In-center Hemodialysis Patients Research Articles

Dialysis nurse demand in Europe: An estimated prediction based on modelling.

Abstract Objective To estimate the projections of supply and demand for dialysis-nurses (DNs) over 5 years in 4 European countries (France, Italy, Spain, and United Kingdom). Methods This study modelled the nursing labour workforce across each jurisdiction, by estimating the current nursing labour force, number of nursing graduates and the attrition rate. Results France has currently the greater demand of DNs (51,325 patients on dialysis), followed by Italy, UK, and Spain with 40,661; 30,301; and 28,007 patients on dialysis, respectively. The number of in-centre haemodialysis patients (ICHD) is expected to increase in the four countries, while the number of patients on home-haemodialysis (HHD) or on peritoneal dialysis (PD) only is expected to increase in the UK. Currently Italy has the greater proportion of DNs (2.6%), followed by France (2.1%), Spain (1.7%), and United Kingdom (1.5%). The estimation of dialysis nursing staff growth rate over 5 years showed that the United Kingdom has the greater estimated growth rate (6%); followed by Italy (2%); France (2%), and Spain (1%). Conclusions Dialysis demand will increase in the coming years, which may exacerbate dialysis-nurse shortage. Additionally, competencies and training requirements of dialysis-nurses should be precisely defined. Finally, implementing and facilitating PD and HHD strategies would be helpful for patients, Health-care professionals, and Health care systems, and can even help ease the dialysis-nursing shortage.

#1857 Difelikefalin experience in a large dialysis organization in the US: one year follow-up on patients after completion of 12 weeks

Abstract Background and Aims Chronic kidney disease associated pruritis (CKD-aP) is a common disorder that negatively impacts a patient's quality of life. Itch can be self-reported using the Worst Itching Intensity Numerical Rating Scale (WI-NRS) where higher numbers indicate more severe itch. Difelikefalin (DFK) has been shown to reduce itch in hemodialysis (HD) patients with moderate to severe CKD-aP in clinical trials. Previously, we reported the real-world results of patients who completed 12 weeks of DFK treatment as part of routine clinical care. This current analysis describes the long-term treatment of these 295 patients. Method Fresenius Kidney Care (FKC) in-center HD patients aged 18-89 who received at least 1 dose of DFK before 15 Nov 2022 and were administered a WI-NRS before first DFK administration were assessed. Patients who received 30+ DFK administrations within 74-84 days were classified as complete and are the focus of this analysis. The current analysis focuses on the 3- to 12-month follow-up after first DFK administration to monitor for DFK discontinuation and severity of itch when DKF therapy is discontinued. Results Eighty-one percent of patients (238/295) were administered DFK doses beyond 90 days. These patients treated included 167 patients who received DFK continuously (doses between days 91-101) and 71 who restarted DFK after day 101. Most patients (62%, 148/238) were treated with DKF between days 354 and 365 and 90 (38%, 90/238) stopped before 354 days. Out of those not treated with DFK beyond 90 days (19%, 57/295), 26 patients died or were transferred outside of FKC and 1 received a kidney transplant. Out of the 84 patients previously reported with WI-NRS measured before DFK and during DFK WI-NRS, 29 had follow up WI-NRS scores during times without DFK doses. We observed a decrease in mean itch severity from 8.0 before DFK to 3.2 during DFK and then a return to higher itch severity after DFK was discontinued (7.3). Conclusion In a real-world analysis of patients who completed 12 weeks of DFK therapy, 81% of patients received further DKF administrations. Most patients were treated with DFK between days 354 and 365, although not all patients received continuous DFK therapy. In a subset 29 patients with WI-NRS scores before DFK, during DFK, and after discontinuation, improvements in itch were noted during DFK treatment and a return to severe itch after DFK discontinuation.

