, dementia, died, and bedridden cases were 39% (n=25), 18.8% (n=12), 15.6% (n=10), 12.5% (n=8), and 14.1% (n=9) respectively. Of the 25 cases of fistula or graft, about 9.5% used catheter. Conclusion: The present study found that mortality rate was 7.8% in elderly (&gt;65 years) diabetes patients. The high mortality risk was substantially related with cognitive disorder, cerebral vascular accident, and lost autonomy. Generally, hemodialysis practice varies with the region’s clinical pattern due to age variation in elderly patients. Keywords: Hemodialysis, Chronic kidney disease, Elderly, Diabetes

Diuretic Use Among Patients Receiving Hemodialysis in the United States

Aspects of volume management, including larger interdialytic weight gains, higher ultrafiltration rates, and chronic hypervolemia, are associated with adverse outcomes among individuals with kidney failure who are dependent on hemodialysis.1 Prescribing diuretics for volume control is a mainstay of advanced chronic kidney disease treatment and peritoneal dialysis care; however, diuretic use in hemodialysis practice is inconsistent.2,3 Observational studies have shown that diuretic use (vs. nonuse) is associated with lower risks of intradialytic hypotension and hospitalization among people receiving hemodialysis; however, firm conclusions are limited by potential confounding from the benefits of residual kidney function among diuretic users.

A new technique for the detection of dry weight in hemodialysis patients: Estimated pulmonary capillary wedge pressure. A tissue Doppler imaging study

Background and objectiveFluid overload is an important factor of morbidity and mortality in hemodialysis patients. Today correct determination of dry weight (DW) remains an important issue of hemodialysis practice. Within this context, it is subjected to new method searching. The objective of this study was to calculate estimated pulmonary capillary wedge pressure (ePCWP) with Tissue Doppler Imaging (TDI) in hemodialysis patients and to evaluate its correlation with the other volume markers and to evaluate whether it can be a new method for detection of DW. Materials and methodsEchocardiographic, hemodynamic, and biochemical volume markers of 41 hemodialysis patients were evaluated in the pre- and post-dialysis periods. Patients were divided into two groups based on ePCWP values (Group 1 ePCWP<20mmHg, Group 2 ePCWP>20mmHg). ResultsIn the pre-dialysis period; parameters related to volume load including ePCWP, systolic blood pressure, mean arterial pressure, pulse pressure, left atrial diameter, left atrial volume, E/é, ratio and E/Vp ratio were statistically significantly higher in Group2 compared to Group1. On the other hand, strong correlations were found between pre-dialysis ePCWP and systolic blood pressure, mean arterial pressure, pulse pressure, NT-ProBNP, left atrial diameter, E/é ratio and E/Vp ratio. ConclusionsStrong correlations found between ePCWP which was calculated with TDI and the other volume markers both in pre-dialysis and post-dialysis periods. These findings can provide a significant contribution to routine evaluating of DW in hemodialysis patients. From this aspect, the prediction of ePCWP with TDI can be a new practical and reproducible method for the determination of DW.

A new technique for the detection of dry weight in hemodialysis patients: Estimated pulmonary capillary wedge pressure. A tissue Doppler imaging study

Background and objectiveFluid overload is an important factor of morbidity and mortality in hemodialysis patients. Today correct determination of dry weight (DW) remains an important issue of hemodialysis practice. Within this context, it is subjected to new method searching. The objective of this study was to calculate estimated pulmonary capillary wedge pressure (ePCWP) with Tissue Doppler Imaging (TDI) in hemodialysis patients and to evaluate its correlation with the other volume markers and to evaluate whether it can be a new method for detection of DW. Materials and methodsEchocardiographic, hemodynamic, and biochemical volume markers of 41 hemodialysis patients were evaluated in the pre- and post-dialysis periods. Patients were divided into two groups based on ePCWP values (Group 1 ePCWP<20mmHg, Group 2 ePCWP>20mmHg). ResultsIn the pre-dialysis period; parameters related to volume load including ePCWP, systolic blood pressure, mean arterial pressure, pulse pressure, left atrial diameter, left atrial volume, E/é, ratio and E/Vp ratio were statistically significantly higher in Group2 compared to Group1. On the other hand, strong correlations were found between pre-dialysis ePCWP and systolic blood pressure, mean arterial pressure, pulse pressure, NT-ProBNP, left atrial diameter, E/é ratio and E/Vp ratio. ConclusionsStrong correlations found between ePCWP which was calculated with TDI and the other volume markers both in pre-dialysis and post-dialysis periods. These findings can provide a significant contribution to routine evaluating of DW in hemodialysis patients. From this aspect, the prediction of ePCWP with TDI can be a new practical and reproducible method for the determination of DW.

