Home Dialysis Patients Research Articles

Reducing Routine Bloodwork in Home Dialysis Patients: A Quality Improvement Initiative

Reducing Routine Bloodwork in Home Dialysis Patients: A Quality Improvement Initiative

Assessment of Patient Experience of Care in Home Dialysis Around the World: Enhancing the Patient’s Voice in Home Dialysis Care and Research

With the global growth in the use of home dialysis modalities, there is a need to better understand patients’ experiences with their home dialysis care. Patient-reported experience measures or PREMs, are standardized survey questionnaires that allow patients to provide input on processes and experiences of care in a confidential and validated manner. Until recently, no validated PREM has been available for assessment of patient-reported experience of care for home dialysis modalities, including peritoneal dialysis or home hemodialysis. The Home Dialysis Care Experience instrument (Home-DCE) is a newly developed and content-valid PREM for use among patients treated with home dialysis modalities. The survey instrument includes 26 core survey questions and 20 demographic questions, and is now available in English, Spanish, and French. Domains of care assessed in the Home-DCE include staff education and patient-centered communication, care coordination, patient safety, concern and helpfulness of the care team, and staff care proficiency. Worldwide use of the Home-DCE will allow incorporation of patients’ experiences and preferences in initiatives to enhance quality of care for home dialysis patients globally. Translation and deployment of a PREM in additional languages should be done using established cultural adaptation methods, the gold standard for which is termed linguistic validation. Translation and linguistic validation are hurdles to global use of the Home-DCE, but challenges that should be met to enhance home dialysis patients’ voice in clinical kidney care.

Home dialysis and Covid-19 in french speaking countries (RDPLF data-base)

Aims of the study: to assess the frequency of symptomatic Covid-19 in home dialysis patients and its influence on the number of patients treated at home in dialysis units of centers included in the French-speaking peritoneal and home hemodialysis Registry (RDPLF). Focus is placed on patients treated by peritoneal dialysis (PD) in mainland France.
 Results: in home hemodialysis (HHD)the incidence is 6% in Belgium and 4.8% in mainland France. On peritoneal dialysis it is 10.6% in Belgium, 6.7% in mainland France, 10.8% in Morocco and 11.5% in Tunisia. Lethality is less than 5% in HHD and between 8.4% and 42.7% in PD depending on age and associated comorbidities. In France, the percentage of patients who have had symptomatic Covid-19 is lower on home dialysis, all methods combined. Nevertheless, among the home methods, the higher frequencies and severities are observed in mainland France in home assisted PD: these are the oldest and most co-morbid patients. Transfers from PD to in center hemodialysis have increased during Covid-19 pandemic while the number of transplants has decreased.
 Conclusion: if the drop in the number of transplants can be explained by a reduced availability of operating theaters and surgical teams during a pandemic period, it is paradoxical that the prescription of home dialysis, which should be supposed to limit the risk of contagion, has decreased. More investigation should be performed to understand this paradox.

Sustainability of Chronic Kidney Disease Care


 Strategies to contain the cost of chronic kidney disease (CKD) care and to improve patient outcomes were found across the continuum of care, from prevention and early disease management through later-stage interventions such as conservative management, dialysis, and transplantation. A variety of health system strategies, including funding reform, were identified to help support and enable sustainable CKD care.
 For those at risk of CKD or in early stages of the disease, public health interventions to support healthy behaviours and ensure access to primary health care seem crucial to preventing or delaying disease progression.
 For later-stage patients requiring renal replacement therapy, enhancing access to transplantation and home-based dialysis has the potential to reduce costs while improving outcomes and quality of life. Conservative management without dialysis is an option for those who may not be good candidates for renal replacement therapy or who wish to choose a less-invasive care option.
 From a health system policy perspective, funding reform may be warranted to enhance team-based CKD care with good continuity. Policy-makers should also consider the ways in which improving financial supports for caregivers, providing travel and expense reimbursement for home dialysis patients and living organ donors, and providing support for utility and ancillary costs of home dialysis could incentivize sustainable CKD care.