#3026 Uncovering the potential of HIF-PH inhibitors to treat renal anemia

Abstract Background and Aims Hypoxia-inducible factor prolyl hydroxylase enzyme inhibitors (HIF-PHis) are a novel class of agents that were developed for the treatment of renal anemia. The agents work by stabilizing the HIF complex and stimulating endogenous erythropoietin production. This research aims to gauge the potential utilization and impact of HIF-PHis based on the perspectives of nephrologists who are based in the EU5. Method Data were collected via an independent online survey of 204 nephrologists based in the EU5 (UK, Germany, Italy, France, and Spain) in November 2023. Results EU5 nephrologists report that most dialysis and CKD non-dialysis patients with renal anemia who are on ESA therapy have an optimal response to treatment; however, a substantial proportion of patients experience a suboptimal response to treatment and up to 13% of patients across dialysis modalities are classified as ESA hypo-responders. Regardless of their geographic location, EU5 nephrologists position HIF-PHis to offer the most value in the CKD non-dialysis patient setting, with a perceived high level of opportunity (80%) for roxadustat to improve renal anemia outcomes among non-dialysis patients. Not surprisingly, the perceived advantages of an oral agent over an injectable medication for the treatment of renal anemia are more substantial for dialysis patients who are receiving home therapies (peritoneal and home hemodialysis) compared to those receiving in-center hemodialysis treatment. EU5 nephrologists also tend to believe that roxadustat represents a high level (64%) of opportunity to improve renal anemia outcomes in dialysis patients, with similar ratings observed for vadadustat (63%) in the same patient population. Specific to the use of HIF-PH inhibitors in the CKD non-dialysis setting, nephrologists are most concerned about patient compliance (51%), followed by safety compared to ESAs in general and as they relate to cardiovascular events (36%). When considering the use of HIF-PH inhibitors in the dialysis setting, nephrologists express similar concerns compared to the non-dialysis setting, with patient compliance (50%) ranked as the top concern, followed by safety compared to ESAs (38%), and the potential for off target effects (33%). Most EU5 nephrologists agree that HIF-PH inhibitors represent a more physiologic way of treating anemia of CKD compared to ESAs (70%) and many would like gain more clinical experience with the class of medications (63%). Current roxadustat treatment rates in dialysis are slowly increasing across the EU5 region, with slightly higher adoption in peritoneal dialysis patients (10%) compared to in-center hemodialysis patients (8%). Meanwhile, their self-reported uptake of roxadustat in CKD non-dialysis patients is also increasing over time, with the largest increase observed in CKD Stage 4 patients (9%). There is little consensus among EU5 nephrologists regarding their expected time to trial vadadustat once it is available, as nearly the same proportion of prescribers project that they will prescribe the agent to their dialysis patients within three months (36%), six months (23%), and within one year (28%). Conclusion With HIF-PHis having more of a physiologic mechanism of action, oral administration, and a similar safety profile compared to ESAs, broader adoption of the novel agents will potentially help address unmet needs and improve patient outcomes in the treatment of renal anemia for both CKD non-dialysis and dialysis patients.

#2598 Risk of vascular access complications in haemodialysis patients initiating dialysis with arteriovenous fistula or arteriovenous graft

Abstract Background and Aims Patients (pts) with end-stage kidney disease (ESKD) rely on successful vascular access (VA) for continual hemodialysis (HD) treatments. Possible VA complications are numerous and complex, which makes them difficult to study. We developed a comprehensive VA complication metric to evaluate VA complications holistically. The goal of this analysis was to describe the risk of having high VA complications in in-center hemodialysis (ICHD) pts whose initial VA included arteriovenous fistula (AVF) or arteriovenous graft (AVG), and who have been successfully receiving regular dialysis care for at least 2 years. Method Adult ICHD pts, with Charlson Comorbidity Index <8, who initiated treatment at one of the clinics of a large dialysis organization between Jan 2016 and Dec 2021, received continuous treatment for ≥2 years, remained on ICHD until censored, and whose initial VA included an AVF or an AVG were investigated. Pts could be censored by death, transplant, discharge from FKC, or study end. Initial VA was determined by use of either AVF or AVG during ICHD treatments in the 90-120 days after initiation of ICHD. Individual-level vascular access complication rates (VACR) were defined as the sum of a patient's VA complication events divided by their duration of follow-up until censor date. VA complication events include: hospitalization due to VA problems or VA infection, VA infections not requiring hospitalization, VA removal due to infection, symptoms of VA infection, symptoms of thrombosis/stenosis, documented stenosis, documented thrombosis, cannulation issues, bacteremia, sepsis. The threshold for high VACR was the highest quintile values. Logistic regression was used to determine the risk of having a high VACR by demographic and comorbid conditions. Results Analyses included 94,208 pts who met our inclusion criteria. The mean VACR for the population was 2.7 VA complications per patient per year (PPY). Pts whose VACR was in the highest quintile, ≥4.34 PPY, were categorized as having high VACR. Table 1 shows the risk of having high VACR by demographic characteristics and comorbid conditions present at ICHD initiation. In general, we observed lower or neutral risk of having high VACR in the demographic characteristics we examined. However, older patients as well as patients with higher BMI had an increase in risk of having high VACR. We observed significant increased risk of having high VACR in diabetic pts (20%), pts with cerebrovascular disease (35%), pts with COPD (10%), pts with Congestive Heart Failure (21%), patients with dementia (22%), and patients with history of myocardial infarction (26%). Conclusion We observed that being older, having increased BMI, or having several comorbid conditions are associated with increased risk of having high VACR in successful ICHD patients who initiated dialysis with an AVF or AVG. Multivariate analyses to further explore these associations are warranted.