Assessment of Nurses Awareness Regarding Hemodialysis Complications: A Cross-Sectional Study in Lahore, Pakistan

Purpose: The purpose of the study was to assess the awareness of nurses regarding hemodialysis complication in Lahore, Pakistan.&#x0D; Methodology: Descriptive research design was used to conduct this study. The study was conducted at the Hemodialysis Unit at tertiary Care Hospital Lahore, Pakistan. The sample of the study consisted of 110 nurses (female) working in the hemodialysis unit, aged between 18 and 55 years has agreed to participate in this study. The self-administered questionnaire sheet was used to collect study-related data with the following sections. Part 1: ''Nurse's socio-demographic characteristics'', Part 2: "Nurses 'Awareness of Hemodialysis Practices", Part 3: "Nurses' Awareness of Hemodialysis Complications"&#x0D; Findings: Most of the nurses had a good level of knowledge about the complications of hemodialysis and very few of them had little knowledge. Most of the nurses were females and were aged 18-27.&#x0D; Unique contribution to theory, practice and policy: Further research should be done on a larger sample of them which focuses on their practice and should make the results of their study regarding their knowledge and its reflection on their practice&#x0D;

Pain on arteriovenous fistula cannulation: A narrative review.

Pain on arteriovenous fistula (AVF) cannulation is a rather persistent problem in the daily hemodialysis practice. Its prevalence varies from 12% to even 80% depending on the definition and the pain-assessment tools and it affects the quality of life of hemodialysis patients. It is associated with fear of the cannulation process, the decision of hemodialysis from an AVF and sometimes the hemodialysis itself. In this narrative review, we tried to tackle the extent of the problem and to present the available published solutions. The literature suggests a large array of methods based on the application of local anesthetic creams, application of cold or hot directly on the cannulation sites or on the contralateral arm, cannulation techniques and AVF localization, distraction as well as alternative treatments. All of them have shown a relative success. There is a serious lack of large multicenter randomized trials and a gap concerning work groups and guidelines or recommendations from national or international societies on this matter. Complementary training starting from the predialysis patient education programs may be useful. Alternative prophylactic measures including counseling, hypnosis, or other physicochemical interventions could also improve our knowledge on the treatment of this seriously uncomfortable condition.

A Korean perspective on the 2019 Kidney Disease Outcomes Quality Initiative guidelines for vascular access: what has changed and what should be changed in practice?

The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines are developed by the National Kidney Foundation in the United States; however, the guidelines have an impact on most international societies, including those in Korea. The KDOQI recently released the updated 2019 guidelines for vascular access based on numerous papers and controversies concerning vascular access since 2006, when the first guidelines were published. The new KDOQI guidelines have undergone significant changes compared to previous guidelines, including a change in the philosophy regarding a patient-centered approach using an end-stage kidney disease “Life-Plan.” In addition, there are newly developed or revised definitions and some key differences from previous guidelines. The process of adapting guidelines needs to be individualized to hemodialysis practice in each country, while agreeing with general principles and philosophy; therefore, we summarize changes in the updated guidelines and discuss the application and implementation of the new principles and concepts of the guidelines for vascular access care in Korea.

Influential factors on dose by ionic dialysance in daily practice in chronic hemodialysis

