Hospital-based Haemodialysis Research Articles

Home before Hospital: a whole of system re-design project to improve rates of home-based dialysis therapy: Experience and outcomes over 8 years.

Despite evidence that clinical outcomes for patients treated with peritoneal dialysis (PD) or home haemodialysis are better than for patients treated with conventional satellite or hospital-based haemodialysis, rates of home-based dialysis therapies world-wide remain low. Home-based dialysis care is also cost-effective and indeed the favoured dialysis option for many patients. Using a lean-thinking framework and established change management methodology, a project embracing a system-wide approach at making a change where a 'Home before Hospital' philosophy underpinned all approaches to dialysis care was undertaken. Three multidisciplinary working groups (pathway, outreach and hybrid) were established for re-design and implementation. The primary aim was to improve home-based dialysis therapy prevalence rates from a baseline of 14.8% by ≥2.5%/year to meet a target of 35%, whilst not only maintaining but improving the quality of care provided to patients requiring maintenance dialysis. A 'future' state pathway was developed after review of the 'current' state (Pathway Working Group) and formed the basis on which a nurse-led outreach service (Outreach Working Group) was established. With the support of the multidisciplinary team, the outreach service model focussed on early, consistent, and frequent education, patient support in decision-making, and clinician engagement. A target prevalence of >30% for home-based therapies (mainly achieved with PD) was achieved within 2 years. This prevalence rate reached 35% within 3 years and was maintained at 8 years. In addition, selected patients already on maintenance satellite-based haemodialysis (Hybrid Working Group) were educated to achieve high levels of proficiencies in self-care. Having the system-wide approach to a Quality Improvement Process and using established principles and change management processes, the successful implementation of a new sustainable model of care focussed on home-based dialysis therapy was achieved. A key feature of the model (through outreach) was early nurse-led education and support of patients in decision-making and ongoing support through multidisciplinary care.

A nonrandomised pilot study to examine the feasibility and acceptability of reflexology in patients undergoing hospital‐based haemodialysis (solitude study)

Patients with end-stage kidney disease, receiving haemodialysis can experience complications-hypotension, headache, muscle cramp, chest pain, nausea and vomiting. Patients who experience all or some of these symptoms will often report reduced health-related quality of life (HRQOL) and poor sleep quality, which may lead to increased morbidity and mortality. The objective of this pilot study is to evaluate the feasibility of a larger randomised controlled trial to determine the effect of foot reflexology on a cohort of patients undergoing hospital-based haemodialysis. A nonrandomised pilot study using a multimethod approach. Twenty patients undergoing hospital-based haemodialysis treatment. HRQOL and quality of sleep were measured using the SF-12 Health Survey and the Pittsburgh Sleep Quality Index (PSQI). Semi-structured interviews were completed with 10 patients, exploring their experiences, opinions and perceptions of the intervention. There was an increase in the mean scores examining the total physical health and mental health components of the SF-12. All corresponding p values were statistically significant following the intervention. The mean total sleep score postintervention signified positive changes in sleep quality, with the corresponding p values being statistically significant. The study established the feasibility of the intervention and the benefits for patients undergoing haemodialysis. This pilot study demonstrated the possibility of recruiting and retaining patients undergoing haemodialysis to a reflexology study. The study did not impact the haemodialysis routine and was positively received. The intervention showed statistically significant improvements in patients' HRQOL and sleep quality.

The work environment of haemodialysis nurses and its mediating role in burnout.

The work environment can contribute to the occurrence of nurses' burnout. This study assessed the work environment of haemodialysis nurses andthe extent of burnout they have suffered, and it explored the connection between work environment and burnout. A multicentre cross-sectional study was conducted in 53 public, hospital-based haemodialysis units in Greece. A total of 537 haemodialysis nurses participated. The majority consisted of females (90.8%) who possessed a university degree or a degree from a technological institute (72.6%). They had an average of 15 years of experience in dialysis. The Practice Environment Scale of the Nursing Work Index and the Copenhagen Burnout Inventory (CBI) were used. The demographic characteristics of the participants were also collected. Although the nurses rated their work environment as healthy, they were experiencing a moderate degree of burnout. The multivariate linear regression analysis with the CBI scales as dependent variables was applied. The increased nurses' participation in hospital affairs was associated with decreased personal (coefficient β = -9.4, 95% confidence interval [CI] = -17.4 to -1.3, p = 0.023), work-related (coefficient β = -12.9, 95% CI = -22.5 to -3.5, p = 0.008) and patient-related burnout (coefficient β = -15.9, 95% CI = -24.5 to -7.4, p = < 0.001). The better collegial nurse-physician relationships were associated with decreased personal (coefficient β = -10.7, 95% CI = -18.3 to -3.0, p = .007) and work-related burnout (coefficient β = -15.1, 95% CI = -23.3 to -7.0, p = < 0.001). The work environment of haemodialysis nurseswas associated with burnout. Its improvement is an important tool in administrations' effort to ensure the nursing staff's well-being.