Home-to-home dialysis transition: A 24-year single-centre experience

Home dialysis (peritoneal dialysis (PD) and home haemodialysis (HHD)) are ideal options for kidney replacement therapy (KRT). Occasionally, because of technique failure, patients are required to transition out of home dialysis, and the most common option tends to be to in-centre HD. There are few published studies on home-to-home transition (PD to HHD or HHD to PD) and dynamics during the transition period. We present a retrospective review of 28 patients who transitioned from a home-to-home dialysis modality at our centre over a 24-year period. We observed a total of 911 home dialysis patients with technique failure (826 PD patients and 85 HHD patients) with only 28 patients (3% of the total with technique failure) having successful home-to-home transition. During the transition period, 11 patients (39%) were hospitalized and 13 patients (46%) required variable periods of in-centre HD. After a median follow-up of 48 months following dialysis modality transition, four patients switched to in-centre HD permanently (home dialysis technique survival of 86% censored for death and kidney transplantation) and four patients died resulting in a patient survival of 86% (censored for switch to in-centre HD and transplantation). In our centre, home-to-home transition is a feasible strategy with comparable patient and technique survival. A significant proportion of patients switching from a home-to-home dialysis modality required variable intervals of hospitalization and in-centre HD during transitions. Future efforts should be directed towards assessment and home dialysis education during the entire process of dialysis transition.

Key elements in selection of pre-dialysis patients for home dialysis.

Most pre-dialysis patients are medically eligible for home dialysis, and home dialysis has several advantages over incentre dialysis. However, accurately selecting patients for home dialysis appears to be difficult, since uptake of home dialysis remains low. The aim of this study was to investigate which medical or psychosocial elements contribute most to the selection of patients eligible for home dialysis. All patients from a Dutch teaching hospital, who received treatment modality education and subsequently started dialysis treatment, were included. The pre-dialysis programme consisted of questionnaires for the patient, nephrologist and social worker, followed by an assessment of eligibility for home dialysis by a multidisciplinary team. Clinimetric assessment and logistic regression were used to identify domains and questions associated with home dialysis treatment. A total of 135 patients were included, of whom 40 were treated with home dialysis and 95 with incentre haemodialysis. The key elements associated with long-term home dialysis treatment were part of the domains 'suitability of the housing', 'self-care', 'social support' and 'patient capacity', with adjusted odds ratios ranging from 0.13 for negative to 18.3 for positive associations. The assessment of contraindications by a nephrologist followed by the assessment of possibilities by a social worker or dialysis nurse who investigates four key elements, ideally during a home visit, and subsequent detailed education offered by specialized nurses is an optimal way to select patients for home dialysis.

Epidemiology and Outcomes of COVID-19 in Home Dialysis Patients Compared with In-Center Dialysis Patients.

Epidemiology and Outcomes of COVID-19 in Home Dialysis Patients Compared with In-Center Dialysis Patients.

Epidemiology of nursing home dialysis patients-A hidden population.

IntroductionDialysis patients are often discharged from hospitals to skilled nursing facilities (SNFs), but little has been published about their natural history.MethodsUsing electronic medical record data, we conducted a retrospective cohort study of nursing home patients treated with in‐SNF hemodialysis from January 1, 2018 through June 20, 2020 within a dialysis organization across eight states. A dialytic episode began with the first in‐SNF dialysis and was ended by hospitalization, death, transfer, or cessation of treatment. The clinical characteristics and natural history of these patients and their dialytic episodes are described.FindingsFour thousand five hundred and ten patients experienced 9274 dialytic episodes. Dialytic episodes had a median duration of 18 days (IQR: 8–38) and were terminated by a hospitalization n = 5747 (62%), transfer n = 2638 (28%), death n = 568 (6%), dialysis withdrawal n = 129 (1.4%), recovered function n = 2 (0.02%), or other cause n = 6 (0.06%). Increased patient mortality was associated with advancing age, low serum creatinine, albumin, or sodium, and low pre‐dialytic systolic blood pressure (sBP). U‐shaped relationships to mortality were observed for intradialytic hypotension frequency and for post‐ > pre‐hemodialysis sBP frequency. Prescription of dialysis five times weekly in the first 2 weeks was associated with better survival in the first 90 days (HR 0.77, CI 0.62–0.96; p < 0.02).DiscussionProvision of in‐SNF dialysis by an external dialysis organization enables discharge from the acute care setting for appropriate treatment with increased nursing contact time in an otherwise under‐resourced environment. SNF ESRD patient clinical characteristics and outcomes are extensively characterized for the first time.

Vaccine and the Need To Be Heard: Considerations for COVID-19 Immunization in ESKD.

Vaccine and the Need To Be Heard: Considerations for COVID-19 Immunization in ESKD.

