Home Dialysis Patients Research Articles

Withdrawing life support--the survivors.

We studied the impact of withdrawal of life support on surviving relatives and families of patients who died when chronic dialysis was discontinued. Fifty-four (57%) relatives answered a written questionnaire. The relatives of 70% of home dialysis patients and 27% of center dialysis answered the questionnaire. The answering relative felt most angry and uncomfortable with the decision, ascribed the least anger and most comfort to the patient and an intermediate value to the rest of the family. Staff physician and resident ranked highest in involvement in making the decision, social workers and chaplains the lowest. Once the decision was made, social workers and nurses were most caring and helpful, residents and chaplains were rated the lowest. The relatives felt that they and the patients were the ones who most often brought up the decision to stop and also made the final decision. The relatives thought that the incompetent patients were most angry and uncomfortable but that they felt that decision to be right. The family and relatives were particularly angry and uncomfortable when the patient had discontinued dialysis for the stress of the procedure alone and not any medical complications. In these cases there was most family disagreement and the staff received startling low scores, both for involvement and caring and helpfulness. In answers to open-ended questions, the relatives expressed disappointment with physicians who were unwilling to talk to them, were overly optimistic and continued too long with treatment. They wished for more openness and truthfulness. No long-term psychological harm seems to have come to the relatives and families with one exception. Our finding suggests that more meetings with families and patients and openness about problems and complications during chronic dialysis and follow-up and counseling of families after the patients have died should be helpful.

Psychological, Social, and Somatic Prognostic Indicators in Old Patients Undergoing Long-term Dialysis

We prospectively studied the influence of 29 demographic, social, psychological, and somatic factors on survival of 78 patients over age 70 years receiving long-term dialysis. Three years after the prospective evaluation, 54% of the patients had died. Only four factors, all psychosocial, were prognostically important. The patients who survived rated higher on the Karnofsky scale (85 vs 78 points), gained less weight between dialyses (1.5 vs 1.9 kg), more often underwent home dialysis (44% vs 21%), and less often wished for transplantation (28% vs 57%). In stepwise and multiple regression analysis, home dialysis and Karnofsky scale resulted in best fit. No somatic variable predicted outcome. Thirty-one patients were reinterviewed three years later. At that time, more patients were depressed and had a lower income, fewer wanted a transplant, and five had lost their living companion. There was a decrease in the number of patients who cooked their own meals, spent time outdoors, went to church, or had hobbies. Activity on the Karnofsky scale decreased from 87 to 84 points. The home dialysis patients' perceived health decreased from 3.9 to 3.4 points. Our study shows that psychosocial, but not somatic variables, are prognostically important in survival of older patients undergoing dialysis, and there is a measurable decline in these variables during a three-year follow-up period.

Efficacy of intramuscular and intraperitoneal deferoxamine for aluminum chelation

As intravenous administration of deferoxamine is difficult in home dialysis patients we set out to determine the efficacy of intramuscular (i.m.) and intraperitoneal (i.p.) deferoxamine for removal of aluminum. Patients with serum aluminum levels greater than 90 micrograms/liter were studied in a paired fashion with each patient serving as their own control. Serum and peritoneal fluid aluminum were determined using flameless atomic absorption. In hemodialysis patients 2 g of intravenous deferoxamine increased serum aluminum from 124.7 +/- 32.4 to 415 +/- 192.4 micrograms/liter. One g of deferoxamine given intravenously or intramuscularly resulted in 76.8 +/- 35.3% and 70.4 +/- 23.2%, respectively, of the 2 g i.v. response. The rate at which serum aluminum increased following i.v. deferoxamine infusion was biphasic, with an initial rapid phase lasting 139 minutes followed by a much slower phase. The volume of distribution of aluminum following deferoxamine administration was 12.6 +/- 1.61 and the half life (t1/2) for aluminum removal during hemodialysis was 9.0 +/- 2.0 hours. The increase in serum aluminum following deferoxamine was not due to chelation of erythrocyte aluminum as erythrocyte aluminum remained constant over 24 hours. In patients on continuous ambulatory peritoneal dialysis, 2 g intravenous deferoxamine resulted in the removal of 560 +/- 267 micrograms of aluminum over 24 hours while 2 g deferoxamine given intraperitoneally gave 91 +/- 13% of the intravenous response. Aluminum clearance over 48 hours was twice that for 24 hours for both i.v. and i.p. deferoxamine.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship of depression to survival in chronic renal failure.

The authors examine the relationship between psychosocial factors and factors and survival of patients with chronic renal failure, while considering simultaneously the influence of parameters of physiologic functioning. Psychosocial and physiologic variables selected for discriminant analysis were extracted from data on 285 home-dialysis patients in Ontario, Canada. This analytical procedure defined which variables best discriminated between the survivor and nonsurvivor groups. The findings suggest that demographic and psychosocial factors may be more important than physiologic variables in determination of survival on home dialysis. The severity and type of depression is of particular importance to outcome.