Quality of life in advanced renal disease managed either by haemodialysis or conservative care in older patients

ObjectiveConsideration of quality of life (QoL) in people with end-stage renal disease has become an important part of treatment decision-making. The aim of this study was to report on QoL...

Rural dialysis nurses’ experiences with challenging patients: a thematic qualitative analysis

Background: This study explored the experience of nurses encountering challenging patient behaviour while working at a rural hospital-based haemodialysis unit. Methods: Focus groups were conducted with haemodialysis nurses at a rural hospital. Five participants across two focus groups were asked questions regarding their experiences of challenging patients, including impacts that the experiences may have had on their ongoing professional practice. Transcripts of the focus groups were analysed thematically. Findings: Three themes arose from the focus group discussion - experiencing challenging behaviour, long-term relationships with patients, and nursing professionalism. Participants described challenges arising when caring for patients who were aggressive, did not comply with self-management, or caused avoidable logistical challenges. Long-term caring relationships presented challenges as patients could become emotionally dependent upon one nurse, making it difficult to share workloads with other nurses. Participants reported decreased confidence, being near tears, being angry, and experiencing 'burnout' when caring for patients with difficult behaviour over extended periods. Participants managed challenging behaviours by identifying triggers, allocating staff to specific patients, and trying to understand the patient's motivation for action. 'Not taking work home' and 'not taking things personally' were ways in which nurses attempted to look after their own wellbeing, although this was not always possible. Participants stressed the importance of working as a team and having supportive management and inter-professional relationships. Significance: Participants' perceptions of working in the nursing profession were more related to their ability to work as a team and manage challenging behaviour exhibited by patients in a supportive environment than the presence of patients exhibiting challenging behaviour.

Lifetime cost-effectiveness analysis of first-line dialysis modalities for patients with end-stage renal disease under peritoneal dialysis first policy

BackgroundThis study aimed to determine the lifetime cost-effectiveness of first-line dialysis modalities for end-stage renal disease (ESRD) patients under the “Peritoneal Dialysis First” policy.MethodsLifetime cost-effectiveness analyses from both healthcare provider and societal perspectives were performed using Markov modelling by simulating at age 60. Empirical data on costs and health utility scores collected from our studies were combined with published data on health state transitions and survival data to estimate the lifetime cost, quality-adjusted life-years (QALYs) and cost-effectiveness of three competing dialysis modalities: peritoneal dialysis (PD), hospital-based haemodialysis (HD) and nocturnal home HD.ResultsFor cost-effectiveness analysis over a lifetime horizon from the perspective of healthcare provider, hospital-based HD group (lifetime cost USD$142,389; 6.58 QALYs) was dominated by the PD group (USD$76,915; 7.13 QALYs). Home-based HD had the highest effectiveness (8.37 QALYs) but with higher cost (USD$97,917) than the PD group. The incremental cost-effectiveness ratio (ICER) was USD$16,934 per QALY gained for home-based HD over PD. From the societal perspective, the results were similar and the ICER was USD$1195 per QALY gained for home-based HD over PD. Both ICERs fell within the acceptable thresholds. Changes in model parameters via sensitivity analyses had a minimal impact on ICER values.ConclusionsThis study assessed the cost-effectiveness of dialysis modalities and service delivery models for ESRD patients under “Peritoneal Dialysis First” policy. For both healthcare provider and societal perspectives, PD as first-line dialysis modality was cost-saving relative to hospital-based HD, supporting the existing PD First or favoured policy. When compared with PD, Nocturnal home Home-based HD was considered a cost-effective first-line dialysis modality for ESRD patients.

Facility size and mortality in hospital-based and freestanding haemodialysis units: A nationwide retrospective cohort study.