Patient Care Technician Staffing and Outcomes Among US Patients Receiving In-Center Hemodialysis

Dialysis patient care technicians (PCTs) play a critical role in US in-center hemodialysis (HD) care, but little is known about the association of PCT staffing with patient outcomes at US HD facilities. To estimate the associations of in-center HD patient outcomes with facility-level PCT staffing. This was a retrospective cohort study, with data analysis performed from March 2023 to January 2024. Data on US patients with end-stage kidney disease and their treatment facilities were obtained from the US Renal Data System. Participants included patients (aged 18-100 years) initiating in-center HD between January 1, 2016, and December 31, 2018, who continued receiving in-center HD for 90 days or more and had data on PCT staffing at their initial treating HD facility. Facility-level patient-to-PCT ratios (number of HD patients divided by the number of PCTs reported by the treating facility in the prior year), categorized into quartiles (highest quartile denotes the highest PCT burden). Patient-level outcomes included 1-year patient mortality, hospitalization, and transplantation. Associations of outcomes with quartile of patient-to-PCT ratio were estimated using incidence rate ratios (IRRs) from mixed-effects Poisson regression, with adjustment for patient demographics and clinical and facility factors. A total of 236 126 patients (mean [SD] age, 63.1 [14.4] years; 135 952 [57.6%] male; 65 945 [27.9%] Black; 37 777 [16.0%] Hispanic; 153 637 [65.1%] White; 16 544 [7.0%] other race; 146 107 [61.9%] with diabetes) were included. After full adjustment, the highest vs lowest quartile of facility-level patient-to-PCT ratio was associated with a 7% higher rate of patient mortality (IRR, 1.07; 95% CI, 1.02-1.12), a 5% higher rate of hospitalization (IRR, 1.05; 95% CI, 1.02-1.08), an 8% lower rate of waitlisting (IRR, 0.92; 95% CI, 0.85-0.98), and a 20% lower rate of transplant (IRR, 0.80; 95% CI, 0.71-0.91). The highest vs lowest quartile of patient-to-PCT ratio was also associated with an 8% higher rate of sepsis-related hospitalization (IRR, 1.08; 95% CI, 1.03-1.14) and a 15% higher rate of vascular access-related hospitalization (IRR, 1.15; 95% CI, 1.03-1.28). These findings suggest that initiation of treatment in facilities with the highest patient-to-PCT ratios may be associated with worse early mortality, hospitalization, and transplantation outcomes. These results support further investigation of the impact of US PCT staffing on patient safety and quality of US in-center HD care.

Longitudinal changes in diffusion tensor imaging in hemodialysis patients.

Hemodialysis patients have increased white matter and gray matter pathology in the brain relative to controls based on MRI. Diffusion tensor imaging is useful in detecting differences between hemodialysis and controls but has not identified the expected longitudinal decline in hemodialysis patients. In this study we implemented specialized post-processing techniques to reduce noise to detect longitudinal changes in diffusion tensor imaging parameters and evaluated for any association with changes in cognition. We collected anatomical and diffusion MRIs as well as cognitive testing from in-center hemodialysis patients at baseline and 1 year later. Gray matter thickness, white matter volume, and white matter diffusion tensor imaging parameters were measured to identify longitudinal changes. We analyzed the diffusion tensor imaging parameters by averaging the whole white matter and using a pothole analysis. Eighteen hemodialysis patients were included in the longitudinal analysis and 15 controls were used for the pothole analysis. We used the NIH Toolbox Cognition Battery to assess cognitive performance over the same time frame. Over the course of a year on hemodialysis, we found a decrease in white matter fractional anisotropy across the entire white matter (p < 0.01), and an increase in the number of white matter fractional anisotropy voxels below pothole threshold (p = 0.03). We did not find any relationship between changes in whole brain structural parameters and cognitive performance. By employing noise reducing techniques, we were able to detect longitudinal changes in diffusion tensor imaging parameters in hemodialysis patients. The fractional anisotropy declines over the year indicate significant decreases in white matter health. However, we did not find that declines in fractional anisotropy was associated with declines in cognitive performance.

Reducing the Frequency of Surveillance Blood Work in Patients Treated With Maintenance Hemodialysis: A Local Quality Improvement Initiative.