Experience with 150 Consecutive Permanent Peritoneal Catheters in Patients on CAPO

From 1978 to 1984, 150 consecutive CAPD catheters have been implanted in our institution. Early (first-week) and late (up to 44 months) follow-up is presented with special attention to possible surgical related complications. A paramedian incision and an original antileakage technique were used in 95% of the catheters. With this combination, hernia and leakage rates are very low (0.7%()). With the patient-training program, described here, and the installation of the catheter in the outpatient department, peritonitis during the first week dropped from 20% to 0%() (p < 0.05). Previous abdominal operations significantly increase early failures (p < 0.05). Skin exit-site infections were not seen in our patients. The most frequent long-term complications were catheter colonization, i.e. recurrent peritonitis with the same organism, and repeated peritonitis episodes leading to obstruction. The one year actuarial catheter survival is 40%. This paper discusses factors responsible for as well as possible improvement of this low figure. Continuous ambulatory peritoneal dialysis (CAPD) is an established treatment for end-stage renal disease (ESRD). Recent surveys show that up to 45% of home-dialysis patients are in CAPD programs (1). Recently Oreopoulos analyzed the benefits and indications of CAPD and showed that the procedure is being used with increasing frequency (2). The CAPD program in our institution was started in 1978. From January 1981 to October 1984, 150 Tenckhoff catheters were implanted as part of that program. These patients who have had careful metabolic and surgical followup form the basis of this report.

家庭透析者のセルフケアからみた介助者の役割について

私共は, 患者の責任と介助者の役割に関する現状を明確にするため. 当院にて管理している65組の患者, 介助者を対象にアンケート調査を施行した.65組中59組から回答があった. それによると家庭透析患者の90%が男性であり, 介助者の90%が女性であった. 患者および介助者の年齢についてはともに30-40歳代の働き盛りが72%を占めた. また, 86%の患者および34%の介助者が職業を持っていた. 介助者の続柄については, 78%の者が妻であった. 約60%の患者が透析開始準備を介助者に依存しており, その準備に要する時間は55±28minであった. 84%の患者が自己穿刺を行っており, 70%の患者は透析中のヘパリン投与量および膜間圧の調整を自分で行っでいた. 76%の介助者が患者にかわって透析後の後始末を行い, その所要時問は41±19minであった. また, 49%の患者が透析カード記録を介助者に依存し, 自己管理ノート記録を39%の患者が, 材料表記入を58%の患者が, 在庫管理を56%の患者がそれぞれ介助者に依存した.しかし, 検査結果のお知らせ文書についてはすべての患者が目を通していた. 患者自身でできることは患者が自分でしてほしいと答えた介助者は全体の10%, これまでに家庭透析をやめたいと思ったことがある介助者は全体の45%, そして患者とともに家庭透析を今後も続けたいと答えた介助者が全体の96%を占めた.以上より, 家庭透析患者は介助者に極めて多くの部分を依存していることがわかる. 一方, 介助者は家庭透析を肯定的にとらえながらも患者により多くのself careを期待している.

Sex Selection Bias in Choosing a Dialysis Therapy

This investigation has sought to determine reasons for the disproportionately higher number of females entering CAPD as opposed to home hemodialysis. A sample of 295 home dialysis patients, 97 women and 198 men, were compared in terms of modality of choice, baseline demographic characteristics, treatment outcome, and quality of life. The results indicate that there is no apparent rationale for the current selection basis.

Cardiovascular changes in chronic hemodialysis patients

Coronary angiography and left ventricular (LV) hemodynamic studies were performed after dialysis in 32 home dialysis patients (20 men) aged 49.8 +/- 8.0 years. They had been on hemodialysis for 1 to 47 months and were being considered for renal transplantation. The controls were 11 normotensive patients (6 men) aged 46.1 +/- 11 years without coronary artery disease (CAD). Ten (31%) patients had significant CAD (5 single vessel, 3 double vessel, 2 triple vessel). Cardiac index (4.57 +/- 1.3 l/min/m2), LV mass (140 +/- 43 g/m2), mean aortic pressure (103 +/- 20 mm Hg), and LV stroke work index (72 +/- 30 g X m/m2) were significantly elevated while stroke index, heart rate, LV ejection fraction, maximum dP/dT, LV end-diastolic volume and LV end-diastolic pressure were normal. The hemodynamic changes did not correlate with the time on maintenance dialysis nor with the duration of treatment for hypertension. Patients with CAD had higher LV mass and mean aortic pressure than those without CAD. The cardiac changes are thought to result from a combination of pressure and volume loads and anemia.