FC 117TIME TRENDS IN PROBABILITY OF STARTING HOME DIALYSIS OVER A 20 YEAR PERIOD: A DUTCH REGISTRY STUDY

Abstract Background and Aims A growing number of patients suffers from End Stage Kidney Disease(ESKD), causing a logistical and economic burden to the healthcare system. Utilization of home dialysis is low in many countries worldwide, although home dialysis has several advantages including higher quality of life and possibly lower costs. The aim of this study is to explore time trends in the use of home dialysis in the Netherlands. Method Anonymized registry data from the Dutch Renal Registry (RENINE) were used for this study. All dialysis episodes of adult patients who started dialysis treatment between 1997 through 2016 in the Netherlands were included, including those who previously underwent kidney transplantation. Dialysis episodes shorter than 90 days were excluded. The probability of starting home dialysis between 1997 through 2016 was evaluated in time periods of 5 years, using logistic regression analysis. Home dialysis was defined as start with peritoneal dialysis or home haemodialysis, or transfer to either within 2 years after dialysis start. A logistic multilevel model was used to adjust for clustering at patient level. The cumulative incidence function of start of home dialysis in incident patients was estimated with a competing risk model with recovery of kidney function, kidney transplantations, and all-cause mortality as competing events. All analyses were stratified for age categories at dialysis start: 20-44 years, 45-64 years, 65-74 years and ≥75 years. Results A total of 33,340 dialysis episodes in 31,569 patients were evaluated. Between 1997 and 2016, mean age at start of dialysis treatment increased from 62.5±14.0 to 65.5±14.5 years in in-centre haemodialysis patients, whereas it increased from 51.9±15.1 to 62.5±14.6 years in home dialysis patients. In patients &amp;lt; 65 years, the probability of starting home dialysis was significantly lower during each 5-year period compared to the previous period, and kidney transplantation occurred more often. In patients ≥ 65 years, incidence of home dialysis remained constant, whereas mortality decreased. Conclusion In patients &amp;lt; 65 years, the overall probability of starting home dialysis declined consistently over the past 20 years. The age of home dialysis patients increased more rapidly than that of in-centre dialysis patients, implying that pre-dialysis education and organization of home dialysis must be adapted to the needs of the elderly patient. These developments have a significant impact on the organisation of home dialysis for patients with ESKD.

Worldwide Early Impact of COVID-19 on Dialysis Patients and Staff and Lessons Learned: A DOPPS Roundtable Discussion

As the worst global pandemic of the past century, coronavirus disease 2019 (COVID-19) has had a disproportionate effect on maintenance dialysis patients and their health care providers. At a virtual roundtable on June 12, 2020, Dialysis Outcomes and Practice Patterns Study (DOPPS) investigators from 15 countries in Asia, Europe, and the Americas described and compared the effects of COVID-19 on dialysis care, with recent updates added. Most striking is the huge difference in risk to dialysis patients and staff across the world. Per-population cases and deaths among dialysis patients vary more than 100-fold across participating countries, mirroring burden in the general population. International data indicate that the case-fatality ratio remains at 10% to 30% among dialysis patients, confirming the gravity of infection, and that cases are much more common among in-center than home dialysis patients. This latter finding merits urgent study because in-center patients often have greater community exposure, and in-center transmission may be uncommon under optimal protocols. Greater telemedicine use is a welcome change here to stay, and our community needs to improve emergency planning and protect dialysis staff from the next pandemic. Finally, the pandemic’s challenges have prompted widespread partnering and innovation in kidney care and research that must be sustained after this global health crisis.

Canaries in the Coal Mine: Nursing Home Dialysis Patients as Sentinels During COVID-19

Canaries in the Coal Mine: Nursing Home Dialysis Patients as Sentinels During COVID-19

Policy and Pandemic: The Changing Practice of Nephrology During the Coronavirus Disease-2019 Outbreak.

The coronavirus (coronavirus disease-2019) pandemic has changed care delivery for patients with end-stage kidney disease. We explore the US healthcare system as it pertains to dialysis care, including existing policies, modifications implemented in response to the coronavirus disease-2019 crisis, and possible next steps for policy makers and nephrologists. This includes policies related to resource management, use of telemedicine, prioritization of dialysis access procedures, expansion of home dialysis modalities, administrative duties, and quality assessment. The government has already established policies that have instated some flexibilities to help providers focus their response to the crisis. However, future policy during and after the coronavirus disease-2019 pandemic can bolster our ability to optimize care for patients with end-stage kidney disease. Key themes in this perspective are the importance of policy flexibility, clear strategies for emergency preparedness, and robust health systems that maximize accessibility and patient autonomy.

Setting Up and Expanding a Home Dialysis Program: Is There a Recipe for Success?