There is little evidence on the ideal frequency of routine blood work in maintenance dialysis patients to manage complications, including anemia, mineral bone disease (MBD), and hyperkalemia. Recent quality improvement studies from Ontario showed no negative impacts when decreasing the frequency from monthly to every 6 weeks in conventional in-center hemodialysis (ICHD) patients. In December 2020, Alberta Kidney Care-South (AKC-S) reduced the frequency of routine blood work from every 6 weeks to every 8 weeks for ICHD patients. We aimed to assess the impact of reducing blood work frequency on patient outcomes. We compared prevalent AKC-S ICHD patients in 2 cohorts: (1) retrospective control (October 31, 2019-October 31, 2020) and (2) prospective intervention (December 1, 2020-December 1, 2021). Primary outcomes were true frequency of routine blood work, odds of patients being within target for anemia and MBD, and proportion of lab values of hyperkalemia. Furthermore, we compared hospitalizations and mortality. A total of 972 patients in Calgary's ICHD program were included, 787 in each period (with 602 patients overlapping both cohorts). The frequency of routine blood work decreased from every 39.5 days in the control period to every 54.2 days in the intervention period (P < .01). There was a reduction in the odds of phosphate values in targets (P = .02), and an increase in the odds of labs with hyperkalemia (>6.0 mmol/L) during the intervention period (P = .01). There was no significant change in the odds of being within the accepted targets during the intervention period compared with the control period for hemoglobin, Tsat, calcium, or parathyroid hormone (PTH). Fewer patients were hospitalized during the intervention period and the risk of death decreased as well, although additional factors such as the COVID-19 pandemic may have affected this. A cost-savings of $32 962 occurred from the reduced anemia and MBD blood work during the intervention period. When ICHD units in Calgary reduced routine blood work frequency from every 6 weeks to 8 weeks, there were no negative impacts on hospitalizations or deaths. A slightly lower proportion of phosphate values were within target, and a 0.7% increase in potassium values greater than 6 mmol/L was demonstrated. Our study suggests that blood work frequency in ICHD dialysis patients may be further reduced to every 8 weeks safely. Ultimately, additional pragmatic trials are needed to identify the optimal frequency of routine blood work.

Challenges to dialysis treatment during the COVID-19 pandemic: a qualitative study of patients' and experts' perspectives.

The global COVID-19 pandemic transformed healthcare services in ways that have impacted individual physical and psychological health. The substantial health challenges routinely faced by dialysis-dependent patients with advanced kidney disease have increased considerably during the ongoing COVID-19 pandemic but remain inadequately investigated. We therefore decided to analyze and compare the perspectives of dialysis patients on their own needs and challenges during the COVID-19 pandemic with those of their professional healthcare providers through interviews with both groups. Qualitative study of seven in-center hemodialysis patients, seven peritoneal dialysis patients, seven dialysis nurses, and seven physicians at the Medical University of Vienna between March 2020 and February 2021, involving content analysis of semi-structured interviews supported by a natural language processing technique. Among the main themes emerging from interviews with patients were: (1) concerns about being a 'high-risk patient'; (2) little fear of COVID-19 as a patient on hemodialysis; (3) questions about home dialysis as a better choice than in-center dialysis. Among the main themes brought up by physicians and nurses were: (1) anxiety, sadness, and loneliness of peritoneal dialysis patients; (2) negative impact of changes in clinical routine on patients' well-being; (3) telehealth as a new modality of care. Preventive measures against COVID-19 (e.g., use of facemasks, distancing, isolation), the introduction of telemedicine, and an increase in home dialysis have led to communication barriers and reduced face-to-face and direct physical contact between healthcare providers and patients. Physicians did not perceive the full extent of patients' psychological burdens. Selection/modification of dialysis modality should include analysis of the patient's support network and proactive discussion between dialysis patients and their healthcare providers about implications of the ongoing COVID-19 epidemic. Modification of clinical routine care to increase frequency of psychological evaluation should be considered in anticipation of future surges of COVID-19 or currently unforeseen pandemics.

Active Vitamin D Use and Fractures in Hemodialysis Patients: Results from the International DOPPS.

Active vitamin D is commonly used to control secondary hyperparathyroidism in dialysis patients, but it is unknown whether active vitamin D directly improves bone strength, independently of its ability to suppress parathyroid hormone (PTH). We analyzed the association between the prescription of active vitamin D and incidence of any fracture and hip fracture in 41,677 in-center hemodialysis patients from 21 countries in phases 3 to 6 (2005 to 2018) of the Dialysis Outcomes and Practice Patterns Study (DOPPS). We used Cox regression, adjusted for PTH and other potential confounders, and used a per-protocol approach to censor patients at treatment switch during follow-up. We also used a facility preference approach to minimize confounding by indication. Overall, 55% of patients were prescribed active vitamin D at study enrollment. Event rates (per patient-year) were 0.024 for any fracture and 0.010 for hip fracture. The adjusted hazard ratio (95% confidence interval) comparing patients prescribed versus not prescribed active vitamin D was 1.02 (0.90 to 1.17) for any fracture and 1.00 (0.81 to 1.23) for hip fracture. In the facility preference approach, there was no difference in fracture rate between facilities with higher versus lower active vitamin D prescriptions. Thus, our results do not suggest a PTH-independent benefit of active vitamin D in fracture prevention and support the current KDIGO guideline suggesting the use of active vitamin D only in subjects with elevated or rising PTH. Further research is needed to determine the role of active vitamin D beyond PTH control. © 2023 American Society for Bone and Mineral Research (ASBMR).