Vocational adaptation of patients on home dialysis: Its relationship to personality, activities and support received

This analysis identifies, in terms of relative contribution, seven independent variables which appear to be associated with the vocational adaptation of home dialysis patients. The tentative model created by the analysis can be used as a guide for assessing a patient's potential vocational adaptation. It has also identified some conditions associated with adaptation which are amenable to treatment by dialysis staff. Validation of the model, however, requires further testing with other patient groups.

Using a Dialysis Need-Projection Model for Health Planning in Massachusetts

More than $5.1 million in unnecessary kidney dialysis facilities, equipment, and staff has been saved in Massachusetts during the past two years as a result of a model used by the Massachusetts Department of Public Health (DPH) to predict future need for dialysis in the state. These savings constitute 63% of the total proposed capital and manpower costs for the two-year period, accomplished mainly through the denial of 59% of the 163 requests for new dialysis stations. In addition to substantial savings in construction, new equipment and staff, the denial of these requests had several other benefits: Existing facilities have operated at more efficient levels, with lower per-patient treatment costs. Through the restriction of center dialysis supply, more patients were encouraged to utilize home dialysis. Greater reliance on home dialysis could translate into an annual savings of at least $2.6 million and an additional 333 person years as a result of the enhanced life expectancy for home dialysis patients. The need model has also been useful in more equitably distributing dialysis resources to regions in Massachusetts which have previously been underserved. The model has been successful in predicting the need for kidney dialysis services to within 1% of actual demand. Versions of the model are now being used by the US Department of Health and Human Services and by the six Health Systems Agencies of Massachusetts. Similar models can also be used to forecast the need for other types of specialized medical care technology, such as cardiac pacemakers.

INFLUENCE OF PSYCHOSOCIAL FACTORS ON SURVIVAL OF HOME-DIALYSIS PATIENTS

An analysis of factors influencing the survival of 285 home-dialysis patients followed for a minimum of 18 months suggests that psychosocial and demographic factors may be more important than physiological variables in determining survival.

Comparison of Psychological Adjustment to Continuous Ambulatory Peritoneal Dialysis and Home Hemodialysis

Two groups of home dialysis patients (40 on CAPD and 37 on home hemo dialysis) matched for length of time on dialysis, and for demographic background were studied and compared. The CAPD patients were significantly more satisfied with the support received from household members and from spouses, more satisfied with the relations with spouses, more understood by them and more understanding of their spouses. Sexual satisfaction declined in both groups. However, sexual satisfaction was slightly higher in the CAPD group and these patients experienced slightly less difficulty in adjusting to the decline; none of these differences were statistically significant.

Comparison of Psychological Adjustment to Continuous Ambulatory Peritoneal Dialysis and Home Hemodialysis

Two groups of home dialysis patients (40 on CAPD and 37 on home hemo dialysis) matched for length of time on dialysis, and for demographic background were studied and compared. The CAPD patients were significantly more satisfied with the support received from household members and from spouses, more satisfied with the relations with spouses, more understood by them and more understanding of their spouses. Sexual satisfaction declined in both groups. However, sexual satisfaction was slightly higher in the CAPD group and these patients experienced slightly less difficulty in adjusting to the decline; none of these differences were statistically significant.

Transposition of the basilic vein in the forearm for the construction of haemodialysis arteriovenous fistula.

Twenty-five dialysis patients have been operated 27 times using a modified surgical technique with transposition of the basilic vein for construction of a forearm arteriovenous fistula. The vein is explored at the elbow and dissected free as far distally as possible using small transverse incisions. The vein is cut distally, taken out at the elbow and positioned in a straight, superficial narrow tunnel on the volar side of the forearm for anastomosis to the side of the radial or the ulnar artery. The operation was successful in 19 (76%) cases giving an easily accessible and well-functioning arterialised vein. The surgical technique is simple and is recommended as a primary procedure in patients where the cephalic or other radial or dorsal vein is not available, and as a secondary procedure after failure of a radiocephalic fistula. It is considered of special value for home dialysis patients.

Survival on home haemodialysis: its relationship with physical symptomatology, psychosocial background and psychiatric morbidity

An entire group of 32 home dialysis patients from one hospital renal unit was assessed for psychiatric morbidity on a standardized interview of proven reliability. A rating of physical symptomatology and an enquiry into the childhood and psychosocial background were made at the same time. Psychiatric morbidity, physical symptomatology and a history of good relationships with both natural parents in childhood were inter-related. They were all related to survival on haemodialysis 3 1/2 years later. Survival was also associated with a coping spouse and full-time employment or housework by the patient. These findings are discussed in the light of current concepts of the psychosocial setting for physical illness.