Home dialysis modalities remain significantly underused in the United States despite similar overall survival in the modalities, and recent incentives to expand these modalities. Although the absolute number of patients using home modalities has grown, the proportion compared to in-center hemodialysis (ICHD) continues to remain quite low. Well known barriers to home dialysis utilization exist, and an organized and team-based approach is required to overcome these barriers. Herein, we describe our efforts at growing our home dialysis program at a large academic medical center, with the proportion of home dialysis patients growing from 12% to 21% over the past 9 years. We prioritized individualized education for patients and better training for physicians, with the help of existing resources, aimed at better utilization of home modalities; an example includes dedicated dialysis education classes taught twice monthly by an experienced nurse practitioner, as well as the utilization of the dialysis educator from a dialysis provider for inpatient education of patients with CKD. The nephrology fellowship curriculum was restructured with emphasis on home modalities, and participation in annual home dialysis conferences has been encouraged. For timely placement and troubleshooting of access for dialysis, we followed a complementary team approach using surgeons and interventional radiologists and nephrologists, driven by a standardized protocol developed at UAB, and comanaged by our access coordinators. A team-based approach, with emphasis on staff engagement and leadership opportunities for dialysis nurses as well as collaborative efforts from a team of clinical nephrologists and the dialysis provider helped maintain efficiency, kindle growth, and provide consistently high-quality clinical care in the home program. Lastly, efforts at reducing burden of disease such as decreased number of monthly visits as well as using innovative strategies, such as telenephrology and assisted PD and HHD, were instrumental in reducing attrition.

Should Buttonhole Cannulation of Arteriovenous Fistulas Be Used? CON.

Fistulas continue to be promoted as the vascular access of choice due to their lower complication rates as compared with catheters (1,2). However, depending on the fistula cannulation method, the infection risk can compared with that of a catheter. Traditionally, cannulation is an area most physicians tend to ignore; instead, the choice and technique of cannulation is routinely left to nurses. However, given the pain, fear, and anxiety with cannulation that most hemodialysis patients experience (3–⇓5), all health care providers should pay more attention to needling. Furthermore, cannulation and its associated mishaps can lead to fistula complications of infection, and decreased patency. The most common method of cannulation among maintenance hemodialysis patients is the rope ladder technique, which rotates needling sites along the full length of the fistula. The area wall technique, where favored regions are repeatedly needled, is actively discouraged due to progressive weakness in the vessel wall and subsequent aneurysm formation (6). Buttonhole cannulation is more often used in home hemodialysis and it was first introduced as a measure to cannulate a fistula with a limited area for needling (7). Buttonhole involves a constant site of needling that, over time, leads to an epithelized track into which a blunt needle is inserted. Since its first introduction almost 50 years ago by Dr Twardoski and his head nurse (Sister Kumara), buttonhole has continued to garner widespread enthusiasm. Support for its use has been mostly promoted by observational data and poor-quality methodology studies showing beneficial effects on pain and fewer needling complications. Nephrology societies (8,9) (renal.org/guidelines) still recommend buttonhole use as a means to reduce pain and increase longevity. In order to promote a novel cannulation technique over the standard of care, there should be evidence of benefit and a lack of demonstrable …

Health-Related Quality of Life in Home Dialysis Patients Compared to In-Center Hemodialysis Patients: A Systematic Review and Meta-analysis

Rationale & ObjectiveDialysis patients judge health-related quality of life (HRQoL) as an essential outcome. Remarkably, little is known about HRQoL differences between home dialysis and in-center hemodialysis (HD) patients worldwide.Study DesignSystematic review and meta-analysis.Setting & Study PopulationsSearch strategies were performed on the Cochrane Library, Pubmed, and EMBASE databases between 2007 and 2019. Home dialysis was defined as both peritoneal dialysis and home HD.Selection Criteria for StudiesRandomized controlled trials and observational studies that compared HRQoL in home dialysis patients versus in-center HD patients.Data ExtractionThe data extracted by 2 authors included HRQoL scores of different questionnaires, dialysis modality, and subcontinent.Analytical ApproachData were pooled using a random-effects model and results were expressed as standardized mean difference (SMD) with 95% CIs. Heterogeneity was explored using subgroup analyses.ResultsForty-six articles reporting on 41 study populations were identified. Most studies were cross-sectional in design (90%), conducted on peritoneal dialysis patients (95%), and used the 12-item or 36-item Short-Form Health Survey questionnaires (83%). More than half the studies showed moderate or high risk of bias. Pooled analysis of 4,158 home dialysis patients and 7,854 in-center HD patients showed marginally better physical HRQoL scores in home dialysis patients compared with in-center HD patients (SMD, 0.14; 95% CI, 0.04 to 0.24), although heterogeneity was high (I2>80%). In a subgroup analysis, Western European home dialysis patients had higher physical HRQoL scores (SMD, 0.39; 95% CI, 0.17 to 0.61), while home dialysis patients from Latin America had lower physical scores (SMD, −0.20; 95% CI, −0.28 to −0.12). Mental HRQoL showed no difference in all analyses.LimitationsNo randomized controlled trials were found and high heterogeneity among studies existed.ConclusionsAlthough pooled data showed marginally better physical HRQoL for home dialysis patients, the quality of design of the included studies was poor. Large prospective studies with adequate adjustments for confounders are necessary to establish whether home dialysis results in better HRQoL.Trial RegistrationPROSPERO 95985.