Conversion from Darbepoetin Alfa to Epoetin Alfa in a Multi-Center Cohort of In-Center Hemodialysis Patients

Conversion from Darbepoetin Alfa to Epoetin Alfa in a Multi-Center Cohort of In-Center Hemodialysis Patients

Infectious complications associated with buttonhole cannulation of native arteriovenous fistulas: a 22-year follow-up.

Buttonhole (BH) cannulation of native arteriovenous fistulas (AVFs) appears to be associated with an increased infectious risk. We previously reported a dramatic increase in the incidence of infectious events (IE) after shift to the BH technique in an in-center hemodialysis unit, which was largely reduced after staff (re)education regarding strict respect of the procedure. We assessed the evolution over the following 12-year period in our center. In this prospective follow-up of a previous, pre [rope-ladder (RL)]-post (BH) comparison (2001-10), all in-center hemodialysis patients with a native AVF were included from 1 July 2010 to 31 December 2022. Primary and secondary outcomes were IE (unexplained bacteremia due to skin bacteria and/or local AVF infection) and complicated IE (metastatic infection, AVF surgery, death). Overall, the impact of several quality improvement strategies was tested according to the events rate over six periods: Period 1: RL in all; Period 2: switch to BH; Period 3: BH in all, before workshops; Period 4: BH in all, after workshops; Period 5: BH withdrawal in problematic AVFs; Period 6: additional procedural changes. This extended observation period allowed the addition of 195180 AVF-days to our previous report. Overall, 381661 AVF-days (366 AVFs, 345 patients) were analysed. After an increase of the IE rate in 2012, the shift to RL in problematic AVFs during Period 5 did not have a significant impact. The incidence of IE decrease significantly during Period 6 compared with Periods 3, 4 and 5 {incidence rate ratio (IRR) 0.24 [95% confidence interval (CI) 0.09-0.52], P=.0001, IRR 0.22 (95% CI 0.09-0.47), P<.0001 and IRR 0.29 (95% CI 0.11-0.66), P=.001, respectively}, and became eventually for the first time comparable to Period 1 [IRR 0.59 (95% CI 0.21-1.62), P=.27]. The constant observance of reinforced hygiene protocols by trained staff and central coordination succeeded in significantly mitigating the infectious risk associated with buttonhole cannulation.

Testing of worn face mask and saliva for SARS-CoV-2.

Exhaled SARS-CoV-2 can be detected on face masks. We compared tests for SARS-CoV-2 RNA on worn face masks and matched saliva samples. We conducted this prospective, observational, case-control study between December 2021 and March 2022. Cases comprised 30 in-center hemodialysis patients with recent COVID-19 diagnosis. Controls comprised 13 hemodialysis patients and 25 clinic staff without COVID-19 during the study period and the past 2 months. Disposable 3-layer masks were collected after being worn for 4 hours together with concurrent saliva samples. ThermoFisher COVID-19 Combo Kit (A47814) was used for RT-PCR testing. Mask and saliva testing specificities were 99% and 100%, respectively. Test sensitivity was 62% for masks, and 81% for saliva (p = 0.16). Median viral RNA shedding duration was 11 days and longer in immunocompromised versus non-immunocompromised patients (22 vs. 11 days, p = 0.06, log-rank test). While SARS-CoV-2 testing on worn masks appears to be less sensitive compared to saliva, it may be a preferred screening method for individuals who are mandated to wear masks yet averse to more invasive sampling. However, optimized RNA extraction methods and automated procedures are warranted to increase test sensitivity and scalability. We corroborated longer viral RNA shedding in immunocompromised patients.

Differences in mental health status during the COVID-19 pandemic between patients undergoing in-center hemodialysis and peritoneal dialysis

BackgroundThe mental health of dialysis patients during the COVID-19 pandemic may have been modulated by dialysis modality. Studies comparing mental health of in-center hemodialysis and peritoneal dialysis patients during the first 2 years of the pandemic are lacking.MethodsWe conducted repeated cross-sectional and multivariable regression analyses to compare the mental health of in-center hemodialysis and peritoneal dialysis patients from March 2019 until August 2021 using data from the Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes. The study period was divided into one pre-pandemic and six 3-month pandemic periods (period 1–period 6). Mental health was assessed with the Mental Component Summary score of the 12-item Short Form health survey and mental symptoms of the Dialysis Symptom Index.ResultsWe included 1274 patients (968 on in-center hemodialysis and 306 on peritoneal dialysis). Mental Component Summary scores did not differ between in-center hemodialysis and peritoneal dialysis patients. In contrast, in-center hemodialysis patients more often reported nervousness during period 3 (27% vs 15%, P = 0.04), irritability and anxiety during period 3 (31% vs 18%, P = 0.03, 26% vs. 9%, P = 0.002, respectively) and period 4 (34% vs 22%, P = 0.04, 22% vs 11%, P = 0.03, respectively), and sadness in period 4 (38% vs 26%, P = 0.04) and period 5 (37% vs 22%, P = 0.009). Dialysis modality was independently associated with mental symptoms.ConclusionsIn-center hemodialysis patients more often experienced mental symptoms compared to peritoneal dialysis patients from September 2020 to June 2021, which corresponds to the second lockdown of the COVID-19 pandemic. Mental health-related quality-of-life did not differ between in-center hemodialysis and peritoneal dialysis patients.Trial registration numberNetherlands Trial Register NL6519, date of registration: 22 August, 2017.Graphical abstract