Existing studies on the association between haemodialysis facility size/volume and patient survival are mostly limited to freestanding dialysis units in the United States. This study in Taiwan explored the facility size - mortality association in both hospital-based and freestanding haemodialysis (HD) units. In this nationwide population-based retrospective cohort study, we used the Taiwan National Health Insurance Research Database to include patients who began maintenance (HD) between 2008 and 2012. Facility size was categorized according to the number of stations in the HD unit. The 5 years mortality rate was analyzed using a frailty model for Cox regression. The patients in hospital-based and freestanding HD units were examined separately. Among the 39 506 patients, 24 597 (62.3%) and 14 909 (37.7%) patients received HD in hospital-based and freestanding facilities, respectively. After the 4th month of dialysis initiation, the 5 years survival rates of patients in hospital-based and freestanding HD units were 50.7% and 52.3%, respectively. When patient and other facility characteristics were adjusted, patients in the smallest facility category (1-15 stations) showed the highest mortality risk (hazard ratio, 1.36; 95% confidence interval, 1.11-1.67) among all the patients treated in hospital-based units. The patients treated in freestanding units with 1-15, 16-30 and 31-45 stations showed 31%, 33% and 36%, respectively, higher mortality risks than those of patients treated in units with more than 45 stations. A small facility size was associated with an increased mortality risk in HD patients, and the threshold size was higher in freestanding units.

Direct and indirect costs of end-stage renal disease patients in the first and second years after initiation of nocturnal home haemodialysis, hospital haemodialysis and peritoneal dialysis.

To estimate the direct and indirect costs of end-stage renal disease (ESRD) patients in the first and second years of initiating peritoneal dialysis (PD), hospital-based haemodialysis (HD) and nocturnal home HD. A cost analysis was performed to estimate the annual costs of PD, hospital-based HD and nocturnal home HD for ESRD patients from both the health service provider's and societal perspectives. Empirical data on healthcare resource use, patients' out-of-pocket costs, time spent on transportation and dialysis by ESRD patients and time spent by caregivers were analysed. All costs were expressed in Hong Kong year 2017 dollars. Analysis was based on 402 ESRD patients on maintenance dialysis (PD: 189; hospital-based HD: 170; and nocturnal home HD: 43). From the perspective of the healthcare provider, hospital-based HD had the highest total annual direct medical costs in the initial year (mean ± SD) (hospital-based HD = $400 057 ± 62 822; PD = $118 467 ± 15 559; nocturnal home HD = $223 358 ± 18 055; P < 0.001) and second year (hospital-based HD = $360 924 ± 63 014; PD = $80 796 ± 15 820; nocturnal home HD = $87 028 ± 9059; P < 0.001). From the societal perspective, hospital-based HD had the highest total annual costs in the initial year (hospital-based HD = $452 151 ± 73 327; PD = $189 191 ± 61 735; nocturnal home HD = $242 038 ± 28 281; P < 0.001) and second year (hospital-based HD = $413 017 ± 73 501; PD = $151 520 ± 60 353; nocturnal home HD = $105 708 ± 23 853; P < 0.001). This study quantified the economic burden of ESRD patients, and assessed the annual healthcare and societal costs in the initial and second years of PD, hospital-based HD and nocturnal home HD in Hong Kong. From both perspectives, PD is cost-saving relative to hospital-based HD and nocturnal home HD, except that nocturnal home HD has the lowest cost in the second year of treatment from the societal perspective. Results from this cost analysis facilitate economic evaluation in Hong Kong for health services and management targeted at ESRD patients.

Compartmentalising time and space: a phenomenological interpretation of the temporal experience of commencing haemodialysis.