Conservative management of uremic pericardial effusions

Although there has been a recent trend toward early operative treatment of uremic pericardial effusions unresponsive to intensified dialysis, this approach may be unnecessarily aggressive. Review of 787 patients in our chronic dialysis program since 1969 has shown 54 patients (6.9 percent) to have developed 56 episodes of large pericardial effusion. All were managed by increasing the frequency of dialysis. If the effusion failed to diminish or if life-threatening signs of tamponade developed, pericardiocentesis was performed. In 63 percent (35/56) the effusion resolved with increased dialysis. In 37 percent (21/56), pericardiocentesis was performed, with 57 percent (12/21) requiring only one aspiration. During a mean follow-up of 34 months (2 to 100 months) only 5.5 percent (3/54) have undergone operation: one partial pericardiectomy incidental to pulmonary decortication and two pericardiectomies for late (3 months and 5 months, respectively) constriction. There were five complications of pericardiocentesis: one pneumothorax, one pneumoperitoneum, one costochondritis, and two myocardial punctures without sequelae. The one death related to pericardial effusion in this series occurred in a home-dialysis patient who arrived in the emergency room moribund. Our experience suggests that the great majority of uremic pericardial effusions can be effectively controlled with simple needle aspiration by experienced personnel and that pericardial resection is usually not necessary.

Treatment of End-Stage Renal Failure in a Defined Geographic Area

The treatment of end-stage renal failure was studied in southern Connecticut from 1967 to 1975 by (1) calculating survival rates for center and home dialysis patients and cadaver and living related donor transplant recipients and (2) assessing the quality of life with structured interviews and psychological tests. While the survival rate for our home dialysis and transplant recipients were similar to previously reported data, mortality for our center dialysis patients was slightly higher than previously reported. Quality-of-life testing, disclosed that dialysis patients had a substantial impairment in all parameters. Transplant recipients achieved a better degree of rehabilitation. Physicians and patients should be aware of the problems that they are likely to face; otherwise, expectations and goals may be raised to unreachable and ultimately frustrating levels.

PHYSICAL, EMOTIONAL AND SOCIAL ADJUSTMENTS TO HOME DIALYSIS

Forty home dialysis patients and their families were interviewed by means of a standard questionnaire to determine their physical, emotional, and social adjustment to treatment. The results indicated a reasonable level of health, particularly in patients under the age of 50 years. However, home dialysis produced considerable strain in the family, particularly in the dialysis partners. Home training programmes should provide appropriate learning and technical experience for the dialysis partners and continued support, including integrated medical and paramedical services, domiciliary visiting, and regular holidays. Limited-care dialysis facilities should be provided where home dialysis is impractical or becomes intolerable.

Home Dialysis Program of the Nashville VA Hospital

Since 1965, 330 patients have received chronic dialysis treatment at the Nashville VA Hospital. Home hemodialysis training was established in 1968, and a unique class format has been used since 1970. Despite the national trend of fewer patients beginning home dialysis each year, more than 50 percent of our patients have chosen this form of therapy yearly since 1969. A total of 182 patients (55 percent) from 15 states have completed home training with an attrition rate of only 8 percent. Mean distance of patients' homes from the training center is 185 miles. Five-year survival for home hemodialysis patients is 91 percent, compared to 59 percent and 55 percent for patients receiving renal transplant and center dialysis, respectively. Seventeen deaths have occurred in home dialysis patients, half of which were due to cardiovascular disease. Home dialysis offers an excellent mode of therapy for patients with chronic renal failure and probably is particularly suitable for patients over 50 years of age.

All about Sex...Despite Dialysis

For patients on maintenance hemodialysis, sex, too, is a wash-out(1). Although information on the sexual functioning of renal patients is minimal, current studies paint a rather gloomy picture. For the majority of dialysis patients, sexual functioning worsens with the progression of uremia and improves only slightly with maintenance hemodialysis(2,3,4). In addition, sterility, amenorrhea, and impotence are not infrequent(5). Before hemodialysis, patients with chronic renal disease seldom lived long enough to be concerned with the emotional and social consequences of their illness. Today, for many of the 25,000 patients in the U.S. on dialysis, life has been extended, living can be relatively normal, and questions of sexual function are of increasing concern. We recognized this when our adult patients on home dialysis at the Artificial Kidney Center of Eugene Talmadge Memorial Hospital began asking us about sterility, diminishing potency, and a lack of interest in sex. The staff was unaccustomed to discussing sexual adjustment, and before assisting patients, we had to become better informed and learn the techniques of counseling. We designed a series of mini-seminars-informal lectures and group discussions-entitled Sexual Adjustment and the Nephrology Patient. Lesson plans were organized as guidelines, such books as The Joy of Sex and The Pleasure Bond were made available to patients and staff, and charts and diagrams were collected to illustrate human sexual response. The mini-seminars were held twice weekly during the regularly scheduled nephrology outpatient clinic. All adult home dialysis patients, both married and single, and their partners were invited to participate. We offered individual sessions for those who could not attend or who did not