Correlates of Rates and Treatment Readiness for Depressive Symptoms, Pain, and Fatigue in Hemodialysis Patients: Results from the TĀCcare Study.

Patients on hemodialysis (HD) often experience clinically significant levels of pain, fatigue, and depressive symptoms. We explored potential sociodemographic differences in symptom burden, current treatment, and readiness to seek treatment for these symptoms in patients screened for the TĀCcare trial. In-center HD patients from Pennsylvania and New Mexico were screened for fatigue (≥5 on 0 to10-point Likert scale), pain (Likert scale ≥4), depressive symptoms (≥10 Patient Health Questionnaire-9) and readiness to seek treatment (5-item Stages of Behavior Change questionnaire). Symptom burden and treatment status by sociodemographic factors were evaluated using chi-square, Fisher's exact tests, and logistic regression models. From March 2018-Dec 2021, 506 of 896 (57%) patients screened met eligibility criteria and completed the symptom screening (mean age 60±13.9 years, 44% females, 17% Black, 25% American Indian, 25% Hispanics). Of these, 77% screened positive for ≥1 symptom and 35% of those were receiving treatment for ≥1 of these symptoms. Pain, fatigue, and depressive symptom rates were 52%, 64%, and 24%, respectively. Age <65 was associated with a higher burden of depressive symptoms, pain, and reporting ≥1 symptom (p<0.05). The percentage of patients ready to seek treatment increased with symptom burden. More males reported readiness to seek treatment (85% vs. 68% of females, p<0.001). Among those with symptoms and treatment readiness, income was inversely associated with pain (>$60k/yr: OR=0.16, CI=0.03-0.76), and living in less walkable neighborhoods with more depressive symptoms (OR= 5.34, CI=1.19-24.05) and fatigue (OR= 5.29, CI=1.38-20.33). Pain, fatigue, and depressive symptoms often occurred together, and younger age, less neighborhood walkability, and lower income were associated with a higher burden of symptoms in HD patients. Male patients were less likely to be receiving treatment for symptoms. These findings could inform priority HD patient symptom identification and treatment targets.

#4199 PSYCHOSOCIAL ASSESSMENTS AND HOSPITAL ADMISSION RATES IN ELEVATED OR HIGH ACUITY HEMODIALYSIS PATIENTS

Abstract Background and Aims Using data routinely captured in electronic medical records of a large dialysis organization (LDO) in close collaboration with social workers (MSW), we developed a weekly patient acuity score to identify the level of need for psychosocial support in hemodialysis patients to help social workers optimize visits to deliver timely personalized care. We evaluated how interventions by a MSW affected future hospital admission rate in in-center hemodialysis (ICHD) patients with Elevated or High acuity in an LDO. Method Using data from prevalent (vintage &amp;gt;90 days) ICHD patients from Mar-2022 through Dec-2022, a weekly acuity score was computed using 95 routinely captured variables considered critical (e.g., psychosocial, cognitive, clinical, treatment, hospitalization). Each variable was assigned points based on a priori criteria which were summed and categorized based on population distribution for each week. Patient acuity was assigned as Low, Moderate, Elevated, or High based upon percentile distribution. We defined MSW interventions as the number of assessments completed (0, &amp;lt;1, 1, or &amp;gt;1 per month) during the baseline period (BL, Mar-2022 through May 2022). Next, we compared hospital admission rate in the BL period to that in a follow-up period (FU, June 2022 through Dec 2022) for patients whose acuity at start of BL was Elevated or High (E/H), stratified by monthly MSW assessment exposure. This analysis focuses on prevalent ICHD patients in the Elevated and High acuity categories at baseline (BL, March 2022 through May 2022) as they were expected to have been prioritized for MSW assessment. Results We identified 29,665 prevalent ICHD patients whose acuity was E/H at the start of BL; 8.2%, 24.8%, 20.9%, and 46.2% had 0, &amp;lt;1, 1, and &amp;gt;1 MSW assessments per month during BL, respectively. As expected, hospital admission rate was generally high for patients with E/H acuity. Likewise, for patients with E/H acuity, hospital admission rate increases as the number of monthly interventions in BL increases (Figure 1). For patients with E/H acuity, in each category of BL MSW assessment exposure, the hospital admission rate in FU is lower than in the BL period and the magnitude of the decrease is larger when there are more MSW assessments in the BL period; for 0, &amp;lt;1, 1, and &amp;gt;1 respective MSW assessments, the respective rate ratios were 0.99, 0.99, 0.98, and 0.90, and rate ratio was significantly lower for patients with &amp;gt;1 MSW assessment in BL. Conclusion Our results suggest that acuity is helping MSW to identify patients with requiring more psychosocial and other needs as 46.2% of patients with E/H acuity had &amp;gt;1 MSW assessment. Our results also suggest that &amp;gt;1 MSW assessments in E/H acuity patients results in a larger magnitude in the decrease of hospital admission rates compared to other levels of MSW assessment exposure. Future analyses are needed to confirm these results.