To interpret the spatio-temporal experience of people with end-stage kidney disease and their families in the first months of haemodialysis. While dialysis is the mainstay of end-stage kidney disease management, the actual initiation of treatment is often unexpected by people and families. Poor biopsychosocial preparation means haemodialysis commencement is experienced as a crisis. While previous phenomenological studies suggest that over time, a habitual incorporation of dialysis into one's self-concept is possible, the spatio-temporal experience of people new to haemodialysis is not well understood. A phenomenological study. Following purposive sampling, 18 participants were recruited either during an inpatient admission or while attending a public hospital-based haemodialysis unit in Sydney, Australia. Eleven people who had commenced haemodialysis within the previous three months and five close family members were separately engaged in semistructured interviews. Hermeneutic interpretation within a Heideggerian framework occurred through a backward-and-forward analysis between the early haemodialysis experience and its relationship to Being. Themes that related to a temporal and spatial understanding of Being-in-the-world as a new haemodialysis patient or carer included the following: 'compartmentalising life into dialysis and non-dialysis days' (lost time, clock time and lived time); 'compartmentalising before, now and future' (normalising the 'before', dealing with the 'now' and the 'foreverness' of dialysis); and finally, 'compartmentalising space'. In the months after dialysis commencement, patients and family carers compartmentalise time and space with a loss of continuity of meaningful, lived time that had framed people's past sense of normal. Resource enhancement activities should focus on social connectivity and provision of personnel and/or infrastructure to reduce boredom, to facilitate engagement with meaningful tasks and, where appropriate, to support the continuation of work activities during the dialysis period.

RENEW-a renal redesign project in predialysis patient care.

BackgroundAn ageing population and geographical growth, along with an increase in the number of people that reside in specific location, are increasing the demand for renal replacement therapies. Hospital-based haemodialysis units are struggling to cope with the associated physical, staffing and cost demands. Home-based dialysis therapies are known to be more cost effective with superior social, physical health and survival outcomes.Methods‘RENEW, a renal redesign project, examined the pre-dialysis health care experience of renal patients to find opportunities to improve patient care outcomes and increase the uptake of home-based dialysis therapies. This article details two crucial parts of the approach to change management: (i) diagnostics—an inclusive, client focused, multidisciplinary approach to identify issues relating to the pre-dialysis journey—and (ii) solution design—an inclusive problem-solving approach to identify and marry solutions to the issues identified during diagnostics.ResultsBased on feedback from patients/caregivers and staff interviews, utilizing a clinical redesign methodology, a new model of care was developed, implemented and subsequently embedded into clinical practice. The results have been evident via improved care coordination, enhanced patient preparation for dialysis, improved patient psychosocial welfare and, importantly, an increased number of patients planned for and commencing home dialysis. This has empowered patients by giving them the confidence, knowledge and skills to be actively engaged in their own care. The project resulted in significant expenditure avoidance.ConclusionChange management strategies with successful implementation are vital components of evolving clinical practice to achieve both clinical and organizational goals.

Évaluation médico-économique des stratégies de prise en charge de l’insuffisance rénale chronique terminale en France

End-stage renal disease is a chronic state that may continue for many years before death. Patients may receive various modalities of renal replacement therapy that vary over time, which we describe as a treatment trajectory. The French health insurance system pays dialysis facilities and professionals various fixed fees according to the dialysis modalities they provide; fees are highest for hospital-based haemodialysis care, which treats around 58% of all dialysis patients. As in other European countries, a variety of dialysis modalities are used in France, and their weight and distribution differ from region to region. This study hypothesizes that some patients currently treated in hospital-based haemodialysis could be treated with another RRT modality without any increase in mortality risk. The aim of this study was to propose new care strategies so as to evaluate the medico-economic impact of replacing some hospital-based HD care by various other modalities for French health insurance. Care strategies were modelled using a statistical tool that predicts course and trajectories of a hypothetical cohort of news patients over a 15-year period. The results confirmed that the development of kidney transplantation in six sub-cohorts (according to age and diabetes status) is an efficient strategy, compared to all evaluated strategies. Strategies considering joint development of peritoneal dialysis and hospital-based haemodialysis are efficient for patients over 45 years but their feasibility has to be evaluated. Other alternative strategies also need to be considered because they are as effective and less costly than the current care practices.

Economic impact of a modification of the treatment trajectories of patients with end-stage renal disease.

This study assumed that some patients currently treated at hospital-based haemodialysis centres can be treated with another renal replacement therapy (RRT) modality without any increase in mortality risk and sought to evaluate the monthly cost impact of replacing hospital-based haemodialysis, for which fees are highest, by different proportions of other modalities. We used a deterministic model tool to predict the outcomes and trajectories of hypothetical cohorts of incident adult end-stage renal disease (ESRD) patients for 15 years of RRT (10 different modalities). Our estimates were based on data from 67 258 patients in the REIN registry and 65 662 patients in the French national health insurance information system. Patients were categorized into six subcohorts, stratified for age and diabetes at ESRD onset, and analyses run for each subcohort. We simulated new strategies of care by changing any or all of the following: initial distributions in treatment modalities, transition rates and some costs. Strategies were classified according to their monthly per-patient cost compared to current practices (cost-minimization analysis). Simulations of the status quo for the next 15 years predicted a per-patient monthly cost of €2684 for a patient aged 18-45 years without diabetes and €7361 for one older than 70 years with diabetes. All of the strategies we analysed had monthly per-patient costs lower than the status quo, except for daily home HD. None impaired expected survival. Savings varied by strategy. Alternative strategies may well be less expensive than current practices. The decision to implement new strategies must nonetheless consider the number of patients concerned, feasibility of renal care reorganization, and investment costs. It must also take into account the role of patients' choice and the availability of professionals.