Are adverse events in newly trained home dialysis patients related to learning styles? A single-centre retrospective study from Toronto, Canada

ObjectivesHome haemodialysis (HD) and peritoneal dialysis (PD) have seen growth in utilisation around the globe over the last few years. However, home dialysis, with its attendant technical complexity and risk...

Measuring quality and impact of telehealth services in home dialysis patients.

US Medicare beneficiaries receiving home dialysis will have the opportunity to engage in telehealth beginning in 2019. This new paradigm, if successful, will be instituted internationally. Any changes in healthcare delivery, such as using telehealth, will affect the process and quality. Quality of care metrics is discussed, and they can be used to evaluate the three domains of structure, process, and outcome when applied to assess telehealth's impact and quality on the dialysis population.

The Impact of Frailty on Technique Failure and Mortality in Patients on Home Dialysis.

Background:Patients on home dialysis therapies experience technique failure, which is associated with morbidity and mortality. Reasons for technique failure are complex, and often related to functional decline in the patient or caregiver. Frailty is associated with an increased risk of adverse health outcomes. We investigated the impact of frailty on technique failure and mortality in a prospective cohort of patients on home dialysis therapies.Methods:We collected objective (Fried criteria and Short Physical Performance Battery [SPPB]), and subjective (physician and nurse impression) measures of frailty from 109 prevalent home dialysis patients. Our primary outcome was a composite of technique failure, defined as a permanent unplanned transition (> 30 days in duration) to facility-based hemodialysis or all-cause death. The association between different frailty assessment tools and the primary composite outcome was evaluated using Cox models.Results:Fried criteria and physician impression was associated with a greater than 2-fold increase in risk of our composite outcome (HR: 2.10 [95% CI 1.09 - 3.99], 2.15 [95% CI 1.15 - 4.00, respectively] in adjusted analyses. Weakness and weight loss subdomains of the Fried criteria were both associated with an increased risk of our composite outcome in adjusted analyses (HR: 2.16 [95% CI 1.23 - 3.78], 2.69 [95% CI 1.39 - 5.40], respectively).Conclusions:Objective and subjective measures of frailty are associated with a more than 2-fold higher risk of technique failure or death in patients undergoing home dialysis. Assessing frailty as part of the clinical evaluation for home dialysis therapies may be useful for prognostication and clinical management.

Predictors of Care Gaps in Home Dialysis: The Home Dialysis Virtual Ward Study

Background: Home dialysis patients may be at an increased risk of adverse events after transitional states. The home dialysis virtual ward (HDVW) trial was conducted in Canadian dialysis centers and aimed to evaluate potential care gaps and patient satisfaction during the HDVW. Methods: The HDVW was a multicenter single-arm trial including peritoneal dialysis and home hemodialysis patients after 4 different events (hospital discharge, medical procedure, antibiotics, completion of training). Telephone-led interviews using a standardized assessment tool were performed over a 2-week period to assess a patient’s care and adjust treatment as required. Upon completion, patients were surveyed to evaluate their perceived impact on domains of care using a rating scale; 1 not satisfied to 10 completely satisfied. Results: The HDVW trial included 193 patients with a median number of potential care gaps/interventions of 1 (0–2) per patient. Patients admitted to the HDVW after hospital discharge were at a higher risk of potential gaps in care (OR 2.16, 95% CI 1.29–3.62), while longer dialysis vintage was ­associated with a lower number of gaps/interventions (OR 0.97 per year, 95% CI 0.95–0.98). A total of 105/193 (54%) patients completed satisfaction surveys. Patients were highly satisfied with the HDVW (median rating scale score 8, IQR 2) and felt it had a positive impact (rating scale score ≥7) on their overall health, understanding of treatment and access to a nephrologist. Conclusion: The HDVW was effective at identifying several potential care gaps, and patients were satisfied across several domains of care. This intervention may be valuable in supporting home dialysis patients during care transitions.