#4421 CHALLENGES TO DIALYSIS TREATMENT DURING THE COVID-19 PANDEMIC: A QUALITATIVE STUDY OF PATIENTS’ AND EXPERTS’ PERSPECTIVES

Abstract Background and Aims The substantial health challenges faced by patients on peritoneal dialysis (PD) or hemodialysis (HD) have increased considerably during the ongoing COVID-19 pandemic, but remain inadequately investigated. We therefore decided to compare the perspectives of PD and in-center HD patients on their needs and challenges through this period with those of their healthcare professionals through interviews with both groups. Method Qualitative study of 7 in-center HD patients, 7 PD patients, 7 dialysis nurses and 7 physicians at the Division of Nephrology and Dialysis, Medical University of Vienna between March 2020 and February 2021, involving content analysis of semi-structured interviews supported by a natural language processing technique. Results Main themes brought up by patients included: 1) Concerns about being a ‘high risk patient’; 2) Having reduced fear of COVID-19 as an HD patient; 3) Whether home dialysis might be better than in-center dialysis during COVID-19; 4) Changes in clinical routine; 5) Positive psychological elements to overcome stress. Main themes emerging from interviews with physicians and nurses included: 1) Fear of COVID-19 infection; 2) Anxiety, sadness, loneliness of PD patients; 3) Negative impact of changes in clinical routine on patients' well-being; 4) Telehealth as a new care modality. Conclusion Physicians did not perceive the full extent of patients’ psychological burdens. Positive psychological constructs were more evident in survivors of previous serious health crises. Patients' concerns related to COVID-19 need to be addressed proactively. Implementation of measures to prevent COVID-19 transmission, introduction of telemedicine, and increased use of home-dialysis have led to communication barriers and reduced contact between healthcare providers and patients. Selection or modification of dialysis modality should include analysis of the patient's support network as well as periodic psychological assessment of patients in anticipation of future surges of COVID-19 or of currently unforeseen pandemics.

#3792 COVID-19 INFECTION AMONG HAEMODIALYSIS PATIENTS - EXPERIENCE FROM A HONG KONG COHORT

Abstract Background and Aims Many haemodialysis patients were infected by COVID-19 during a severe wave of outbreak due to the Omicron variant in Hong Kong in 2022, which had a great impact on the hospital haemodialysis service. To better prepare for future outbreaks, the patient characteristics and outcomes were examined in this study. Method This was a retrospective cohort study of all haemodialysis patients infected with COVID-19 from February to April 2022 in our hospital. The infection rates of in-centre and home haemodialysis were analysed. The mortality rate and the rate of moderate to severe disease (as defined by requiring 2L of oxygen or above) were recorded. Factors affecting mortality and disease severity were analysed using Fisher's exact test and independent t test. Results There were ninety-nine haemodialysis patients infected with COVID-19 during the study period (Table 1). The infection rate of in-centre haemodialysis patients was 98/232 (42.2%) compared with 1/19 (5.3%) of home haemodialysis patients. The mortality rate was 7.1%, and the rate of moderate to severe disease was 10.1%. A higher Charlson Comorbidity Index was identified as the only significant factor associated with mortality (6.7 ± 3.4 vs. 4.9 ± 2.0) and disease severity (6.5 ± 3.0 vs. 4.9 ± 2.0). Age, gender, presence of diabetes mellitus and vaccination status did not correlate with the outcome in this cohort. Conclusion Home haemodialysis had the benefit of a lower infection rate during the COVID-19 outbreak. A higher burden of comorbidities increased the risk of mortality and the severity of COVID-19. Close monitoring is warranted in these group of haemodialysis patients.