Patterns of health-related quality of life and associated factors in Chinese patients undergoing haemodialysis.

BackgroundHaemodialysis (HD) is a life-saving but burdensome therapy for patients with end-stage renal disease (ESRD) which can have a detrimental impact on patients’ quality of life and outcomes. There is currently little data on the health related quality of life (HRQOL) of Chinese ESRD patients undergoing HD and this study sought to examine the patterns of HRQOL and its associated factors within this population, as well as in comparison with the general local population.MethodsA cross-sectional study of 244 ESRD patients receiving HD in the hospital and in the community in Hong Kong was conducted using the Short Form-12 Health Survey version 2 (SF-12v2). All study subjects were one-to-one matched with subjects in a Hong Kong general population database by sex and exact age. Independent t-tests were performed to compare the mean SF-12v2 scores between HD patients and the general population, followed by one-way analysis of variance with post hoc Tukey’s HSD tests to compare community-based haemodialysis, hospital-based haemodialysis and the general population. Multiple linear regressions were used to identify the factors (socio-demographic, clinical characteristics and comorbidities) associated with the HRQOL scores of ESRD patients receiving HD.ResultsThe SF-12v2 Physical Functioning, Role Physical, Bodily Pain, General Health and Physical Component Summary scores of HD patients were significantly lower than the age-sex adjusted general population. However, the SF-12v2 Mental Health and Mental Component Summary scores of HD patients were significantly higher than the corresponding general population. Poorer HRQOL was associated with being female, smoking, unemployment and hospital-based haemodialysis.ConclusionsHD patients had substantially poorer physical HRQOL but better mental HRQOL than the age-sex adjusted general population. Patients receiving HD in the community setting had better HRQOL. Reasons for these observations will need to be further investigated. Those patients who are female, smokers and unemployed may warrant more attention as their poorer HRQOL may be associated with poorer outcomes.

EUROPEAN TRAINING AND RESEARCH IN PERITONEAL DIALYSIS: SCIENTIFIC OBJECTIVES, TRAINING, IMPLEMENTATION AND IMPACT OF THE PROGRAMME

Peritoneal dialysis (PD) offers many advantages over hospital-based haemodialysis, including better quality of life. Despite this, there is a general under-utilisation of PD in Europe, which, to some extent, can be attributed to a lack of knowledge and education amongst renal clinicians and nurses. The specific aim of the European Training and Research in Peritoneal Dialysis (EuTRiPD) programme is to address this lack of knowledge, to develop a minimum of five biomarkers that allow the prediction of outcome in PD and three therapeutic treatments to improve outcome in PD. EuTRiPD is a EU-wide consortium with clinical, academic and commercial partners set up to address this knowledge gap. By training through research and close collaboration between academic and commercial entities we hope to improve the outcome and uptake of PD. It is the goal of EuTRiPD to improve the currently hampered diagnostic therapeutic developments in renal replacement therapy (RRT) and structure existing high-quality PD-related research across Europe. It is hoped that EuTRiPD can and will have a significant impact on socio-economic and scientific aspects of PD. It is the aim for EuTRiPD to boost the uptake of PD throughout Europe by making PD the obvious choice for patients.