BackgroundThe determination of Kt/V by ionic dialysance is a technique that has extended its use in hemodialysis clinics. The clinical guidelines have reflected the need to validate this method as a determinant of the dose of dialysis. ObjectivesDetermine in daily practice, the influence of hemodialysis characteristics and medication on Kt/V results by ionic dialysance (Kt/V OCM) and compare them with Kt/V measures by serum urea (Kt/V Daugirdas). DesignCross-sectional and observational study. Participants: 127 patients on chronic hemodialysis. Measurements: Descriptive variables, study variables (Kt/VOCM, Kt/VDaugidas), and the variables that modified the effect (patient temperature, serum sodium, vascular access, recirculation, blood flow, hemodialysis technique, dialyzer, acid concentrate, conductivity, dialyzate flow). ResultsThe mean of Kt/V Daugirdas was 1.84 and the Kt/VOCM mean 1.65; Pearson's was CC r=0.54; P<0.001 and Lin CCC=0.48. In the linear regression, the variables related to hemodialysis technique showed no statistical association with the measurement obtained by Kt/VOCM. Monosodium phosphate and 20% sodium chloride dispensing were associated with a higher Kt/VOCM. ConclusionsThe different technical aspects noted during HD sessions do not influence Kt/V OCM outcomes. Kt/V determined by ionic dialysance isn’t similar to that determined by serum urea. When assessing dialysis doses measured by dialysance, consider that it is not the same as determined with serum urea, but it provides an approximation to estimate dialysis doses in real time. It is necessary to consider if drugs or supplements have been administered that can modify it when interpreting the results.

Knowledge and Practice of Incremental Hemodialysis: A Survey of Canadian Nephrologists.

Background:Incremental hemodialysis, a strategy to individualize dialysis prescription based on residual kidney function, may be associated with enhanced quality of life and decreased health care costs compared with conventional hemodialysis.Objective:We surveyed practicing Canadian nephrologists to assess knowledge, perceptions, and practice pattern on the use of incremental hemodialysis.Design/Setting:We distributed a cross-sectional, web-based survey. We asked about incremental hemodialysis prescribing practices, including frequency of prescription, clinical factors used to determine suitability for treatment, and barriers to implementation. The survey was conducted from September 21 to October 30, 2020.Participants:We distributed the survey to practicing Canadian nephrologists identified from a private membership list of the Canadian Society of Nephrology (CSN), as well as to nephrologists named on a publicly available national list of practicing Canadian nephrologists created from provincial College of Physician registries. These were samples of convenience.Methods:We conducted descriptive analysis of categorical data including frequencies for nominal variables and measures of central tendency (mean) and dispersion (standard deviation) for ordinal variables. We used chi-square analysis to identify association between participant and practice characteristics and their opinions and attitudes toward incremental dialysis. We used simple thematic analysis on free-text responses on questions regarding the prescription of incremental hemodialysis, focusing on age and baseline management of cardiac and noncardiac comorbidities.Results:The response rate was 35% (243/691). Most (138/211, 65%) of the participants prescribed incremental hemodialysis using an individualized approach at the nephrologist’s discretion. Most participants (200/203, 98%) did not report any policy for implementation. Residual urine output was identified as the most important factor for eligibility (112/172, 65%), followed by electrolyte stability (76/172, 44%) and patient goals of care (69/117, 40%). Most participants agreed that dialysis prescriptions should take residual kidney function into consideration; however, 74% of the participants disagreed with a statement that there was strong evidence supporting incremental hemodialysis. Barriers identified included patient safety, patient acceptance of dose escalation, and logistics of scheduling. Despite these barriers, 82% of participants felt that that incremental hemodialysis is feasible with their current resources and 78% agreed that with specific criteria, it is a safe option.Limitations:The generalizability of our study is limited by its response rate of 35%; however, this is comparable with typical response rates seen in electronic surveys. Most participants practice in an academic setting, which may have introduced bias to the results.Conclusions:Despite the perception of limited evidence and a lack of guidance on implementation, incremental hemodialysis is frequently practiced by Canadian nephrologists. Barriers to implementation were identified, highlighting the need for research to guide practice.

Evidence-Based Nursing Practice of Hemodialysis induce Hypoglycemia in a Diabetic Kidney Disease Patient

The primary goal of optimizing glycemic control to reduce the development of microvascular and macrovascular complications is universal. The medication regimen is based on the comfort of the patient and physician and should be individualized, especially as renal function changes. For those who need insulin, MDI with an average of 4 daily injections is common. The closest approximation of physiologic insulin secretion can be achieved with an insulin pump delivering a continuous subcutaneous infusion. A single type of insulin is used in the pump such as a rapidacting analog that serves as the basal, bolus and correction insulin. Insulin pumps require vigilance on the part of the patient and their use should be overseen by endocrinologists and experienced diabetes educators.