#5510 CKD-ASSOCIATED PRURITUS SEVERITY AND ITS ASSOCIATION WITH BODY DISTRIBUTION AND EQ-5D HEALTH-RELATED QUALITY OF LIFE IN HAEMODIALYSIS PATIENTS

Abstract Background and Aims Chronic Kidney Disease associated pruritus (CKD-aP) is common affecting 40% of people with kidney disease receiving dialysis. It is associated with decreased health-related quality of life (HRQoL) as assessed using disease-specific instruments. A better understanding of how the severity of CKD-aP is related to the distribution of affected body parts and generic of HRQoL assessed using the EQ-5D instrument could improve the identification, assessment, and treatment of CKD-aP including advocating for access to new therapies. Method Prevalent in-centre haemodialysis patients from five centres prospectively completed the EQ-5D-5L HRQoL questionnaires, the severity-based worst itch numeric rating scale (WI-NRS) and multi-dimensional 5-D itch pruritus disease specific quality of life instruments. Latent class mixture models were used to identify clusters of patients with similarly affected body parts as assessed through the 5-D itch and map the pruritus measures to the EQ-5D utility value (1 being perfect health and 0 being dead, heavily skewed). Patient demographics, comorbidities, dialysis prescription and anti-pruritus medications were collected. Results Pruritus data on 485 respondents were obtained. No pruritus was reported in 164 (33.8%), with 117 (24.1%) reporting mild, 123 (25.4%) reporting moderate and 81 (16.7%) reporting severe pruritus. Commonly affected body parts included groin (22%), upper arms (21%), forearms (11%), and back (10%). Anti-pruritus medication use across CKD-aP severity (none to severe) was 40.6%, 38.5%, 36.6% and 55.6%, and varied by body part with 38.8%, 21.0% and 14.5% use in those affected in the upper limbs, groin and lower legs respectively. Latent class analysis identified three groups of patients who had progressively worsening severity and number of body parts affected, but the distribution of affected body parts was relatively constant (left-hand figure) and reduction in EQ-5D by affected body part was similar. Although the WI-NRS and 5-D itch instruments correlated with each other, only the 5-D itch had a strong relationship with EQ-5D-3L: Controlling for age, sex, diabetes, and years receiving dialysis, predicted EQ-5D utility dropped linearly from 0.69 to 0.41 (right-hand figure). Conclusion Contemporary UK data shows CKD-aP remains highly prevalent amongst people with kidney failure on dialysis. Severe CKD-aP was commonly reported despite half of the patients with severe CKD-aP receiving antipruritic medication, illustrating a high unmet need and likely undertreated. Although there were similar reductions in HRQoL, medication use varied by body part and those whose groin is affected may be reporting other body parts to access therapies. High use of CKD-aP medications in none or mild severity may represent more severely affected individuals benefiting from these drugs as the cross-sectional nature of the study means those who reported no pruritus may have had pruritus in the past which resolved in response to the medications prescribed and reported in these analyses. Overall, as it worsens CKD-aP appears to affect a similar distribution of body parts. Pruritus instruments that include domains that are broader than just pruritus severity more closely approximate the EQ-5D generic HRQoL measure and therefore more strongly advocate for the value of treating this unpleasant condition. Funded by CSL Vifor.

Real-time prediction of intradialytic hypotension using machine learning and cloud computing infrastructure.

In maintenance hemodialysis patients, intradialytic hypotension (IDH) is a frequent complication that has been associated with poor clinical outcomes. Prediction of IDH may facilitate timely interventions and eventually reduce IDH rates. We developed a machine learning model to predict IDH in in-center hemodialysis patients 15-75min in advance. IDH was defined as systolic blood pressure (SBP) <90mmHg. Demographic, clinical, treatment-related and laboratory data were retrieved from electronic health records and merged with intradialytic machine data that were sent in real-time to the cloud. For model development, dialysis sessions were randomly split into training (80%) and testing (20%) sets. The area under the receiver operating characteristic curve (AUROC) was used as a measure of the model's predictive performance. We utilized data from 693 patients who contributed 42 656 hemodialysis sessions and 355 693 intradialytic SBP measurements. IDH occurred in 16.2% of hemodialysis treatments. Our model predicted IDH 15-75min in advance with an AUROC of 0.89. Top IDH predictors were the most recent intradialytic SBP and IDH rate, as well as mean nadir SBP of the previous 10 dialysis sessions. Real-time prediction of IDH during an ongoing hemodialysis session is feasible and has a clinically actionable predictive performance. If and to what degree this predictive information facilitates the timely deployment of preventive interventions and translates into lower IDH rates and improved patient outcomes warrants prospective studies.

203 Assessment and Correlation of Pruritus Scales Among Chronic In-Center Hemodialysis Patients

203 Assessment and Correlation of Pruritus Scales Among Chronic In-Center Hemodialysis Patients