The work environment of haemodialysis nurses and its impact on patients’ outcomes

The aims of this study were to assess haemodialysis nurses' work environment and investigate the correlation between work environment and patients' outcomes. A cross-sectional study was conducted at the 11 public hospital-based haemodialysis units of the 5th Regional Health Authority of Greece. The Practice Environment Scale of the Nursing Work Index (PES-NWI) was used to assess work environment. Nurses were asked to report the frequency of a series adverse events and errors. Study population consisted of 133 nurses (response rate 89.3%). The overall PES-NWI scored just < 2.5 (Mean = 2.48, standard deviation = 0.34) indicating a non-favourable haemodialysis workplace. Nurse-physician Relations, nurse manager ability and nursing foundations for quality of care were the most favourable aspects of work environment. Multivariate logistic regression analysis identified that hypotension (odds ratio (OR) = 0.3, 95% confidence interval (CI) = 0.1-0.9, P = 0.03), venous needle disconnection (OR = 0.14, 95% CI = 0.03-0.65, P = 0.012) and patient fall (OR = 0.02, 95% CI = 0.001-0.51, P = 0.018) were associated with a non-favourable work environment. Findings have important implications for improvement of haemodialysis work environment and enhancement of patients' safety.

Waiting for a kidney transplant: patients’ experiences of haemodialysis therapy

This paper is a report of an exploration of the experiences of patients with end-stage kidney disease who were having haemodialysis. The losses and lifestyle disruptions caused by end-stage kidney disease are a fundamental source of suffering for people. The hope of a transplant is an important factor in people's ability to cope with end-stage kidney disease and dialysis. A Heideggerian phenomenological methodology was used. A purposive sample was selected of 16 patients with end-stage kidney disease having hospital-based haemodialysis therapy in the Republic of Ireland. Qualitative interviews were conducted in 2006-2007. Data were analysed using qualitative interpretive analysis. The overarching pattern identified was 'Waiting for a kidney transplant'. This pattern consisted of three themes: living in hope, uncertainty and being on hold. Participants described their experiences of living in hope while they waited for a kidney transplant. However, as the waiting time continued indefinitely, participants became uncertain, and this meant that they were unable to contemplate opportunities in the future. Moreover, the restrictions of haemodialysis therapy prevented them from performing many of the activities they had taken for granted in the past. Consequently, they described their experiences of being on hold while they waited for a kidney transplant. Nurses should engage in open and honest discussions with patients in relation to kidney transplantation so that they are able to recognize and address their concerns about kidney transplantation.

Lacking evidence for calcium-binding protein fetuin-A to be linked with chronic kidney disease-related pruritus (CKD-rP).

Sir, Uraemic pruritus, now better known as chronic kidney disease-related pruritus (CKD-rP), is still a commonly experienced, tormenting and challenging symptom in patients with chronic kidney diseases [1]. There has been an ongoing discussion whether pruritus in chronic kidney disease is brought about by the common disturbance of calcium/phosphate homeostasis [2]. Recently it has been proposed that a vicious circle of metabolic derangements (malnourishment, inflammation, arteriosclerosis) may explain the exaggerated morbidity and mortality in a subset of haemodialysis patients [3]. Inflammation might be the most deleterious factor in this respect which, besides other factors, is related to the occurrence of CKD-rP and down-regulation of fetuin-A, an important calcium-binding circulating protein favouring tissue-calcifications in these patients [4]. Thus, we were interested in whether patients with CKD-rP display lower levels of serum fetuin-A. Ten patients in a hospital-based haemodialysis centre complaining about CKD-rP were compared to another 12 patients who did not report to have suffered from CKD-rP at least 6 months prior to the interview. Patients with CKD-rP were asked to score the intensity of current pruritus using a visual analogue scale (VAS) ranging from 0 to 10. In both groups, 10 ml of blood was taken immediately after puncture of the arterio-venous fistula, and fetuin-A, 25-hydroxyvitamin D3 (25[OH]D3), total protein, albumin, calcium (corrected for serum albumin), phosphate, and high-sensitivity CRP (hsCRP) were measured. Independent t-tests (continuous variables) and a χ2-test (gender) evaluated whether there were significant (P < 0.05) differences between patients with and without CKD-rP. The mean pruritus intensity of patients with CKD-rP was 5.9 ± 1.9. After identifying one univariate outlier (hsCKP = 35.6) in the group of patients without CKD-rP, CRP was significantly higher in patients with CKD-rP. We failed, however, to find significant differences in serum-calcium, phosphate, fetuin A and 25-OH-Vitamin D3 between the two groups (Table ​(Table1).1). Additionally, there was no relationship between the intensity of CKD-rP and the metabolic factors measured (including CRP) in patients suffering from pruritus. Table 1 Patient and clinical characteristics between the two groups. PTH (intact parathyreoid hormone), hsCRP (high-sensitivity C-reactive protein), 25(OH)D3 (25-hydroxyvitamin D3) Although our study approach has methodological limitations (small number of patients, no matched pairs) the results suggest that neither calcium-binding protein fetuin-A levels nor 25(OH)D3 values were noticeably different in patients with CKD-rP compared to patients without CKD-rP. On the other hand, the marker for inflammation, CRP, was found to be significantly higher in patients with CKD-rP as shown before [5]. We hence believe that other inflammation-driven processes need to be studied in the future in order to understand the pathomechanisms of CKD-rP. Conflict of interest statement. None declared.

A NEW HAEMODIALYSIS CATHETER‐LOCKING AGENT REDUCES INFECTIONS IN HAEMODIALYSIS PATIENTS

Intravenous catheters for haemodialysis increase the risk of sepsis. This study investigates the use of a taurolidine/citrate catheter-locking agent for patients receiving hospital-based haemodialysis, auditing the number and cost of infections before and after its introduction. The incidence and cost of treatment of catheter sepsis occurring in all patients receiving haemodialysis via a line were investigated over 6-month periods before and after introducing the taurolidine/citrate line-locking agent. A reduction of 4.62 infections per 1000 catheter days, or 88.5%, was shown after the introduction of the new line-locking agent. The total costs of line infections in the first 6 months were 52,500 euros, (41,000 pounds); after the introduction of the taurolidine/citrate locks, these reduced to 33,300 euros, (26, 000 pounds), a reduction of 19,200 euros (15,000 pounds). The use of a taurolidine/citrate haemodialysis catheter-locking agent in our haemodialysis population has significantly reduced the line sepsis rate, with a positive impact on morbidity, mortality and cost.

The prediction of self-care behaviors in end-stage renal disease patients using Leventhal's Self-Regulatory Model

Objective To assess the utility of Leventhal's Self-Regulatory Model (SRM) to predict self-care behavior with regard to dietary, medication, and fluid regimes in end-stage renal disease (ESRD) patients. Methods In a prospective study, ESRD patients treated via hospital-based haemodialysis ( N=73) were screened for cognitive deficits and completed questionnaires that enquired about illness perceptions, coping strategies, knowledge of kidney disease, and psychological distress at Time 1. Physiological proxy measures of self-care behaviors regarding diet (serum potassium levels), fluid intake (mean and standard deviation of interdialytic weight gain), and medication (serum phosphate levels) regimes were collected 3 weeks later at Time 2. Results Illness representations (emotional and timeline perceptions) predicted self-care behaviors with regard to diet and medication. Emotion-focused coping strategies predicted higher levels of variation in adherence to fluid restrictions. Younger males were less likely to adhere to the fluid restrictions. Conclusions The SRM has predictive utility. Psychological interventions should focus on alleviating disease-specific distress and challenging erroneous timeline perceptions in order to increase adherence to dietary and medication regimes in ESRD patients. A more specific measure of coping for ESRD is required to clarify the role of coping strategies in this population. Younger, male patients should be targeted for extra support with fluid restrictions.

The cost of renal dialysis in a UK setting--a multicentre study

The UK National Health Service (NHS) will fund renal services using Payment by Results (PbR), from 2009. Central to the success of PbR will be the creation of tariffs that reflect the true cost of medical services. We have therefore estimated the cost of different dialysis modalities in the Cardiff and Vale NHS Trust and six other hospitals in the UK. We used semi-structured interviews with nephrologists, head nurses and business managers to identify the steps involved in delivering the different dialysis modalities. We assigned costs to these using published figures or suppliers' published price lists. The study used mixed costing methods. Dialysis costs were estimated by a combination of microcosting and a top-down approach. Where we did not have access to detailed accounts, we applied values for Cardiff. The most efficient modalities were automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD), the mean annual costs of which were pound21 655 and pound15 570, respectively. Hospital-based haemodialysis (HD) cost pound35 023 per annum and satellite-unit-based HD cost pound32 669. The cost of home-based HD was pound20 764 per year (based on data from only one unit). The main cost drivers for PD were the costs of solutions and management of anaemia. For HD they were costs of disposables, nursing, the overheads associated with running the unit and management of anaemia. Renal tariffs for PbR need to reflect the true cost of dialysis provision if choices about modalities are not to be influenced by erroneous estimates of cost. Knowledge of the true costs of modalities will also maximize the number of established renal failure patients treated by dialysis within the limited funds available from the NHS.